Fluid and Electrolytes: Balance and Disturbance

1. Mrs. Dean is 75-year-old woman admitted to the hospital for a small bowel obstruction. Her medical history includes hypertension. Mrs. Dean is NPO. She has a nasogastric (NG) tube to low continuous suction. She has an IV of 0.9% NS at 83 mL/hr. Current medications include furosemide 20 mg daily and hydromorphone 0.2 mg every 4 hours, as needed for pain. The morning electrolytes reveal serum potassium of 3.2 mEq/L. (Learning Objective 4)

1. What are possible causes of a low potassium level?
2. What action should the nurse take in relation to the serum potassium level?
3. What clinical manifestations might the nurse assess in Mrs. Dean? 

2. Conrad Jackson is a 28-year-old man who presents to the emergency department with severe fatigue and dehydration secondary to a 4-day history of vomiting. During the interview, he describes attending a family reunion and states that perhaps he “ate something bad.” Upon admission his vital signs are a temperature of 102.7°F, heart rate of 116 bpm, respiratory rate of 18 breaths/min, and blood pressure of 86/54 mm Hg. The nurse also notes the patient has dry mucous membranes and tenting of skin. The physician orders an IV to be started with 0.45% normal saline, and orders a serum electrolytes and an arterial blood gas. (Learning Objective 7)

The following results are returned from the laboratory:

Sodium (Na+)  150

Potassium (K+)  5.5

Chloride (Cl¯)  110

BUN    42

Creatinine   0.8

Glucose   86

pH   7.32

PaCO2    35

HCO3¯    20

PaO2    90

O2 Sat    98%

1. What is your interpretation of this arterial blood gas sample?
2. Explain the high potassium in this patient.
3. Calculate the patient’s anion gap:
4. What is the interpretation of this anion gap? 

 Respond to your colleagues by providing additional insights or alternative perspectives. 

Positive comment

                                Main Post

Mental  health disorders, even though suffered by many, remains stigmatized and  receives less attention than other health care issues (Swanton, 2016).   Many patients are not willing to disclose their mental health diagnosis  because of the fear of being looked down on or judged. There are also  limited mental health resources as well as some communities are not able  to gain some of these benefits due to insurance issues or the inability  to pay (Choi et al, n.d.).

             Two of the issues, that this writer believes need change are that of   the granting of FMLA leave to patients with diagnosed psychiatric  disorders and making treating options available to everyone. This writer  has worked with several clients who were having difficulties being  granted  FMLA or being denied. The FMLA is the Family and Medical Leave  Act. It works on behalf of those with medical and mental health  disorders who are unable to perform their job duties due to the  disability from the diagnoses (Wray et al., 2015).  Clients with  physical ailments may find it less difficult to be granted this paid  leave as their disorder is visible by the employer and those granting  the leave. When it comes on to mental health disorders, client tend to  run into several road blocks as their disorder is not readily visible. 

Many  clients explain that their request was denied or met several obstacles  as their diagnoses was not considered chronic or disabling. Many of the  clients argue that anxiety and depression make it difficult for them to  carry out their jobs that require them to come in contact with people.  The increased stress from interacting with others and trying to fit in  to the workplace can be debilitating but is rarely considered so by  employers. This is an area that needs attention and change. This writer  believes that Nurse Practitioners and other health care providers can be  an advocate for the client by providing thorough information on the  client’s illness that support the need for a leave.  The Nurse  Practitioner should be readily available to answer questions and educate  the employers on mental health disorders. In addition, the Nurse  Practitioner could advocate for change on a federal or state level by  writing congress or their elected leaders.

             Another issue that this writer believes need special attention is that  of making special procedures available to everyone. When treating mental  health disorders there are many treatments that would be beneficial for  a client, but the client will end up not receiving the treatment due  their inability to pay or insurance coverage (Wang & Xie, 2019).  This writer has worked with several client suffering with depression who  have exhausted the use of antidepressants but were not qualified for  ECT due to monetary reasons. The client is simply placed back on the  antidepressants with limited hope to treat their disorder. This issue is  also another social change issue that we as Nurse Practitioners could  propose to our elected leaders. The mental health community on a whole  is stigmatized and separated and this only separates them more by  causing a separation amongst themselves.

                                              References

Choi, N. G., DiNitto, D. M., & Marti, C. N. (n.d.). Relationship Between the Types of Insurance 

Coverage and Outpatient Mental Health Treatment Use Among Older Adults. JOURNAL 

OF APPLIED GERONTOLOGY, 35(12), 1343–1362.

Swanton, M. (2016). Mental Distress. InsideCounsel, 16(181), 26–28. Retrieved from 

ebscohost. com.ezp.waldenulibrary.org/login.aspx?direct=true&db=bth&AN=

23498644&site=eds-live&scope=site

Wang, N., & Xie, X. (2019). Associations of health insurance coverage, mental health problems, 

and drug use with mental health service use in US adults: An analysis of 2013 National 

Survey on Drug Use and Health. Aging & Mental Health, 23(4), 439–446.

Wray, T. B., Dvorak, R. D., & Martin, S. L. (2015). Demographic and economic predictors of 

mental health problems and contact with treatment resources among adults in a low-

income primary care setting. Psychology, Health & Medicine, 18(2), 213–222.

 Leadership Styles

There are many articles and books written about the differences between managers and leaders. Leaders are visionary, influential in positive ways, value their teams, support their growth, and empower their staff. Leaders who are positive in their actions coach, delegate, and share recognition. Read the following scenarios and answer the questions given in each scenario.

Scenario A

Consider a time when you had the experience of being led by someone who was able to get you to achieve more than you thought you could. Based on what you learned about leadership styles, describe events examining how your selected leader worked by certain principles. In addition, report details of an event demonstrating how you were led to perform.

Scenario B

Now, recall a time when you were led by someone who could not motivate you. Describe events pointing out how your selected leader’s working style made subordinates feel uncomfortable .

On the basis of the Leadership Styles Scenario A, answer the following questions:

• What style did the leader exhibit? Describe events pointing out how your selected leader worked by certain principles.
• Report details of the scenario demonstrating how you were led to perform.
• How did you improve your overall attitude and motivation based on a supportive leader?
• How does working in a positive organization with supportive leadership encourage staff performance at work each day?
• What leadership skills will you take from your positive experience and use when you are in a leadership position?

On the basis of the Leadership Styles Scenario B, answer the following questions:

• What style did the leader exhibit? Describe events pointing out your selected leader’s leadership style.
• Report details of the scenario demonstrating how you were led in his or her team.
• How did the manager’s action make you feel? Explain.
• Which leadership behaviors do you think your selected leader lacked?
• How important is it for a leader to be trained to guide and motivate  the staff members to enhance team unity, enthusiasm, and positive  attitudes?

Peer 1

The Institute of Medicine (IOM) nursing reports from 2010 to 2016 are the summarized findings of the IOM committee that examined changes in the field of nursing since the publishing of “The Future of Nursing: Leading Change, Advancing Health” (Shalala et al., 2011). The summarized findings found in our class reading assignments outline recommendations and provide an essential path for the individuals involved to implement the changes outlined in these works. Some of the direct “take away” from the IOM nursing reports align with the nursing scope of practice. They identify that nurses should practice to the full extent of their education and training, achieve higher levels of education through an improved educational system, gain rights as full partners with physicians and other health care professionals and require effective workforce planning and policy making through better data collection and an improved information infrastructure.

Throughout my career, I will directly be addressing these main points as I work to achieve and work with full practice autonomy. I recently moved from Maryland, which is one of 28 states that allow nurse practitioners full practice authority to treat and prescribe without formal oversight (Weiland, 2015). This report calls all advanced practice nurses to practice to their full extent, meaning we should implement all necessary and appropriate interventions within our scope of practice as defined by the American Nurses Association. In Maryland, this is an expected outcome in my daily practice where I use my full power to treat patients for the optimal health outcomes. Another area I will strongly indulge in is the necessity for continuing education. As a health care professional, we take on the role of a lifetime learner as we continue to learn best practices and evidence-based practice updates that form as time goes on. Health care is an everchanging field and staying up to date on your education and health understandings can be the difference between patient outcomes. We have a professional duty to our patients to learn everything we possibly can to make the best decisions when developing a plan of care for our patients who expect nothing but competent care. Overall, these nursing reports do a phenomenal job of outlining how nurses in advanced roles can best prepare themselves to provide optimal patient care and how to protect the health of the community through policies and best practices.

References:

Shalala, D., Bolton, L. B., Bleich, M. R., Brennan, T. A., Campbell, R. E., & Devlin, L. (2011). The future of nursing: Leading change, advancing health. Washington DC: The National Academy Press. doi: 10.2956.

Weiland, S. A. (2015). Understanding nurse practitioner autonomy. Journal of the American Association of Nurse Practitioners, 27(2), 95-104.

Peer 2

Describe how you will utilize and implement the IOM Nursing Reports from 2010 and 2016 in your role as an Advanced Practice Nurse.

In 2008, The Institute of Medicine (IOM) along with The Robert Wood Johnson Foundation (RWJF) comprised a report that would made recommendations for an action-oriented blueprint for the future of nursing. This was in response to a need to assess and transform the nursing profession. Nurses have an important role in transforming our current health care system (IOM, 2010). The IOM nursing reports have several recommendations that will propel us into the future of nursing.  

There are eight total recommendations and it is important for all advanced practice nurses to focus on the recommendations to provide better practices. There is a lot of focus on education for nurses. IOM states that nurses should have lifelong continuing education, the number of nurses with a DNP should double by 2020, and the number of nurses with a baccalaureate degree should be increased to 80% by 2020 (IOM, 2010). I will have my master’s degree as an advanced practice nurse and depending on the setting of my practice, I will encourage other registered nurses to complete continuing education courses as well as pursue a higher degree in nursing. I, myself, plan to obtain a doctorate of nursing in 2020 if not before that time. Continuing education will help prepare nurses to lead change in advancing health and providing positive patient outcomes, another recommendation of IOM. It is my plan to participate in any continuing education course that is pertinent to my patients and specialty.

            According to the IOM (2010), implementing nurse residency programs will be extremely helpful to nursing. This not only applies to new graduate nurses but nurses going from one position to another. As a nurse practitioner, I will make myself available to participate in these residency programs. If there is a nurse advancing from a staff nurse position to nurse practitioner, I will volunteer to be a mentor or preceptor to them just as I have with nursing students. I currently work at a teaching facility and recently a nursing residency program was implemented. Many advanced practice nurses function in helping this program succeed by teaching and mentoring. Nurse residency programs improve nurses’ work experiences, increase retention of new nurses, and show financial return for organizations investing in nurses as resources. Residency evaluations show increases in leadership and communication skills and decreases in stress and turnover (Kosman, 2011).

            Collaborating with an interdisciplinary team is also a recommendation of the IOM. As a nurse practitioner it will be my duty to collaborate with others so that my patient receives adequate care. The patient should be treated holistically so if there is a service that I can not provide, it would be wise of me to collaborate with other people so that the patient gets the best care possible. Collaboration could include working with other physicians, physical therapists, occupational therapists, case managers, or social workers. 

            As a nurse practitioner, with my knowledge and experience, I should be able to practice to the full extent of my education. Working in Georgia, I will be aware of what my scope of practice allows me to do in this state. If there is something outside of my scope of practice, I will be sure to refer my patient to someone more appropriate. Along with my contributions, congress and legislative members should be diligent in allocating funds to research and appropriate technology as well as making sure that nurse practitioners get proper insurance reimbursements.

With recommendations from the IOM, nurses should be able to provide effective and efficient care. Patients will receive the best care because the nurses will be up to date on current evidence based practices.

References

Institute of Medicine of the National Academies. (2010). The Future of Nursing Leading Change, Advancing Health, Report Recommendations. Retrieved from https://myclasses.southuniversity.edu/content/enforced/16337-2360697/media/transcripts/Future%20of%20Nursing%202010%20Recommendations.pdf?_&d2lSessionVal=Zo3eS3GHNjkvUMYMbPaQtri9Y

Kosman, S. (2011). Nurse Residencies: Building a Better Future for Patients and Nurses. Robert Wood Johnson Foundation. Retrieved from https://www.rwjf.org/en/culture-of-health/2011/10/nurse-residencies-building-a-better-future-for-patients-and-nurses.html

Polypharmacy is defined as being on 5 or more medicines, and is a major concern for providers as the use of multiple medicines is common in the older population with multimorbidity, and as one or more medicines may be used to treat each condition.

• Discuss two (2) common risk factors for polypharmacy. Give rationale for each identified risk factor.
• Discuss two interventions you can take as a Nurse Practitioner in your clinical practice to prevent polypharmacy and its complications.

Using  at least 2 evidenced-based, peer-reviewed references no older than 5 years.