NR601 Primary Care of the Maturing and Aged Family
Week 2 Discussion
DQ1 Polypharmacy
Polypharmacy
is a common concern, especially in the elderly.
List the
definitions of polypharmacy you encounter in your assigned reading. Include an
additional reference from an evidence based practice journal article or
national guideline.
Discuss
three risk factors that can lead to polypharmacy. Explain the rationale for why
each listed item is a risk factor. Risk factors are different than adverse drug
reactions. ADRs can be a result of polypharmacy, and is important, but ADRs are
not a risk factor.
Discuss
three action steps that a provider can take to prevent polypharmacy.
Provide an
example of how your clinical preceptors have addressed polypharmacy.
Discussion
Guiding Principles
The ideas
and beliefs underpinning the discussions guide students through engaging
dialogues as they achieve the desired learning outcomes/competencies associated
with their course in a manner that empowers them to organize, integrate, apply
and critically appraise their knowledge to their selected field of practice.
The use of discussions provides students with opportunities to contribute
level-appropriate knowledge and experience to the topic in a safe, caring, and
fluid environment that models professional and social interaction. The ebb and
flow of a discussion is based upon the composition of student and faculty
interaction in the quest for relevant scholarship. Participation in the
discussion generates opportunities for students to actively engage in the
written ideas of others by carefully reading, researching, reflecting, and
responding to the contributions of their peers and course faculty. Discussions
foster the development of members into a community of learners as they share
ideas and inquiries, consider perspectives that may be different from their
own, and integrate knowledge from other disciplines.
DQ2 ACC/AHA
Guidelines Discussion
Chief
complaint: medication refill "ran out of medicine"
HPI: BJ, a
68-year-old AA female presents to the clinic for prescription refills. The
patient also indicates that she has noticed shortness of breath which started
about 3 months ago. The SOB gets worse with activity, especially when she is
playing with her grandchildren but it goes away once she sits down to rest. She
reports that she is also bothered by shortness of breath that wakes her up at
night, but it resolves after sitting upright on 3 pillows. She also has lower
leg edema which started 1 week ago. She also indicates that she often feels
light headed and faint while going up the stairs, but it subsides after sitting
down to rest. She has not tried any OTC medications at home. She never filled
her prescriptions, which she received at her checkup 6 months ago, she did not
think it was important.
PMH:
Hypertension
Previous
history of MI in 2010
Surgeries:
2010-Left
Anterior Descending (LAD) cardiac stent placement
Allergies:
Amoxicillin
Vaccination
History:
She
receives an annual flu shot. Last flu shot was this year
Has never
had a Pneumovax
Has not had
a Td in over 20 years
Has not had
the herpes zoster vaccine
Social
history:
High school
graduate, a widow with one son who loves out of state. She drinks one 4-ounce
glass of red wine daily. She is a former smoker that stopped 20 years ago.
Family
history:
Both
parents are deceased. Father died of a heart attack; mother died of natural
causes. She had one brother who died of a heart attack 20 years ago at the age
of 52.
ROS:
Constitutional:
Lightheaded and faint with exertion.
Respiratory:
Shortness of breath with exertion (playing with grandchildren and stairs). +
Orthopnea
Cardiovascular:
+ leg and ankle swelling x 1 week
Psychiatric:
Not taking medications for 6 months - "ran out"
Physical
examination:
Vital Signs
Height: 5
feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 oral P 100 R 22,
non-labored;
HEENT:
normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower
dentures in place a fitting well. No tinnitus
NECK: Neck
supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable
LUNGS:
inspiratory crackles
HEART:
Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic
murmur noted at the right upper sternal border without radiation to the
carotids.
ABDOMEN:
Normal contour; active bowel sounds all four quadrants; no palpable masses.
PV: Pulses
are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting
edema to her knees noted bilaterally
GENITOURINARY:
no CVA tenderness; not examined
MUSCULOSKELETAL:
Heberden's nodes at the DIP joints of all fingers and crepitus of the bilateral
knees on flexion and extension with tenderness to palpation medially at both
knees. Kyphosis and gait slow, but steady.
PSYCH:
normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.
SKIN:
Sparse hair noted on lower legs and feet bilaterally with dry skin on her
ankles and feet.
Labs:: Hgb
12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL
190, TSH 3.7, glucose 98 BUN 12 Cr 0.8
A:
Primary
Diagnosis:
Congestive
Heart Failure (CHF) (150.9)
Secondary
Diagnoses:
Primary
Hypertension (I10)
Depression
F32.3:
Obesity
(E66):
Osteoarthritis
(OA) (715.90)
Differential
Diagnosis:
Peripheral
Vascular Disease (PVD) (173.9)
P:
Medications:
Sertraline
25 mg. Take 1 tab PO QD disp#30, 1 refill
Tylenol 650
mg PO Q4 hours as needed for arthritis pain
Labs: UA;
Brain natriuretic peptide (BNP); LFTs and TSH.
12-lead
EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index
Education:
Congestive
heart failure is caused by the inability of your heart to pump blood
effectively enough to meet the demands of your body. If you think of your body
as any other pump, if fluid does not move well through the system, then it will
back up into other spaces. When blood backs up it puts a lot of pressure on the
blood vessels, which forces fluid to leak out into the nearby tissue. With CHF,
this fluid usually moves into your lungs, legs, or abdomen.
The signs
of worsening CHF include decreased energy level, shortness of breath during
your normal routine, increased swelling to your legs and feet, your clothes
feel tight, or a wet sounding cough. Call the office if these symptoms occur.
Weigh
yourself every morning at the same time. If you have a 3 pound weight gain in
24 hours, or a 5 pound weight gain over a week, you should call the office.
Exercise
and maintaining a normal weight is very important. You should try to exercise
at least 20-30 minutes a day, more if possible. Start slow with walking.
Decrease
your salt intake. Do not add any extra salt to foods. Salt makes you retain
fluid, and it makes you want to drink more fluid. Avoid fast food and prepared
food as they are usually very high in sodium.
If you notice
your legs swelling, elevate them up and rest. Do not drink alcohol and continue
to avoid smoking or second hand smoke.
Take your
medications as directed, with water. Do not stop them abruptly or skip doses.
I have
started you on a medication for depression. It can take 2 weeks to start to
feel it working and up to a month until you can fell the real benefits.
If you
start to feel more depressed, like you want to harm yourself or others, please
contact me right away or got to the ER.
Referrals:
may refer based on lab results
Follow up:
return to office in 2 weeks to review lab results and adherence to treatment
plan.
Additional
lab results:
Echo
results: LVEF 39%
BNP - 682
pg/ml
Questions:
According
to the ACC/AHA Guidelines, what is BJ's heart failure stage? Include the
pertinent positives (the signs and symptoms AND the objective data) to support this finding. Cite your reference.
According
to the ACC/AHA Guidelines, what medications should BJ be prescribed? Include
the drug class and rationale statement for each medication listed. Cite your
reference for each medication.
Given her
history of MI, what additional medications will you prescribe? Include the drug
class and rationale statement for each medication listed. Cite your reference
for each medication, prescribed or OTC .
Write her
complete prescriptions using the prescription writing format.
NR601 Primary Care of the Maturing and Aged Family
Week 3 Discussion
DQ1 Geriatric
Assessment Tools
Review the
course library page list of available screening tools. Link to Library (Links
to an external site.)
Scroll down
and look on the left hand side of the screen: Geriatric Assessment tools
Choose two
assessment tools that are appropriate for primary care (excluding depression,
anxiety and pain screening tools) and discuss the following:
explain the
purpose of the tool
scoring
guidelines
how you
apply the assessment in practice
*If you
would like to present a screening tool that is not listed, contact your
instructor for approval.
DQ2 Psychiatric
Disorders and Screening
Anxiety and
depression are the most common psychiatric problems you will encounter in your
primary care practice.
Review this
case study
HPI: KB, 55
year old Caucasian female who presents to office with complaints of fatigue.
The fatigue has been present for 6 months and seems worse in the morning,
improving slightly through the day. KB reports a lack of energy and "loss
of joy". States" I really don't feel like going anywhere or doing anything"
Reports she often has difficulty staying on task and completing projects for
work. She reports not feeling hungry and does not feel rested when she wakes up
in the morning. KB is a widow for 2 years, social events that are couples only
can make her symptoms worse. She tries to do at least one social activity a
week but it can be really exhausting. Her husband died in their car while she
was driving him to the hospital and sometimes driving in that car makes all the
memories come back. She recently got a puppy, which she thought would help with
the loneliness but the care of the puppy seems overwhelming at times. Rest and
exercise, specifically yoga and meditation seem to make her feel better. At
this time she does not want to do either. She has not tried any medications,
prescribed or otherwise. She reports drinking a lot of coffee, but that does
not seem to help.
Current
medications: Excedrin PM about once a week when she can't sleep, seems to help
a bit. NKDA.
PMH: no
major illnesses. Immunizations up to date.
SH:
widowed, employed full time as a manager. Drinks wine, 1 glass every night. No
tobacco, no illicit drugs. Previously married while living in France, reports
an abusive relationship. The French government gave custody of her son to the
ex-husband. She returned to US without her son 10 years ago. She sees her son
two times a year, they skype and text "all the time" but she misses
him.
FH: Parents
are alive and well. Has one son, age 21, he is healthy but lives in France with
his father.
ROS
CONSTITUTIONAL:
reports weight loss of 2-3 pounds, no fever, chills, or weakness reported
HEENT:
Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR:
No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY:
No shortness of breath, cough or sputum.
GASTROINTESTINAL:
Reports decreased appetite for about 3 months. No nausea, vomiting or diarrhea.
No abdominal pain or blood.
NEUROLOGICAL:
No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the
extremities. No change in bowel or bladder control.
GENITOURINARY:
no burning on urination. Last menstrual period 4 years ago.
PSYCHIATRIC:
No history of diagnosed depression or anxiety. Reports great anxiety due to
verbal and concern for physical abuse, reports feeling very sad and anxious
when divorcing and leaving her son in France. Did not seek treatment. She
started to feel better after about 4 months.
ENDOCRINOLOGIC:
No reports of sweating, cold or heat intolerance. No polyuria or polydipsia
ALLERGIES:
No history of asthma, hives, eczema or rhinitis.
Discussion
Questions:
undefinedResearch
screening tools for depression and anxiety.
Choose one screening
tool for depression and one screening tool for anxiety that you feel are
appropriate to screen KB.
Explain why
you chose that particular tool for KB. Score KB based on the information
provided (not all data may be provided). Include what questions could be
scored, and your chosen score. Assume that any question topics not mentioned are
not a concern at this time.
2. Identify
your next step for evaluation and treatment for KB. Include any necessary
physical medicine evaluation.
3. What
medication, if any, would you recommend for treatment? Provide the rationale.
This should include the medication class, mechanism of action of the medication
and why this medication is appropriate for KB. Include initial prescribing
information and education to include side effects and when KB should notice
efficacy.
4. If the
medication works as expected, when should KB expect to start feeling better?
NR601 Primary Care of the Maturing and Aged Family
Week 6 Discussion
DQ1 Post
Menopausal and Sexuality Issues in the Maturing and Older Adult
Students
will not receive credit for any discussions posted after Sunday 11:59pm MT.
Ageism and
gender bias can affect who and how we ask about sexual health, sexual activity,
and concerning symptoms. Depending on your own level of comfort and cultural
norms this can be a tough conversation for some providers. But this is an
important topic and as our videos discussed, women are wanting us to ask about
sexual concerns. This week we also reviewed sexually transmitted diseases and
the effects of ageism on time to diagnosis so it is necessary to ask these
questions and provide good education for all patients. You will not know any
needs unless you ask.
Discussion
Questions:
Review the
required NAMS videos. What was the most surprising thing you learned about in
the videos? Explain why it was surprising.
What is
GSM? What body systems are involved? How does this affect a woman's quality of
life?
What
treatment does Dr Shapiro recommend?
Review one
aspect of treatment that Dr Shapiro recommends and include an EBP journal
article or guideline recommendation in addition to referencing the video in
your response.
Sexuality
and the older adult
What is
your level of comfort in taking a complete sexual history? Is this comfort
level different for male or female patients? If so, why?
How will
this information impact the way you will interact with your mature and elderly
clients?
DQ2 Urologic
Concerns in the Maturing and Older Adult
Men and
women both can experience urologic concerns with aging. This week's
presentations and readings covered urologic concerns and common problems.
Utilize the national guidelines and scholarly references to develop your
responses.
Urinary
Tract Infections
What risk
factors contribute to the development of a UTI in men versus women?
In which
sex is a UTI more concerning and why?
It is
important to know when to treat a UTI and when not to treat. Is there a
particular situation where you would not treat a UTI?
BPH
As a
provider it is essential for you to know to interpret DRE findings and what
your next step should be. The American Urology Association has specific
recommendations based on age. Be sure you know these because the guidelines
will guide your patient counseling and treatment plan.
What does
the AUA state about drawing PSA levels?
If you do
decide to draw a level what specific counseling should you include in your
education today?
NR601 Primary Care of the Maturing and Aged Family
Week 7 Discussion
Reflection
Reflect
back over the past seven weeks and describe how the achievement of the course
outcomes in this course have prepared you to meet the MSN program outcome #5,
the MSN Essential VIII, and the Nurse Practitioner Core Competency # 8 Ethics
Competencies.
Chamberlain
College of Nursing Program Outcome #5
Advocates
for positive health outcomes through compassionate, evidence-based,
collaborative advanced nursing practice. (Extraordinary nursing)
Masters
Essential VIII: Clinical Prevention and Population Health for Improving Health
Design
patient-centered and culturally responsive strategies in the delivery of
clinical prevention and health promote on interventions and/or services to
individuals, families, communities, and aggregates/clinical populations.
Integrate
clinical prevention and population health concepts in the development of
culturally relevant and linguistically appropriate health education,
communication strategies, and interventions.
NONPF: #8
Ethics Competencies
Integrates
ethical principles in decision making.
Evaluates
the ethical consequences of decisions.
Applies
ethically sound solutions to complex issues related to individuals, populations
and systems of care
