Respond at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches: Share additional interview and commu

Respond to  at least two of your colleagues  on 2 different days who selected a different patient than you, using one or more of the following approaches:

· Share additional interview and communication techniques that could be effective with your colleague’s selected patient.

· Suggest additional health-related risks that might be considered.

· Validate an idea with your own experience and additional research

Peer 1

Introduction

            The case study analysis assigned to me involves an 85-year-old white female living alone with no family who is in declining health. In expanding upon the case study, I utilized the SOAP note format, which is presented below:

Subjective (S): JD is an 85-year-old white woman who presents to the emergency department with concerns about declining health due to multiple falls and pain in the left hip. The falls began about a year ago and have increased in frequency and severity in the past three months. The most recent fall was today when the patient fell while getting up to use the bathroom, and she fell to the floor and landed on her left side. She immediately called 911. She states that pain in the left hip increases with weight-bearing activities, and she has been unable to put weight on the left side. She has not taken anything for the pain. She states that pain is 10/10 with any weight-bearing or ROM activities. She does not use any assistive devices for mobility. She eats one meal daily and tries to have a Boost supplemental shake daily. Patient has intermittent urine incontinence. She does not have relatives or friends available to assist her. She still drives, though she avoids driving at night.

She has a history of osteoporosis, hypertension, dyslipidemia, anxiety, and depression. Her medications include: metoprolol tartrate 50 mg twice daily, atorvastatin 20 mg daily, sertraline 50 mg daily, multivitamin daily, and vitamin D3 25 mcg daily.

Objective (O): JD is an older white woman who appears frail, malnourished, and anxious. Alert and oriented x 3. VS: 143/94, P 101, RR 20, 97% on room air at rest, and T 97.8F. Weight 91 pounds and height 5’1”. BMI is 17.2. Significant bruising was noted in the LLE from the lateral aspect of the hip that extends medially towards the groin and distally above the knee. X-rays demonstrate a left femoral neck fracture.

Assessment (A): 1.) Traumatic fracture of the left femoral neck 2.) falls 3.) malnourishment 4.) hypertension 5.) osteoporosis 6.) dyslipidemia 7.) anxiety 8.) depression.

Plan (P): Patient is being admitted to the hospital for immediate surgery for a traumatic left femoral neck fracture. Referral and transfer to orthopedics are planned. Patient was provided education on proper nutritional requirements and how to maintain a healthy weight via teach-back and literature. The provider had a conversation with the patient regarding the safety of living within her home, and the patient plans to return home accordingly. Patient is to follow up with the orthopedic surgeon, primary care provider, and cardiologist upon discharge. A discussion for plans to discharge from the hospital to a skilled nursing facility was had, and the patient agreed with this plan. Medication additions include: hydrocodone-acetaminophen 5-325 every 4-6 hours as needed. No medications were discontinued.

Communication and Interview Techniques

            Providers must efficiently use several communication and interview techniques with various populations. In this case study, the patient is an elderly 85-year-old woman. One study provides evidence that the elderly population does not tend to seek out emergency department care unless severe or life-threatening injuries occur (Lutz et al., 2018). She has no hearing or visual concerns; therefore, the provider does not need to make adjustments. The provider should position themselves near the patient with as few obstacles in between as possible (Ball et al., 2019). Maintaining eye contact, having an open posture, using appropriate non-verbal cues, and utilizing appropriate follow-up questions are necessary to gain the patient’s trust (Ball et al., 2019). Since the interview is occurring in the emergency department, the interview must be focused and timely. The provider should begin with open-ended questions to ascertain the patient’s chief concern and follow up with appropriate questions to gain the patient’s trust (Ball et al., 2019). Once rapport is developed and the patient is more at ease, the provider can ask more personal questions, such as about lifestyle and socioeconomic status (Ball et al., 2019). Questions should occur one at a time and in a manner that allows for the patient to respond fully before proceeding. Though the patient’s care will be transferred to the orthopedic surgeon, education should be provided to the patient. Since the patient is in a heightened emotional state, it is necessary to provide educational materials in the form of literature for the patient to reference later (Hoek et al., 2020). Keeping the patient informed at every step of care is imperative to ease the patient’s anxiety and ensure safe outcomes.

Risk Assessment Instrument

            Several risk assessment instruments would be beneficial in this case study. A fall risk assessment tool is the most common and pertinent tool for the patient in this case study. A widely used tool is the Johns Hopkins Fall Risk Assessment Tool, which consists of 7 questions about age, fall history, elimination, bowel and urine, medications, patient care equipment, mobility, and cognition (Johns Hopkins Medicine, n.d.). Scores between 6-13 are a moderate fall risk, and greater than 13 points are a high fall risk (Johns Hopkins Medicine, n.d.). Patient in this case study is a high-fall risk as demonstrated by her age (85), fall in the past six months, incontinence, medications (antihypertensive, opiate), and impaired mobility.

            Another risk assessment tool that should be utilized in this case study should involve nutritional status. Significant evidence suggests that malnourishment is a risk factor for falls and should be addressed at every point of care (Adly et al., 2019). Since the patient in this case study is below the recommended BMI and only eats one meal/daily with the occasional supplemental beverage, it is necessary to provide extensive education to inform the patient of the importance of maintaining a healthy diet to prevent future falls and fractures. One of the most commonly used nutritional risk screening tools for the elderly is the Mini Nutritional Assessment Short-Form (MNA). The MNA includes various components such as loss of appetite, altered sense of taste and smell, loss of thirst, frailty, and depression, all of which are relevant in the older population (Reber et al., 2019). Information gathered from this tool allows for timely nutritional intervention. Maintaining an optimal nutritional status could lead to fewer falls.

Health Risk Interview Summary

· What is your past medical history?

· What is your living situation?

· Do you live alone? Have any relatives or friends that would be able to assist you?

· What obstacles within your home make it difficult for you to complete daily activities? Do you use an assistive device for mobility?

· Take me through a typical day.

· How many meals are you eating? What do the meals consist of?

· What are your bowel and urinary habits? Do you wake up at night to use the bathroom?

· Are you able to shower/bathe yourself? Do you use any assistive devices? Do you feel safe and steady when doing these activities?

· How do you manage your medications? Do you always take them as they are prescribed? How do you pick up your medications?

· How often do you fall in a week, month, or year?

· Is there a specific time of day when you fall? Is there a specific activity that you are doing when you fall?

Peer 2

he Comprehensive History and Physical

          When gathering a comprehensive history and physical (H&P), several areas need to be addressed (Sullivan, 2019). Components of an H&P include the chief complaint with history of present illness, past medical history, family history, social history, review of systems, physical examination, laboratory data, problem list with assessments and differential diagnoses, and the treatment plan (Sullivan, 2019). There is not a one size fits all technique to completing a H&P meaning that the patient’s situation should lead the conversation (Ball et al., 2019). Communication is paramount; therefore, healthcare providers need to make sure they are being understood by using non-medical jargon as well as clarifying what the patient states (Ball et al., 2019). If the patient is presenting in an emergency setting, the emergency care is provided prior to the H&P as needed (Ball et al., 2019). This paper will address working with a 4-year-old male African American child.

          One of the first things to address when working with children is if a consenting adult is present with the patient (Ball et al., 2019). It cannot be assumed that the person in the room with the child has guardianship (Ball et al., 2019). Asking a direct question such as their name and their relation to the child, plus if they have the right to consent to care should be asked upon initial meeting (Ball et al., 2019). The child should be a part of the introductions as well and can be included by getting down to their level to be able to look into their eyes and speak to them (Ball et al., 2019). Asking the guardian and child how they would like to be addressed helps establish a respectful relationship while clarifying the relationship between the patient and person in the room (Ball et al., 2019). The 4-year-old child should be able to answer some questions with the guardian being able to expand on the answers (Ball et al., 2019). The patient is best able to answer what something feels like to them (Ball et al., 2019). Letting the guardian expand on their observations helps to clarify the symptoms and situation that is beyond the understanding of a 4-year-old (McCance & Huether, 2019). Asking direct open-ended questions such as “what prompted you to seek care today” or “when was the child’s last know well day” can allow for the person to tell the narrative of the condition without being prompted by the health care professional (Ball et al., 2019). Also, by asking last know well day rather than first sick day, it opens up the idea of really when the symptoms started (Ball et al., 2019). Allowing for a narrative enables many questions to be answered without having to ask them and they will be in the patient or guardian’s own words (Ball et al., 2019). The healthcare provider can listen to the narrative without interrupting, getting a sense of the chief complaint, then ask directed follow up questions (Ball et al., 2019).

          Children may be anxious or nervous about being in the office so they should be allowed to sit where they are comfortable when able (Ball et al., 2019). For example, in the lap of a parent (Ball et al., 2019). Having a sick child can be stressful so emotions maybe running high (Ball et al., 2019). The health care professional should use respectful candor to gain trust of the patient and guardian (Ball et al., 2019). It is also important to run a risk assessment for maltreatment when a vulnerable population, such as a child, is being seen (van der put et al., 2017). van der put et al. (2017) found that ancillary staff assessments, such as social work, had a better risk assessment tool than clinical tools being used. Van der put et al. (2017) suggest combining aspects of both type of assessments to limit patients falling through the cracks. Healthcare providers are assessing the guardian in the room as well, looking for signs of stress from caregiving (van der put et al., 2017). Ball et al. (2019) also highlights that witnessing violence as a child can hinder appropriate growth and development. Asking a direct question like “has something scared you” or “do you ever have bad dreams about something that you have seen” can help to open a discussion on the situation that occurred (Ball et al., 2019). Getting feedback from the guardian on how they addressed the situation can also assist in gathering information on how this is affecting the child (Ball et al., 2019).

          Asking what a typical day looks like for the child can help gather information (Ball et al., 2019). For example, when asked if there are pets in the home the answer may be no, but there may be pets in the home of a babysitter which could trigger allergies (Ball et al., 2019). Running through a typical day can help determine the patient’s social determinants of health from the environments that the child is exposed to (Ball et al., 2019). Some information can be gathered based on where the patient lives (Ball et al., 2019). For example, if the patient lives in an area with high known child asthma cases due to air quality, then the child should be checked for signs and symptoms of asthma and the guardian educated on the risks and what signs to look for (Ball et al., 2019).

          Part of a child’s H&P should include if the child is hitting developmental milestones (Ball et al., 2019). A four-year-old child could be in preschool in which case the information could be gathered as to how the child in doing in a social school environment (Ball et al., 2019). History of milestone development is important as well; did the child hit developmental markers up to this age (Ball et al., 2019)? In preschool aged children, gross motor skills can be especially meaningful for other developmental functions (Amemiya et al., 2018). Gross motor skills can affect physical and psychological functions, but also social participation for children (Amemiya et al., 2018).  Monitoring the gross motor skills in the preschool years can help to see developmental delays or deficits (Amemiya et al., 2018).

          Gathering a family history is especially important for children as many genetic diseases can be seen by tracing the family (Ball et al., 2019). The child is African American. Some diseases are more prevalent in populations with ancestors from Africa (McCance & Huether, 2019). For example, if the family has a history of sickle cell disease, the child may need to be checked for the disease (McCance & Huether, 2019). Gathering cultural and religious practices that may affect care is also imperative as it may guide the direction of care in a different route (Ball et al., 2019).

          If medications are being prescribed two key factors need to be addressed. Can the patient’s guardian afford the medication and do they understand how the medication is to be taken (Rosenthal & Burchum, 2021)? Practitioners throw around the word noncompliance easily but what is behind the noncompliance (Rosenthal & Burchum, 2021)? If the patient’s guardian does not understand the importance of the medication or they cannot afford the medication, it is the job of the healthcare professional to remedy these situations (Rosenthal & Burchum, 2021). If they cannot afford the top tier medication, can they afford a second-tier medication? These medications may not have as high of efficacy but it may be better than the patient being without anything (Rosenthal & Burchum, 2021). Guardians also need to understand that children process medications differently than adults due to immature organ systems and that many medications are not studied in children so they are being written off label (Rosenthal & Burchum, 2021). Teaching the importance of monitoring the child after medication doses should be part of the education in the visit (Rosenthal & Burchum, 2021).

          In conclusion, a comprehensive history and physical is just that, comprehensive. Obtaining the history and physical is just as important as the physical exam (Sullivan, 2019). Documentation is also key as the record is often used as a base throughout the patient’s entire clinical course (Sullivan, 2019). As a healthcare provider it is our goal to provide above adequate care to our patients, which all begins with the initial H&P (Sullivan, 2019).

,

Read a selection of your colleagues’ responses and  respond to  at least two of your colleagues on  two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.

Peer 1

Pharmacokinetics is the science that analyzes how the human body interacts with a drug. It examines how drugs are absorbed, distributed, metabolized, and excreted by the body. Pharmacodynamics focuses on the biochemical and physiologic effects of drugs and their organ-specific mechanism of action, including effects on the cellular level.

 

As an RN, I have cared for numerous older adults suffering from chronic to acute pain associated with injuries they sustained from falls.  Recently, I had a patient suffering from severe pain due to an injury from a fall. The report from a previous nurse who helped the patient indicates that the patient at baseline was A&Ox4; however, now the patient is alert to self only with visual and auditory hallucinations.  When I reviewed the patient’s H&P, the patient has stage-3 kidney disease and is on Morphine 2mg q2hrs, oxycodone 10mg q4hrs, and Tylenol for pain control.  The patient’s MAR shows that the patient was taking both Oxycodone, Morphine, and Tylenol often together.

 

Age-related changes can affect the pharmacokinetics and pharmacodynamics of an opioid, thereby changing both the intensity and duration of analgesia (Rogers et al., 2013). Typically, opioids are metabolized by the liver and excreted in the urine or feces. Decreased hepatic and renal clearance often occurs with advancing age, leading to an increased half-life and decreased excretion of drugs cleared by the liver/kidney. In addition, older persons have an increase in body fat (20%–40% on average), leading to an increased volume of distribution for fat-soluble drugs (Hutchinson & O’Brien, 2007). As age-related changes in gastrointestinal absorption function to lower gastrointestinal transit times and the possibility of increased opioid-related dysmotility, in older adults, the elimination of Lipid-soluble opioids, such as fentanyl, from the body may take longer times.

 

Considering these factors, during morning rounds, I discussed with the provider a care plan that may help the patient with his pain besides opioids. I planned to try lidocaine patch warm packs and reduce Oxycodone from 10mg to 5mg and Morphine from 2mg to 1mg only during PT therapy, not at the same time as Oxycodone, and scheduled Tylenol. The provider agreed with the plan of care.  At the end of my shift, the patient’s mental status improved. The patient’s pain was well controlled.  

 

Peer 2

Post a description of the patient case from your experiences, observations, and clinical practice from the last five years.

A recent case that comes to mind would be a 76-year-old male who was diagnosed with new heart failure. The patient had recent bouts of extreme shortness of breath and fatigue. He was found to have left-sided heart failure with an ejection fraction of 20%. He had not been seen by a primary care doctor in over 20 years and had a long list of medical problems and non-compliant behaviors. He was a functioning diabetic with an A1C of 12.3, unmedicated, and very little dietary compliance. He had some existing kidney failure with a creatine of 2.01 and was a two-pack-a-day smoker.

Factors that might have influenced pharmacokinetics.

The pharmacokinetics involved with this patient would be to study his body's relationship with any treatments initiated to treat his heart failure. The absorption of any HF medications could be altered in this patient due to his diabetes, which would cause decreased or sluggish blood flow. DM can also significantly impact gastric emptying and the PH of gastric plasma, dramatically affecting the drug's partitioning during absorption. It is believed that the more extended amount of time spent in an acidic environment causes drugs to be more soluble and can alter the body's absorption (Stillhart et al., 2020). DM also affects the distribution due to decreased or sluggish blood flow in DM patients, especially those with high A1C. The distribution of a drug also correlates significantly with the amount of obesity in the patient, which is very common in insulin-resistant and diabetic patients. The metabolism of most drugs is regulated by Cytochrome P450 (CYP450) enzymes responsible, which is a significant variability in drug pharmacokinetics. In diabetic patients, this cytokine becomes involved in an inflammatory response and can alter the metabolism of many drugs (Gravel et al., 2018). The delayed excretion of drugs in diabetic patients can be due to microvascular changes that lead to hyperfiltration and an increased glomerular filtration rate.

The patient's undiagnosed and untreated kidney failure may also affect the passive concentration by increasing or decreasing the bioavailability of the drug, which is the absorption rate, depending on the specific medication. The distribution is affected in kidney failure because it is highly dependent on the amount of water in the body and adipose tissue. In the case of kidney disease, the changes in drug bioavailability may increase the dosage required to achieve the maximum effect (Lea-Henry et al., 2018). The most apparent alteration from kidney failure would be renal drug excretion; in all forms of kidney failure, there are alterations in glomerular filtration, passive tubular resorption, and active tubular secretion. This can cause acceleration of renal excretion of drugs, delay of renal excretion, inaccurate half-life, and the retention of certain compounds not meant for active circulation.

Pharmacodynamics

The pharmacodynamics that needs to be assessed before the distribution of any medications with this patient that the plasma drug levels would need to be monitored more closely due to his noncompliance and comorbidities that could affect the therapeutic levels required. The single dose time course would need to be observed as the patient's metabolism and excretion may change with his declining health regarding his diabetes and kidney function. The initial medication dosage would most effectively be evaluated in a hospital setting due to the half-life and dosing alterations. In this way, the clinician could have an accurate picture of the dose-response relationship and maximum efficacy in the safest way.

 

Details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. 

The personalized plan of care I would develop in this case would be initiating medication in a hospital setting. The patient being untreated for multiple comorbidities, will require various medication initiation concurrently. The patient will require insulin, a diuretic, ace or ARB, or a combination of the two, and a beta blocker. The patient will be initially given lower doses due to his kidney function and the current state of his diabetes. This will all be required to be initiated with a daily comprehensive metabolic panel, complete blood count, hourly vital signs, and symptomatic response. For example, one of the most effective medications for end-stage heart failure is Entresto or Sacubitril/Valsartan, a new class of drugs called angiotensin receptor neprilysin inhibitor (ARNI). This new drug has been shown to significantly improve the ejection fraction of patients with end-stage heart failure (Kerndt et al., 2022). It could be initiated at a low dose in the hospital and monitored for subsequent hypertension, hyperkalemia, decreasing renal function, and angioedema. In this patient's case, you must consider the patient's declining renal function. Additionally, there is no history of using an ace or an ARB. Therefore you would not know if there was an allergy or adverse effect.

The patient would also start on insulin therapy due to his elevated A1C. In the hospital setting, the patient could be given a sliding-scale insulin to evaluate the effects of the drug on his blood sugar and assist him with the ongoing care that he will require when being discharged. Again, in this way is performed in the hospital, a plan of care regarding the patient's medication regimen could be in place to streamline the patient's compliance.

Due to his noncompliance, the patient would be given extensive education on each medication, its action, side effects, laboratory monitoring, interaction, and dietary restrictions. Before his discharge, a cost analysis and plan for acquiring all successful medications. He will then be given a follow-up with his primary provider, who will be established before release; he will have a consultation with the diabetes educator and the nutritionist, with subsequent follow-up. Lastly, the patient will be extensively educated on his kidney, diabetes, heart failure, and the dire need for smoking cessation.

 

APA format ansd at least 2 references for each peer

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