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 Neurocognitive Disorders

Case #3  Neurocognitive Disorders

BACKGROUND

Mr. Charles Wingate is a 76-year-old Caucasian male who presents to your office for an initial psychiatric evaluation. He is accompanied by his eldest son, Mark, who lives with Mr. Wingate. Mr. Wingate was referred to you by his primary care provider who has performed an extensive diagnostic workup to rule out an organic basis for his changes in cognition. Mr. Wingate’s son Mark has verbalized a concern that Mr. Wingate may have Alzheimer’s disease. When questioned, Mr. Wingate states that he is unaware of anyone in his family ever having been diagnosed with Alzheimer’s disease.

SUBJECTIVE

Mr. Wingate states that he has always been “a little bit forgetful,” but he noticed that in his 60s and 70s, it got worse. Mark states that “for the past 2 years, it has been getting worse. He doesn’t even notice how bad his memory has become.” On at least two occasions, Mr. Wingate has gotten lost when he was driving to the grocery store. Mr. Wingate protested his disagreement with this accusation stating, “but they were doing road construction, anyone could have gotten mixed up!” While his son conceded to this, he pointed out that Mr. Wingate’s memory has caused some other problems, such as errors with paying his monthly utility bills (at one point, the electric company threatened to shut off his electricity due to his nonpayment of the bill).

His son Mark also pointed out that the family is concerned for Mr. Wingate’s safety as he twice left his keys hanging in the door and just two evenings ago, put food in oven and forgot about it until the smoke detector in the kitchen began to alarm.

Mr. Wingate also has had a few issues with managing his medications. Specifically, he took too many Norvasc tablets a few months ago, which resulted in hypotension and a fall. Since that time, Mark’s wife has been setting up Mr. Wingate’s pills in pill boxes, but recently, multiple “missed doses” have been noted.

Mr. Wingate states: “but those are my night pills that I miss—I’m always better at remembering things in the morning.” Mark agrees, stating that Mr. Wingate’s cognition does vary throughout the course of the day and appears to worsen in the evening. He also reports that his father seems much less alert in the evenings, and more alert in the mornings.

Mr. Wingate reports that he has had poor sleep for “a long time now.” He does report that over the past few months, he has been having what he describes as “very vivid nightmares.” His son states that sometimes he is awakened by his father’s yelling during nightmares, and enters his father’s room, and sees his father swinging or kicking in his sleep.

He reports that his appetite is “alright” and that his energy levels do fluctuate throughout the course of the day. He states: “sometimes, I can concentrate really well; other times I can’t … it is very frustrating!” Specific to substance use, Mr. Wingate notes that he used to enjoy a glass of wine or two with dinner, but states that it just doesn’t interest him, anymore. Plus, he stated that he notices that when he does drink, he develops slow muscle contractions.

Mr. Wingate’s son also shares a concern about his father’s abnormal movements. He states that for about the last 6 months, his father has had problems with coordination. He states that he raised these concerns with the family doctor who suggested it may be “late onset Parkinson’s disease.” However, he was not treated because the symptoms were “not that bad.”

OBJECTIVE

Mr. Wingate was overall calm and pleasant during the clinical interview. Throughout the clinical interview, you notice that Mr. Wingate is not really involved in the discussion. He seems somewhat indifferent to the assessment and does not seem very concerned with what is being discussed. He only protested when discussing how he got lost on his way to the supermarket and his evening medication dose.

Review of systems and screening physical assessment were unremarkable, with the exception of fine resting tremors noted in both of Mr. Wingate’s hands. The psychiatric/mental health nurse practitioner (PMHNP) also reviewed laboratory studies that were sent from Mr. Wingate’s primary care provider; they were within normal limits with the exception of a serum sodium level of 130 mEq/L.

MENTAL STATUS EXAM

Mr. Wingate is alert. He is oriented to person, place, and partially oriented to time (he knows that it is morning, but cannot tell the hour). His speech is clear, coherent, goal directed, and spontaneous. Mr. Wingate’s self-reported mood is “ok.” Affect is somewhat constricted. His eye contact is fleeting throughout the clinical interview. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes appreciated. Judgment seems well preserved, but insight appears impaired as he is having trouble understanding why his son brought him to this appointment. Concentration and attention also appear impaired, which prompts the PMHNP to perform a mini-mental status exam (MMSE) on Mr. Wingate.

RESULTS OF MMSE

Score of 17, with primary deficits in orientation; calculation; recall (he was unable to recall any of the three items presented after 5 minutes); and he was unable to perform serial 7’s or spell the word “WORD” in reverse, despite the fact that he is a high school graduate and attended 1 year of college. He also needed prompting with the three-step command. His score suggests severe cognitive impairment.

At this point, please discuss any additional diagnostic tests you would perform on Mr. Wingate.

ASSIGNMENT

Answer the following question based on the scenario above

Examine Case 3 Above: You will be asked to make three decisions concerning the diagnosis and treatment for this client described above. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

Decision Point 1

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO MR. WINGATE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

OPTIONS to CHOOSE FROM BELOW:

Major frontotemporal neurocognitive disorder (FTNCD)

Major neurocognitive disorder due to Alzheimer’s disease

Major neurocognitive disorder with Lewy bodies

Decision #1 ANSWER: Differential Diagnosis

1) Which Decision did you select?   Major neurocognitive disorder with Lewy bodies

Why did you select this Decision? Support your response with evidence and references

to the Learning Resources.

2) What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

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

Decision Point 2

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

OPTIONS to CHOOSE FROM BELOW:

Begin Rivastigmine 1.5 mg orally twice a day

Begin Olanzapine 5 mg orally at bedtime

Begin Ramelteon 8 mg at bedtime

Decision #2 ANSWER: Treatment Plan for Psychotherapy

1) Why did you select this Decision Below?

 Begin Rivastigmine 1.5 mg orally twice a day

2) Support your response with evidence and references to the Learning Resources.

3) What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

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

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Upon his return to your office, Mr. Wingate’s son reported that Mr. Wingate seems to be tolerating the medication well, but he has not noticed any improvement in his father’s memory. He denies any worsening of other symptoms, but also reports no improvement either.

· Mr. Wingate’s son does report that Mr. Wingate’s nightmares appear to be getting worse in that he seems to “act out” his nightmares more.

Decision Point 3

BASED ON THE ABOVE INFORMATION IN THE RESULT OF DECISION POINT TWO, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

OPTIONS to CHOOSE FROM BELOW:

Begin Clonazepam 0.5 mg orally at bedtime

Begin Seroquel 25 mg orally at bedtime

Educate Mr. Wingate and his son regarding the fact that it will take time for the Rivastigmine to stop the nightmares

Decision #3: Treatment Plan for Psychopharmacology

1) Why did you select this Decision?

 Begin Clonazepam 0.5 mg orally at bedtime

2) Support your response with evidence and references to the Learning Resources.

3) What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

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

Decision #4

Also write and include how ethical considerations might impact your treatment plan and communication with clients and their family.

Guidance to Student

In the case of Mr. Wingate, he meets the diagnostic criteria for major neurocognitive disorder as evidenced by a decline from a previous level of performance in more than one cognitive domain—in this case, complex attention and executive function. The decline is based on a knowledgeable informant, as well as a clinician (the patient’s primary care provider) who referred him to you, as well as substantial impairment in another quantified clinical assessment (the MMSE). Cognitive deficits that Mr. Wingate demonstrates interfere with independence in everyday activities and he requires help with complex IADLs such as medication management and paying bills.

Nothing in the scenario suggests that delirium could be responsible for the cognitive decline, nor is anything in the scenario suggestive of another mental disorder.

While one may be initially inclined to consider major neurocognitive disorder due to Alzheimer’s disease, probable Alzheimer’s would require evidence of a causative genetic mutation either from family history or genetic testing; and/or decline in memory and learning and at least one other cognitive domain; steadily progressive, gradual decline in cognition without extended plateaus; and no evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological, mental, or systemic disease or condition likely contributing to the cognitive decline). Similarly, while there is some evidence of mild apathy, and decline in executive abilities, there is insufficient evidence of three or more behavioral symptoms that would be needed to make a diagnosis of major frontotemporal neurocognitive disorder (e.g., behavioral disinhibition, loss of sympathy or empathy, perseverative, stereotyped or compulsive/ritualistic behavior, hyperorality and dietary changes, or prominent decline in social cognition and/or executive abilities) nor is there evidence of prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension that would suggest major frontotemporal neurocognitive disorder.

In Mr. Wingate’s case, there is clear evidence of fluctuating cognition, and spontaneous features of Parkinsonism, which had their onset subsequent to the development of cognitive decline. These symptoms, coupled with the presence of a rapid eye movement sleep behavior disorder, are suggestive of major neurocognitive disorder with Lewy bodies. Diagnostic testing should focus on determining the presence of a synucleinopathy.

Since Mr. Wingate’s symptoms are more consistent with MNDLB, the addition of Seroquel may result in severe side effects that could be life threatening and include severe sedation, muscle rigidity, delirium, neuroleptic malignant syndrome, and depending on the source of the study reviewed, neuroleptics may be associated with a 2- to 3-fold increase in mortality, including cerebral vascular accident. Also, although Seroquel can be used off-label to induce sleep in some patients, there is an FDA warning against the use of antipsychotics in older adults with dementia as they have been associated with an increase in mortality.

Acetylcholinesterase inhibitors may be useful in the treatment of NDAD, but there is limited data of their efficacy with MNDLB. If the PMHNP decides to try an acetylcholinesterase inhibitor, the PMHNP should always begin with the lowest starting dose, and then slowly titrate upward, being mindful of the development of side effects. Mr. Wingate and his son should be educated as to the fact that acetylcholinesterase inhibitors may slow disease progression, but will not have a significant impact on existing cognitive deficits.

The addition of low-dose Clonazepam (0.25 or even 0.125 mg) may be considered as a treatment for REM sleep disorders in individuals with MNDLB. Since Clonazepam has a long half-life, the PMHNP should begin at a low dose, and slowly titrate upward, being mindful to educate the client and family about potential side effects and therapeutic end-goals. Remember that safety is always the first priority with prescribing.

PLEASE DO NOT FORGET INTRODUCTION, CONCLUSION AND REFERENCES LESS THAN 5 YEARS OLD. Thanks.

Details: View The Scenario Called “Critical Decision Making For Providers

“Critical Decision Making For Providers

Details:

View the scenario called “Critical Decision Making for Providers” found in the Allied Health Community media (http://lc.gcumedia.com/hlt307v/allied-health-community/allied-health-community-v1.1.html)

In a 800-1,200 word paper, describe the scenario involving Mike, the lab technician, and answer the following questions:

1. What were the consequences of a failure to report?

2. What impact did his decision have on patient safety, on the risk for litigation, on the organization’s quality metrics, and on the workload of other hospital departments?

3. As Mike’s manager, what will you do to address the issue with him and ensure other staff members do not repeat the same mistakes?

Prepare this assignment according to the APA guidelines

In addition to your textbook, “The Interprofessional Health Care Team: Leadership and Development”. A minimum of FOUR academic references from credible sources are required for this assignment.

RUA Paper: Obesity Among African American Adults

Agenda Comparison Grids

Agenda Comparison Grids

• Review the agenda priorities of the current/sitting U.S. president and the two previous presidential administrations.
• Select an issue related to healthcare that was addressed by each of the last three U.S. presidential administrations.
• Reflect on the focus of their respective agendas, including the allocation of financial resources for addressing the healthcare issue you selected.
• Consider how you would communicate the importance of a healthcare issue to a legislator/policymaker or a member of their staff for inclusion on an agenda.

Part 1: Agenda Comparison Grid

Use the Agenda Comparison Grid Template found in the Learning Resources and complete the Part 1: Agenda Comparison Grid based on the current/sitting U.S. president and the two previous presidential administrations and their agendas related to the public health concern you selected. Be sure to address the following:

• Identify and provide a brief description of the population health concern you selected and the factors that contribute to it.
• Describe the administrative agenda focus related to the issue you selected.
• Identify the allocations of financial and other resources that the current and two previous presidents dedicated to this issue.
• Explain how each of the presidential administrations approached the issue.

Part 2: Agenda Comparison Grid Analysis

Using the information you recorded in Part 1: Agenda Comparison Grid on the template, complete the Part 2: Agenda Comparison Grid Analysis portion of the template, by addressing the following:

• Which administrative agency would most likely be responsible for helping you address the healthcare issue you selected?
• How do you think your selected healthcare issue might get on the agenda for the current and two previous presidents? How does it stay there?
• Who would you choose to be the entrepreneur/ champion/sponsor of the healthcare issue you selected for the current and two previous presidents?

Based on the feedback that you received from your colleagues in the Discussion, revise Part 1: Agenda Comparison Grid and Part 2: Agenda Comparison Grid Analysis.

Then, using the information recorded on the template in Parts 1 and 2, develop a 1-page Fact Sheet or Talking Points Brief that you could use to communicate with a policymaker/legislator or a member of their staff for this healthcare issue. You can use Microsoft Word or PowerPoint to create your Fact Sheet or Talking Point Brief. Be sure to address the following:

• Summarize why this healthcare issue is important and should be included in the agenda for legislation.
• Justify the role of the nurse in agenda setting for healthcare issues.

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Case Study: Cardiorespiratory

Case Study:

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 850 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, and abstract is required.

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Health Care Delivery Models And Nursing Practice -US English Proficiency Required

Nursing Practice -US English Proficiency Required

Nursing Practice -US English Proficiency Required

Nursing Practice -US English Proficiency Required

Nursing Practice -US English Proficiency Required

Nursing Practice -US English Proficiency Required

Nursing Practice -US English Proficiency Required

Examine changes introduced to reform or restructure the U.S. health care delivery system. In a 1,000-1,250 word paper, discuss action taken for reform and restructuring and the role of the nurse within this changing environment.

Include the following:

1. Outline a current or emerging health care law or federal regulation introduced to reform or restructure some aspect of the health care delivery system. Describe the effect of this on nursing practice and the nurse’s role and responsibility.
2. Discuss how quality measures and pay for performance affect patient outcomes. Explain how these affect nursing practice and describe the expectations and responsibilities of the nursing role in these situations.
3. Discuss professional nursing leadership and management roles that have arisen and how they are important in responding to emerging trends and in the promotion of patient safety and quality care in diverse health care settings.
4. Research emerging trends. Predict two ways in which the practice of nursing and nursing roles will grow or transform within the next five years to respond to upcoming trends or predicted issues in health care.

You are required to cite a minimum of three 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.

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PICOT Question Paper

PICOT Question Paper

PICOT Question Paper

Review your problem or issue and the study materials to formulate a PICOT question for your capstone project change proposal. A PICOT question starts with a designated patient population in a particular clinical area and identifies clinical problems or issues that arise from clinical care. The intervention used to address the problem must be a nursing practice intervention. Include a comparison of the nursing intervention to a patient population not currently receiving the nursing intervention, and specify the timeframe needed to implement the change process.  Formulate a PICOT question using the PICOT format (provided in the assigned readings) that addresses the clinical nursing problem.

The PICOT question will provide a framework for your capstone project change proposal.

In a paper of 500-750 words, clearly identify the clinical problem and how it can result in a positive patient outcome.

Describe the problem in the PICOT question as it relates to the following:

1. Evidence-based solution

2. Nursing intervention

3. Patient care

4. Health care agency

5. Nursing practice

Prepare this assignment according to the guidelines found in the APA Style Guide.

Benchmark – Capstone Change Project Objectives

Review your problem or issue and the cultural assessment. Consider how the findings connect to your topic and intervention for your capstone change project. Write a list of three to five objectives for your proposed intervention. Below each objective, provide a one or two sentence rationale.

After writing your objectives, provide a rationale for how your proposed project and objectives advocate for autonomy and social justice for individuals and diverse populations.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies:

1.5:  Advocate for autonomy and social justice for individuals and diverse populations

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Health Care Delivery Models And Nursing Practice

2 DQ 2

The Patient Protection and Affordable Care Act of 2010 (PPACA) contains many provisions that seek to intertwine the quality of care with the cost of care. Nurses’ education, skills and professional scope make them indispensable contributors to the successful implementation of evolving patient–centred care delivery models. One of the innovative healthcare delivery models is Accountable Care Organizations (ACOs). It is a collaboration among primary care clinicians, a hospital, specialists and other health professionals who accept joint responsibility for the quality and cost of care provided to its patients (HPI, n.d.). It is a group of providers that promotes accountability patient population and coordinates items and services under Medicare and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery.

The largest benefit that accountable care could bring for the healthcare industry is to garner cost savings or reduce spending.  Another major benefit of ACOs is their ability to improve population health management and patient outcomes. A brief from the Center for Health Care Strategies and the Urban Health Research and Practice at Northeastern University shows that new healthcare delivery models like ACOs offer innovative methods for payers and providers to achieve better population health outcomes. Medicaid ACOs, for instance, have shown a greater focus on preventing disease and promoting wellness, which leads to stronger population health improvements. This reduces the likelihood that a disease would progress and lead to more costly hospital stays. The community gains a wide number of advantages including, improved patient outcomes, the better quality of care, greater engagement with providers, and an overall reduction in out-of-pocket costs.

Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team. Explain how this model is advantageous to patient outcomes.

Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years.

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Rough Draft Quantitative Research Critique And Ethical Considerations

Rough Draft Quantitative Research Critique

Use the practice problem and a quantitative, peer-reviewed research article you identified in the Topic 1 assignment to complete this assignment.

In a 1000-1,250 word essay, summarize the study, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study.

Refer to the resource “Research Critique Guidelines” for suggested headings and content for your paper.

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.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

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