Week 7

Week 7

Week 7

The use of spirituality in nursing practice is not new.  However, it is more studied and utilized in a more structured format in nursing.  Identify and discuss tools used to evaluate spirituality.

Please include 400 words in your initial post with two scholarly articles .

Most important is PLAGIO FREE……………………

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Make Sure You Provide 2 References With 5 Yearsand Utilize APA Style

Provide 2 References With 5 Yearsand Utilize APA Style

Discussion 400 Words. Make Sure You Provide 2 References With 5 Yearsand Utilize APA Style.. .

Identify some of the social, ethical, and economic reasons for addressing immigration policy reform.

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See Below

See Below

Therapy Modalities

Therapy Modality Focus Points

Week X

Therapy Modality:

Creator:

Therapy used for what DSM5 Diagnoses:

(support with APA reference)

Emphasis of Therapy Modality:

Goals of Therapy Modality:

Notes:

References

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Health And Assessment

Health And Assessment

Health And Assessment

Health And Assessment

Health And Assessment

Overview

An increasing number of geriatric patients live in assisted living facilities. Please read this article from The New York Times,  /orders/www.nytimes.com/2014/01/19/opinion/sunday/emanuel-sex-and-the-single-senior.html?_r=0  and then consider interventions or educational programs that you might suggest for residents of an assisted living facility. Discuss your thoughts with your fellow students.

Your initial post must be posted before you can view and respond to colleagues, must contain minimum of two (2) references, in addition to examples from your personal experiences to augment the topic. The goal is to make your post interesting and engaging so others will want to read/respond to it. Synthesize and summarize from your resources in order to avoid the use of direct quotes, which can often be dry and boring. No direct quotes are allowed in the discussion board posts.

Post a thoughtful response to at least two (2) other colleagues’ initial postings. Responses to colleagues should be supportive and helpful (examples of an acceptable comment are: “This is interesting – in my practice, we treated or resolved (diagnosis or issue) with (x, y, z meds, theory, management principle) and according to the literature…” and add supportive reference. Avoid comments such as “I agree” or “good comment.”

Points: 30

Due Dates:

· Initial Post: Fri, Jun 24 by 11:59 p.m. Eastern Standard Time (EST) of the US.

· Response Post: Sun, Jun 26 by 11:59 p.m. Eastern Standard Time (EST) of the US – (the response posts cannot be done on the same day as the initial post).

References:

· Initial Post: Minimum of two (2) total references: one (1) from required course materials and one (1) from peer-reviewed references.

· Response posts: Minimum of one (1) total reference: one (1) from peer-reviewed or course materials reference per response.

Words Limits

· Initial Post: Minimum 200 words excluding references (approximately one (1) page)

· Response posts: Minimum 100 words excluding references.

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Reflection: Reaction to Documentary Gender Revolution

Reflection: Reaction to Documentary

Reflection: Reaction to Documentary

Write down your reactions to the video Gender Revolution as you watch it and answer the following questions: What was your reaction to the documentary? Did it change any thoughts or perceptions that you had (ok if it didn’t)? How do you think being a transgender person might affect that person’s health? What do you think are some of the health disparities affecting transgender people? (1-2 pages, double spaced, using APA format)

Video link – /orders/fb.watch/dMTz5U_TJl/ 

Grading Criteria

Reflect on personal reaction to the video                   2 pts

Identify health issues and health disparities affecting transgender people                       2 pts

Utilize at least 2 sources* & correct APA format                1 pts

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Q1 Post 1

Q1 Post 1

Alma Faulkenberger is an 85-year-old female outpatient sitting in the waiting room awaiting an invasive pelvic procedure. The health care professional who will assist in her procedure enters the room and calls “Alma.” There is no reply so the professional retreats to the work area. Fifteen minutes later the professional returns and calls “Alma Frankenberg.” Still no reply, so he leaves again. Another 15 minutes pass and the professional approaches Alma and shouts in her ear, “Are you Alma Frankenberg?” She replies, “No I am not, and I am not deaf either, and when you get my name correct I will answer you.”

Using the Topic 1 Resources, develop a plan to help Alma be compliant with the procedure and post-treatment medication. Also, describe the approach you would take to patient education in this case.

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PLEASE EDIT AND ADD TO ASSIGNMENT.

Analyzing the Readability of the Asthma Brochure

The Simple Measure of Gobbledygook (SMOG) is an evaluation instrument that employs a hand-scored technique. According to Grabeel et al. (2018), the tool enables healthcare provider to assess the grade level of patient education. From the asthma brochure, there are multiple words containing three or more syllables in different sections of the document.

10 sentences near the beginning = 14 syllables

10 sentences in the middle = 12 syllables

10 sentences near the end = 22 syllables

Total syllables sampled = 48

Approximate square root = 7

SMOG = 7 + 3 = 10.

The readability of the given text is of great significance since it determines how well the audience understands a given text. The document can be improved using various approaches. For instance, shortening the longest sentences (Oliffe et al., 2019). This can be achieved by splitting long sentences into two. Another approach is to use fewer syllables. Using one to two-syllable words when possible can help improve the scores of the education material. Besides, long words should be avoided unless they are broadly used and familiar to many people. The third approach involves the use of short words. This is because it is highly likely that longer words will contain at least three variables.

The results were not expected and this is based on the general appearance of the text. Overall, the brochure appears to be written in short sentences and short paragraphs, suggesting that it should have a higher readability score. On the contrary, the SMOG tool has demonstrated the material is comprised of multiple syllables that affect its readability scores. Based on the outcomes, it is evident that the brochure can be improved to make it more engaging to the target audience. This would help ensure that the patients understand and adhere to the message being communicated in the brochure.

2

References

Grabeel, K. L., Russomanno, J., Oelschlegel, S., Tester, E., & Heidel, R. E. (2018). Computerized versus hand-scored health literacy tools: a comparison of Simple Measure of Gobbledygook (SMOG) and Flesch-Kincaid in printed patient education materials. Journal of the Medical Library Association, 106(1), 38–45. /orders/doi.org/10.5195/jmla.2018.262

Oliffe, M., Thompson, E., Johnston, J., Freeman, D., Bagga, H., & Wong, P. (2019). Assessing the readability and patient comprehension of rheumatology medicine information sheets: A cross-sectional Health Literacy Study. British Medical Journal Open, 9(2), e024582. /orders/doi.org/10.1136/bmjopen-2018-024582

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Discussion 6 Respond Patho

Discussion 6 Respond Patho

Discussion 6 Respond Patho

Discussion 1 (Luna)

Sensory and Integumentary Function

Integumentary Function

Question I

Name the most common triggers for psoriasis and explain the different clinical types.

The etiology of psoriasis generates sporadic flares with various time gaps, however, some stressors, such as drunkenness, skin damage, and hormonal changes, can trigger the condition. The syndrome is triggered by excessive alcohol consumption since it creates a conducive atmosphere. Overconsumption of alcohol causes severe inflammation which encourages psoriasis given the condition’s chronic inflammatory properties (Kimmel & Lebwohl, 2018). Skin injuries work similarly. Due to the inflammatory reaction associated with open wounds, patients with latent psoriasis may experience a return if the skin sustains injuries such as cuts, sunburn, or abrasions. Hormonal changes can trigger psoriasis as well. Some hormones, such as the vascular endothelial growth factor, alter inflammatory changes by inhibiting or encouraging leucocyte action and psoriasis’ chronic inflammation hyperproliferation(Kimmel & Lebwohl, 2018). Other triggers include smoking and stress.

Clinical Types Psoriasis is present in multiple guises in different populations. Plaque psoriasis is the most prevalent and appears to be red inflamed skin with white scales around elbows, knees, and the scalp (Zhukova & Kasikhina, 2018). Inverse psoriasis presents similar skin patches but lacks white scales and can be triggered by friction, sweat, or fungi. Guttate psoriasis appears in children as pink spots on the trunk which disappear within weeks without medical therapies. Other psoriasis types include pustular, erythrodermic, and nail psoriasis.

Treatment Question II

There are several types of treatments for psoriasis, explain the different types and indicate which would be the most appropriate approach to treat this relapse episode for K.B. Also include non-pharmacological options and recommendations.

The goal of psoriasis treatment is to prevent cell reproduction in the afflicted areas. Pharmacological therapy is one type of intervention. Corticosteroids are frequently used as a last option due to their widespread effectiveness. This drug’s anti-inflammatory and immunosuppressive properties reduce cell division rates by affecting gene transcription in the cell nucleus (Albanesi, 2019). Vitamin D analogs provide relief in psoriasis as well. Calcipotriene and calcitriol achieve slow cell growth by binding nuclear receptors involved in inflammation and division(Albanesi, 2019). Some non-pharmacological therapies achieve a similar effect but efficiency decreases with severity. Light therapy, which involves controlled exposure to forms of light like sunlight and ultra-violet rays, can slow down cellular growth and inhibit psoriasis with a repeated application (Albanesi, 2019). Fish oil, aloe vera cream, and essential oils all have a similar effect.

Question III

Included in question 2

A pharmaceutical intervention involving corticosteroids is the most appropriate therapy for K.B.’s condition. This intervention’s efficiency in previous topical prescriptions implies a higher likelihood of better outcomes in subsequent use. Moreover, the patient is experiencing widespread outbreaks covering large regions. Corticosteroids’ availability in a variety of forms including sprays, shampoos, gels, lotions, and creams provide multiple application methods to choose from which allows convenience and treatment adjustment with preference. These options will encourage application despite the wide surface area (Albanesi, 2019).

Question IV

A medication review and reconciliation are always important for all patients, describe and specify why in this particular case is important to know what medications the patient is taking?

The diagnosis of psoriasis and the development of treatment programs for better patient outcomes are aided by knowledge of active prescriptions. Given the nature of certain medicines provoking psoriasis, medication evaluation and reconciliation is critical in K.B.’s case. Exposure to certain beta-blockers, lithium, chloroquine and terbinafine has a triggering an exacerbating effect on dormant and active psoriasis (Dogra & Kamat, 2019). Knowledge of active prescriptions for K.B. can identify such drugs and inform better medication recommendations. This step improves the patient’s outcome.

Question V

What other manifestations could present a patient with Psoriasis?

Patients with plaque psoriasis have a variety of symptoms. In addition to K.B.’s symptoms, the patient may have cracked skin and ridged nails. After a long period of rest, joints may become stiff and swollen, with numbness. K.B. may experience fever and malaise too. Broken skin in affected areas may ooze pus and produce a foul smell. The condition can develop into psoriatic arthritis if mismanaged (Dogra & Kamat, 2019).

Sensory Function

Question I

Based on the clinical manifestations presented in the case above, which would be your eyes diagnosis for C.J. Please name why you get to this diagnosis and document your rationale.

C.J.’s condition is consistent with bacterial conjunctivitis. After sleeping, the patient has a yellowish discharge that creates a crust. This symptom and the red eyes caused by increased capillary vasodilation and visibility resulting from increased blood density due to inflammatory responses in the eyes are consistent with conjunctivitis infection (Wirfs, 2020). Fast symptom progression within 24 hours and a throbbing ear suggest an advanced infection that spreads deeper into the sinus cavity causing redness and swelling inside the ear. The presence of a discharge eliminates several conditions, including viral conjunctivitis, foreign objects, and blocked tear ducts, whose presentations exclude discharge(Wirfs, 2020). Bacteria can cause pus discharge at the injection site, which contains damaged inflammatory compounds and dead bacteria. Pus discharge and bilateral conjunctival erythema indicate inflammatory activity which follows a bacterial infection. This combination of factors sums up a bacterial conjunctivitis diagnosis.

Question II

With no further information would you be able to name the probable etiology of the eye affection presented?

Viral, bacterial, allergic, gonococcal, trachoma. Why and why not. C.J.’s illness appears to be the result of a bacterial infection, according to the information available. The presence of a yellowish discharge eliminates viral etiology because viral infections cause little or no discharge (Marinos et al., 2019). Similarly, the presentations eliminate an allergic cause. Allergic reactions are temporary, often improving within hours and upon removal of the stimuli (Wirfs, 2020). These reactions also rely on the trigger to cause the infection. The lack of a possible trigger in the C.J.’s routine and sustained effects, which worsened within 24 hours, disqualified allergic cause. Several factors support a bacterial etiology including bilateral conjunctival erythema. Erythema indicates acute anterior inflammation which targets bacterial infections. Eye discharge supports a bacterial cause as well. This discharge results from the inflammatory activity and contain bacteria and tissue debris from this process. Redness and bulge in the tympanic membrane are an effect of the infection and the associated immune response processes.

Question III

Based on your answer to the previous question regarding the etiology of the eye affection, which would be the best therapeutic approach to C.J’s problem.

The best treatment plans take into account the nature and identification of the pathogenic bacteria, but for mild to moderate infections, some programs’ broad aim suffices. For eight days, C.J. may use topical antibiotics such as tobramycin, fluoroquinolone, and chloramphenicol four times every 24 hours. As an alternative, chloramphenicol and fusidic acid have similar results. The goal of this treatment is to get rid of the bacteria that is causing the problem. Some treatments fail to achieve this elimination, leading symptoms to worsen and the illness to spread. Every two days, patients should be examined to assess the efficacy of the treatment plan and to check for such progression. Besides that, the condition’s easy transmission necessitates isolation from work for four days to allow microbial clearance or recovery (Wirfs, 2020).

C.J. needs to implement additional steps for better outcomes, including hygienic strategies. Patients may need to clean their eyes several times a day to prevent the accumulation and formation of crust. Besides crust, pus may irritate the eyes and tear. Regular cleaning prevents such discomfort and associated complications. In addition, hygiene can help prevent contamination and the introduction of new bacteria types. Some bacteria, such as Chlamydia trachomatis, are contagious and are transmissible via contact. A patient’s contamination with such pathogens can lead to new infections which may fall without a treatment scope. The resulting sustained inflammatory state and symptom presentation will contribute to a poor outcome. Therefore, patient hygiene as part of treatment plans is crucial for microbial remission (Wirfs, 2020).

References

Albanesi, C. (2019). Immunology of Psoriasis. In Clinical Immunology. /orders/doi.org/10.1016/b978-0-7020-6896-6.00064-8

Dogra, S., & Kamat, D. (2019). Drug-induced psoriasis. Indian Journal of Rheumatology, 14(5). /orders/doi.org/10.4103/0973-3698.272159

Kimmel, G. W., & Lebwohl, M. (2018). Psoriasis: Overview and Diagnosis. /orders/doi.org/10.1007/978-3-319-90107-7_1

Marinos, E., Cabrera-Aguas, M., & Watson, S. L. (2019). Viral conjunctivitis: a retrospective study in an Australian hospital. Contact Lens and Anterior Eye, 42(6). /orders/doi.org/10.1016/j.clae.2019.07.001

Discussion 2 ( Javier)

Discussion 6

Case Study #1: Integumentary Function

Common triggers for Psoriasis

Psoriasis is a skin condition that is known to produce scaly patchy rashes throughout a person’s torso and extremities. Common triggers for psoriasis flare-up are infections, extreme weather changes hot or cold, sunburns, any opening to the skin like cuts, scrapes or insect bites, stress, alcohol consumption, medications for HTN, and others (Mayo Clinic, 2022). The most common type of psoriasis is plaque psoriasis which causes dry raised, red patches covered in gray scales (Mayo Clinic, 2022). Nail psoriasis presents on both fingernails and toenails it can cause pitting, discoloration, onychosis, or become brittle. Guttate psoriasis is commonly caused by a bacterial infection and is characterized by small lesions. Inverse psoriasis is caused by fungal infections and commonly affects areas where there is increased sweat such as the groin, breast, or sacral regions. Pustular psoriasis is less common, and it presents as pus-filled lesions commonly found on hands or feet (Mayo Clinic, 2022). Erythrodermic psoriasis is the least common, causing the entire body to break out in peeling, red dermatitis. Psoriatic arthritis causes swollen fingers, toes, and joints it can also eventually lead to irreversible joint damage (Mayo Clinic, 2022).

Treatments for Psoriasis

There are multiple treatment options for those who suffer from psoriasis, including topical treatments, traditional P.O. medication, and even non-pharmaceutical options. Some of the topical options include topical treatments, corticosteroids, retinoids, vitamin D, salicylic acid, or moisturizers. Several systemic medications used to treat psoriasis include methotrexate, cyclosporine, and retinoids (Mayo Clinic, 2022). Non-pharmacological options include using light therapy to kill the overactive white blood cells that are attacking the healthy skin cells and halt the rapid cell growth (Sullivan, 2020). The recommended treatment for K.B. would be topical corticosteroids and retinoids because her outbreak is acute and localized to her elbows and knees at the moment.

Medication review and reconciliation

Medication reconciliation is essential to do with every patient, but for patients living with psoriasis, a variety of medications can trigger outbreaks such as lithium, antimalarial, and HTN medications. For instance, cyclosporine can cause kidney problems and HTN while methotrexate can cause acute liver damage and reduced blood counts (Sullivan, 2020). Therefore, it is crucial to have a complete list of medications currently being taken by the patient to develop the best course of treatment.

Signs and symptoms of Psoriasis

Other manifestations a patient with psoriasis can present with consist of swollen or stiff joints, dry skin, thickened nails, and generalized itching, burning, or soreness (Sullivan, 2020).

Case Study #2: Sensory Function

Diagnosis

C.J. is presenting with classic symptoms of conjunctivitis. In both bacterial and viral conjunctivitis, the person usually experiences eye crusting and adhesion of the eyelids upon waking and blurry vision with eye discomfort (A. Azari & Arabi, 2020). His tympanic membrane appears to be opaque, bulging, and red which is a symptom of an ear infection (A. Azari & Arabi, 2020). Receiving bilateral bacterial conjunctiva erythema may also cause otitis media and C.J is currently presenting with all the.

Etiology of the eye affection

Despite conjunctivitis presenting as different etiologies, C.J. currently has the signs & symptoms correlated with bacterial conjunctivitis. Viral conjunctivitis is normally brought on by another acute infection such as a cold or the flu. If C.J. would have also complained of symptoms such as cough, fever, and sore throat, that might have been a possibility. Allergic conjunctivitis presents with watery discharge from the eye not, not yellow, or purulent (A. Azari & Arabi, 2020). Gonococcal conjunctivitis is usually caused by the Neisseria gonorrhea bacteria which is a sexually transmitted infection. This form of conjunctivitis is more commonly observed in newborn babies when born vaginally through a woman with active gonorrhea (Delugash and Story, 2020). One study showed that 14% of adult patients with chlamydial conjunctivitis were positive for C. trachomatis when a fluorescent antibody staining of the middle ear aspirate was done to confirm the diagnosis (A. Azari & Arabi, 2020). Without any further information, one would conclude the most likely cause for C.J.  based on his symptoms would be bacterial conjunctivitis since the onset source is from his eyes and ears.

Best therapeutic approach

The most appropriate therapeutic approach for C.J. would be a course of antibiotics for both the eye and also ear infection. C.J. also needs to be educated to perform good hand hygiene practices and wipe down any surface he encounters regularly as bacterial conjunctivitis is highly contagious. Washing his eyes regularly and applying artificial eye drops might also help with the discharge and discomfort associated with bacterial conjunctivitis.

References

1. Azari, A., & Arabi, A. (2020). Conjunctivitis: A systematic review. Journal of Ophthalmic and Vision Research. /orders/doi.org/10.18502/jovr.v15i3.7456

Delugash, L., Story, L. (2020). Applied Pathophysiology for the Advanced Practice Nurse.                      

Goh, B. T., Hadley, J. M., Lomax, N. J., Patel, H. C., & Viswalingam, N. D. (2006, June). Otitis media in adults with chlamydial conjunctivitis. Sexually transmitted infections. /orders/www.ncbi.nlm.nih.gov/pmc/articles/PMC2564741/.

Texas Joint Pain Management (2020). Osteoarthritis vs rheumatoid arthritis – explaining the pain. /orders/www.texasjointpain.com/osteoarthritis-vs-rheumatoid-arthritis/ (Links to an external site.)

Neurological Function: Case Study Questions

Risk factors for Alzheimer’s disease

The risk factors for Alzheimer’s are advancing age, a strong family history, genetics, and a previous head injury (Alzheimer’s Association, 2022a). Those who are 65 years old and over have a greater risk for Alzheimer’s and as individuals get even older, the risk increases. Families with a strong history of the disease are also likely to have other family members later developing it. The closer and more direct the relationship, the more likely an individual would later develop the disease (Alzheimer’s Association, 2022a). There are also genes that may place an individual at risk for Alzheimer’s. Risk genes (APOE-e4) are more likely to lead to Alzheimer’s as compared to deterministic genes (Alzheimer’s Association, 2022b).

Head injuries can also later lead to Alzheimer’s. This head injury may occur due to a stroke, a sports injury (boxing and other high-contact sports), or automobile accidents (Alzheimer’s Association, 2022a). A heart-head connection can also lead to Alzheimer’s. This can be noted in instances where an individual has cardiovascular disease. This includes hypertension, coronary artery disease, and other issues which can elevate blood pressure (National Health Services, 2021). Those with Down Syndrome can also be at risk for Alzheimer’s. Those who may have a tendency towards loneliness and depression also carry a higher risk for Alzheimer’s (National Health Services, 2021).

Similarities and differences between Alzheimer’s, Vascular dementia, Dementia with Lewy bodies, and Frontotemporal dementia

Alzheimer’s, vascular dementia, dementia with Lewy bodies, and frontotemporal dementia are all types of dementia. These diseases, therefore, affect the memory of the individual, including their behavior and problem-solving skills (Alzheimer’s Society, 2022). They mostly also affect older adults.

Alzheimer’s is the most common of these diseases (Alzheimer’s Society, 2022). It is caused by neurofibrillary tangles as well as plaques in the amyloid (Better Health Victoria, 2022). These tangles and plaques give rise to cognitive issues as seen in the disorder (Better Health Victoria, 2022). In vascular Dementia, the blood vessels of the brain are mostly affected. There are issues and damage to the blood vessels which can then lead to cognitive issues (Better Health Victoria, 2022). The Lewy bodies are protein groupings that are noted in the nerve cells of the brain and they lead to symptoms of dementia (Alzheimer’s Society, 2022). Frontotemporal dementia mostly impacts the frontal and temporal lobes of the brain (Better Health Victoria, 2022). These symptoms cause changes in the individual’s behavior and in their personality (Better Health Victoria, 2022). Aside from memory loss, their self-control and judgment are also often compromised.

Explicit and implicit memory

Implicit memory also refers to unconscious memories. These can be hard to express as they are mostly emotional. They often affect current attitudes but sometimes individuals may not be conscious that their memory is affecting their behavior (McLaughlin, 2020). Memories like playing games or playing music are for example part of unconscious memories and usually become second nature to individuals (McLaughlin, 2020). Individuals often have a specific reaction to stimuli due to their implicit memory. These memories can therefore manipulate their reactions and behavior (McLaughlin, 2020). Classical conditioning is associated with implicit memories (McLaughlin, 2020).

Explicit memory notes the presence of more conscious memories, intentionally remembered and consciously expressed (McLaughlin, 2020). These are memories that are anchored on personal experiences and actual events taking place which are recalled by the individual (McLaughlin, 2020). As for semantic memories, these refer to more specific data and ideas (McLaughlin, 2020). Autobiographical memories are more related to events.

Diagnosis and criteria for Alzheimer’s disease

The diagnostic criteria set by the National Institute of Aging and the Alzheimer’s Association cover primary clinical standards related to mild cognitive impairment. This would refer to the symptomatic stage. Updates in the stages of Alzheimer’s now include three new stages (National Institute of Aging, n.d). In the preclinical stage, there are changes in the brain as seen in the amyloid buildup and differences in nerve cells (National Institute of Aging, n.d). No symptoms are present as yet. For mild cognitive impairment, symptoms are present. Most symptoms are related to thinking issues not matching the individual’s knowledge and age (National Institute of Aging, n.d). They are still independent. The disease progresses at this point, with symptoms becoming more pronounced. The memory loss worsens and there is a greater difficulty in finding the right words to use. The individual’s independence is now affected (National Institute of Aging, n.d).

Best Therapeutic Approach

CJ needs diagnostic tests to establish if she has Alzheimer’s. When this is confirmed, she needs to be prescribed the appropriate medications. These medications would help manage the symptoms. Cholinesterase inhibitors work to stem the progression of the disease. Memantine helps with memory and learning. Antidepressants help manage mood and anxiety while antipsychotics can also help reduce aggression (Salamon, 2020). Cognitive Stimulation Therapy can be applied to CJ to help promote mental engagement (Salamon, 2020). Reality Orientation Time Therapy can also improve the individual’s awareness of her surroundings, where she is, what she is doing, what day it is, and what she has done (Salamon, 2020).

References

Alzheimer’s Association (2022a). Causes and risk factors for Alzheimer’s disease. /orders/www.alz.org/alzheimers-dementia/what-is-alzheimers/causes-and-risk-factors

Alzheimer’s Association (2022b). Is Alzheimer’s Genetic?

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clinical skill.

Write a short (50-100-word) paragraph response for each question. This assignment is to be submitted as a Microsoft Word document.

1. Define patient compliance and explain its importance in your field.( Psych)
2. Identify the health care professionals’ role in compliance and give examples of ways in which the health care professional may actually contribute to noncompliance.
3. Compare compliance and collaboration.
4. Compare and contrast patient education in the past with that practiced today.
5. Explain the importance of professional commitment in developing patient education as a clinical skill.
6. Explain the three categories of learning and how they can be used in patient education.
7. List three problems that may arise in patient education and how they would be solved?
8. List some methods of documentation of patient education.
    

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Multifactorial Medication Mishap

Annie Yang, PharmD, BCPS | February 1, 2014

Case Objectives

· Understand the system-based causes of medication errors.

· Describe a model for a systems approach to error analysis.

· Identify weaknesses or failures in key elements of the medication use system.

· Select effective risk reduction strategies to prevent medication errors.

The Case

A previously healthy 50-year-old man was hospitalized while recovering from an uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to transition him from intravenous to oral opioids prior to discharge. The patient experienced nausea with pills but told the bedside nurse he had taken liquid opioids in the past without difficulty.

The nurse informed the physician that the patient was having significant pain, and liquid opioids had been effective in the past. When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system, multiple options appeared on the list—two formulations for tablets and two for liquid (the standard 5 mg per 5 mL concentration and a more concentrated 20 mg per mL formulation). At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry with a brand name. In all, the physician saw eight different choices for oxycodone products. The physician chose the concentrated oxycodone liquid product, and ordered a 5-mg dose.

All medication orders at the hospital had to be verified by a pharmacist. The pharmacist reviewing this order recognized that the higher concentration was atypical for inpatients but assumed it was chosen to limit the volume of fluid given to the patient. The pharmacist verified the order and, to minimize the risk of error, added a comment to both the electronic medication administration record (eMAR) and the patient-specific label that the volume to be given was 0.25 mL (5 mg). For added safety, the pharmacist personally retrieved, labeled, and delivered the drug and a calibrated syringe to the bedside nurse to clarify that this was a high concentration formulation for which the volume to administer was 0.25 mL (a smaller volume than would typically be delivered).

Shortly thereafter, the nurse went to the bedside to administer the drug to the patient for his ongoing pain. She gave the patient 2.5 mL (50 mg) of liquid oxycodone, a volume that she was more used to giving, and then left for her break. A covering nurse checked on the patient and found him unconscious—a code blue was called. The patient was given naloxone (an agent that reverses the effect of opioids), and he responded well. He was transferred to the intensive care unit for ongoing monitoring and a continuous infusion of naloxone to block the effect of the oxycodone. By the following morning, the patient had returned to his baseline with no apparent adverse effects.

The Commentary

Medication errors in the hospital are all too common. Although it may seem that the only error in this case was the nurse giving the wrong amount of medication to the patient, many  latent errors  contributed to harm reaching the patient. Medication errors are rarely caused by failure of a single element or the fault of a single practitioner.( 1 ) For example, in a root cause analysis (RCA) of a fatal medication error in which a nurse administered the wrong medication by intravenous route, an external review found four main proximate causes and multiple performance-shaping factors that contributed to the event.( 2 ) To prevent similar errors from occurring, the reviewers identified more than 15 suggested changes that spanned the medication use system at the hospital.( 2 ) Because medication errors are often multifactorial, analysis of errors should always identify weaknesses in the system and corrective plans should include risk reduction strategies that span multiple processes.

Systems Approach to Medication Errors

The goal of a system-based analysis of errors is to discover underlying system failures that are amenable to correction. In their landmark study using a systems analysis of adverse drug events, Leape and colleagues identified several domains where underlying problems occurred. These domains included lack of information about the patient, drug stocking and delivery problems, and inadequate standardization.( 3 ) Similarly, the Institute for Safe Medication Practices (ISMP) has identified 10 key system elements that have the greatest influence on safe medication use ( Table 1 ).( 4 ) Although other categorizations also exist, this commentary will use ISMP’s model to analyze the case. Readers who also wish to analyze errors in this manner can use a worksheet available on ISMP’s Web site ( http://www.ismp.org/tools/AssessERR.pdf ).

Developing Effective Risk Reduction Strategies

Identifying errors in the system may indicate where changes need to be made. There are two objectives of safe system design: (i) to make it difficult for individuals to make mistakes and (ii) to permit the detection and correction of errors before harm occurs.( 3 ) However, designing effective strategies to make the system safer is difficult. It is easy to implement low leverage strategies (“weak” interventions) as a quick fix for an error. For example, a simple response to this case would be to tell the nurse to read the medication label and electronic medication administration record (eMAR) more carefully, the pharmacist to give better instructions, and the physician to be more careful when using the CPOE system. Such strategies are unlikely to prevent an error from occurring again as they rely on humans to avoid mistakes. Instead, higher leverage strategies (“strong” interventions) that prevent human errors from propagating through the system should be implemented.

In the rank order of error-reduction strategies ( Table 2 ), high leverage strategies create lasting change in the system. Fail-safes, constraints, and forcing functions are types of strategies that improve the system with minimal reliance on human vigilance and memory. On the other hand, providing education and information and drafting rules and policies are easy to implement but often rely on human vigilance. These low leverage strategies are likely to only be effective if combined with interventions that target systems issues.( 5,6 )

System-Based Analysis

A robust system-based analysis of this error might discover failures that are amenable to higher leverage solutions to prevent future occurrence. Rigorous analysis of medications errors should use the ISMP model and examine the 10 key system elements ( Table 1 ). Applying the framework in the analysis of this case reveals a substantial number of failures and areas for clear system improvement.

Patient Information

Both the pharmacist and the physician in this case were likely unaware of key patient information which may have contributed to the error. For example, the physician may not have known the patient’s opioid-use history, such as which liquid opioid he used in the past, and thus could not reorder that specific medication and dose. It appears the pharmacist was not directly aware of the patient’s opioid use in the past and assumed the patient was a candidate for concentrated oxycodone. To prevent similar gaps in the future, the institution should ensure that information about a patient’s diagnoses, allergies and adverse reactions to medications (including the inability to tolerate specific formulations of medications), and patient-monitoring information is readily available to all practitioners.

Drug Information

All three practitioners lacked pertinent drug information to make safe decisions. The physician was unaware that liquid oxycodone comes in two concentrations, the pharmacist did not know that the concentrated product was not appropriate for an opioid-naïve patient, and the nurse, who was unfamiliar with the concentrated formulation, did not realize that the volume to be administered was indeed much less than to what she was accustomed. Multiple steps can be taken to prevent these knowledge gaps in the future. Up-to-date drug information should be available to all practitioners, and practitioners should know how to use these references. High-alert medications, such as concentrated oxycodone, should have additional safeguards that guide practitioners to their appropriate use. For example, a pain order set, guideline, or protocol could be used to identify when a patient is ready for escalation to more potent pain medications. Finally, restrict prescribing of certain medications, especially those that are used rarely, to specialized practitioners who are familiar with their use (e.g., a pain specialist in this case).

Communication of Drug Information

Not only were there issues with knowledge about the drug, but the lack of clear communication of drug information also contributed to the error. The list of choices that resulted when oxycodone was searched in the CPOE system was confusing. Even though there were four distinct oxycodone products, eight were listed due to duplication. Furthermore, the concentrated liquid was not sufficiently distinct from the regular product on that list. Unfortunately, the pharmacist and prescriber did not communicate on the intended plan for the patient to clear up the confusion. In response, the institution should ensure that when new products are added to a hospital’s formulary and built into the CPOE system and all aspects of the user interface should be examined. If medications are restricted to certain patient populations, that restriction should be reflected in the CPOE system. For example, if concentrated oxycodone is restricted to ordering by pain specialists, this drug should not be available on the list of medications available to general practitioners in the CPOE system. There should be clear lines of communication between all practitioners. If a pharmacist or nurse has concerns about the appropriateness of a medication order, he should feel comfortable and obligated to question the prescriber.

Drug Standardization, Storage, and Distribution

The manner in which the medications were stored and distributed contributed to the error in this case as well. For distribution, the pharmacist dispensed the entire bottle of oxycodone, and the nurse was required to measure out the patient-specific dose. Ideally, medications should be dispensed from the pharmacy in the most ready-to-use form, which minimizes manipulation by the nurse. Pharmacies should dispense liquid medications that come in bulk bottles in unit-dose cups or oral syringes for those with standardized dosages or in oral syringes with the patient-specific dose already drawn into the syringe for the nurse.

Staff Competency and Education

Knowledge gaps in the safe use of opioids may have also contributed to this error. It is not clear if the physician, pharmacist, and nurse had adequate training on the optimal use of opioids for acute pain. According to an opioid knowledge assessment conducted by the Pennsylvania Hospital Engagement Network Adverse Drug Event Collaboration, practitioners of all levels had a weak understanding of important aspects of safe opioid use. The study suggests that organizations educate and assess staff understanding regarding effects of opioids on sedation and respiratory depression, differences between opioid-naïve and opioid-tolerant patients, indications for long-acting opioids, equianalgesic dosing among opioids, and required monitoring.( 7 )

Patient Education

Although it is not discussed directly in the case, the patient may not have been aware of the medication he was taking. Furthermore, he may not have been able to request the same opioid he tolerated in the past because he did not know the name. To help them prevent errors, patients and families should be empowered to detect medication errors by encouraging them to ask questions about their medications and the purpose of their medications and by explaining the safeguards that are being used to ensure they are receiving the right medication and dose.

Quality Processes and Risk Management

Lastly, more robust quality control processes may reduce the likelihood of this type of error. For example, the nurse did not have another practitioner independently double-check the medication before administering it. Although they should not be the only safeguard and should be used judiciously, independent double checks (the procedure in which two clinicians independently check each component of prescribing, dispensing, and administering a medication) can detect up to 95% of errors.( 8 ) While the case does not detail the hospital’s processes surrounding identifying, reporting, and analyzing medication errors, all organizations should actively cultivate a culture in which error reporting is encouraged and non-punitive and leads to meaningful change. Using errors and near misses to identify systems issues should be done in an interdisciplinary manner. Proactive risk assessment tools, such as failure mode and effects analysis (FMEA), will help institutions ensure that new medications, processes, and services are implemented safely.

Conclusion

This case highlights the different system weaknesses that together resulted in an error harming the patient. Although it would be easy to fault the individuals involved, the absence of prescribing criteria for and restriction of concentrated oxycodone, the lack of a standard dispensing practice that minimizes nursing manipulation, and the need for staff education and guidance on such high-alert medications, among other factors, contributed to this event. To ensure all gaps in the system are addressed, a rigorous analysis using a model, such as ISMP’s Key Elements of the Medication-Use System that is used here, should be employed. Furthermore, when designing changes, hospitals should adopt high leverage risk reduction strategies as much as possible. For example, instead of telling the nurse to read the label more carefully next time, the manipulation of the medication can be taken out of the nurse’s responsibility. Although the patient did not experience any lasting adverse consequences in this case, adopting strategies that address system weaknesses will decrease the risk that an error of this type will reach another patient.

Take-Home Points

· Medication errors are multifactorial; they are rarely due to only one failure mode or individual.

· When analyzing medication errors, employ a systems approach by identifying weaknesses throughout the medication use system.

· When choosing risk reduction strategies to implement, focus on those that do not rely on human vigilance or memory.

· Use proactive risk assessment tools whenever new medications, processes, and services are implemented to prevent errors.

Annie Yang, PharmD, BCPS

Medication Safety Manager

NYU Langone Medical Center

New York, NY

Faculty Disclosure:  Dr. Yang has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

1. Smetzer JL, Cohen MR. Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. Hosp Pharm. 1998;33:640-657.

2. Smetzer J, Baker C, Byrne FD, Cohen MR. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf. 2010;36:152-163.  [go to PubMed]

3. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35-43.  [go to PubMed]

4. Cohen MR. Causes of medication errors. In: Cohen MR, ed. Medication Errors. 2nd ed. Washington, DC: American Pharmacists Association; 2006:55-66.  [Available at]

5. ISMP Medication Safety Alert! Acute Care Edition. Medication error prevention “toolbox.” June 2, 1999;4:1.  [Available at]

6. ISMP Medication Safety Alert! Community/Ambulatory Care Edition. Selecting the best error-prevention “tools” for the job. February 2006;5:1-2.  [Available at]

7. Grissinger M. Results of the opioid knowledge assessment from the PA Hospital Engagement Network adverse drug event collaboration. Pa Patient Saf Advis. 2013;10:27-33. [ Available at ]

8. ISMP Medication Safety Alert! Acute Care Edition. Independent double checks: undervalued and misused. June 13, 2013;18:1-4.  [Available at]

Tables

Table 1. ISMP’s Key Elements of the Medication-Use System.( 4 )

Table 2. Rank Order of Risk Reduction Strategies.( 5,6 )

POWER (LEVERAGE)	ERROR REDUCTION STRATEGY	DESCRIPTION
Fail-safes and constraints	• Prevent malfunctioning or unintentional operation by reverting back to a safe state if failure occurs • Restrict access to medications or conditions that may require special training for safe use
Forcing functions	• Procedures that create a “hard stop” during a process to help ensure that important information is provided before proceeding
Automation and computerization	• Use of automation and computerization to lessen human fallibility by limiting reliance on memory
Standardization	• Creation of a uniform model to adhere to when performing various functions to reduce the complexity and variation of a specific process
Redundancies	• Inclusion of duplicate steps or multiple individuals to a process to force additional checks in the system
Reminders and checklists	• Alerts and warnings to make important information highly visible • References to help make important information readily available and to assist with remembering steps
Rules and policies	• Rules and policies guide staff toward an intended positive outcome
Education and information	• Activities to impart knowledge and skills about medications and their safe use • Verification of knowledge and skills
Suggestions to be more careful or vigilant	• An ineffective strategy to prevent errors

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report.  View AHRQ Disclaimers

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