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Explicitly describe the task you undertook to complete the exam for Esther Park
To complete this exam, I interviewed Ms. Park to establish the history of her presenting illness and discovered that the abdominal discomfort had began almost a week ago and worsened over the last 3 days. Having established that she had no history of GI disorders, I conducted a physical exam on my patient. General physical assessment showed she was stable, though mildly distressed. Cardiovascular, respiratory and HEENT exams all revealed no abnormal finding. A physical exam of her abdomen revealed no discoloration, bruits or friction sounds over the liver and spleen. However, an oblong mass with mild guarding and distension appeared on the left lower quadrant of the abdomen. The exam further revealed no CVA tenderness and no organomegaly.
Explain the clinical reasoning behind your decisions and tasks
With the patient reporting pain in the abdomen, the first action was to examine her bowel sounds in all quadrants to establish the exact pain location. The patient’s bowel sounds were normoactive in all quadrants, with no registered bruits or friction sounds. On percussing the left lower quadrant, a scattered dullness was noted, which is often suggestive of feces in the colon (Setya, Mathew & Cagir, 2020). Further, palpating the abdomen showed that it was soft with mild guarding, and an oblong mass was present, confirming the presence of feces in the colon. To rule out any doubt, I conducted a digital rectal exam, which showed fecal mass in the rectal vault, hence my positive diagnosis of fecal impaction.
Identify and discuss at least 3 things that you learned from completing this assessment and how you can apply to your practice.
Completing this abdominal assessment enabled me to learn pertinent information regarding patient pain assessment. Firstly, prior to this assessment, I had hardly any knowledge on how to conduct abdominal palpations especially when a patient is in pain. Secondly, prior to this assessment, I had difficulty interpreting patient’s facial responses to mild pain during palpations. Finally, this assessment enabled me to learn the basics of abdominal pain assessments that I intend to leverage when assessing patients during my practice.
In what ways did this assignment affect your development into proficiently interviewing and assessing patients?
The Esther Park Abdominal Assessment tests one’s ability to concisely collect a patient’s history of present illness and how to leverage such information in determining the best course of action. Since the assessment requires comprehensive inspection and evaluation, alongside such physical examinations as palpation and percussion, I was able to master how to proceed with these activities, and the vital patient responses to note during the assessment. I believe this experience will help me practice better when handling patients presenting with similar complaints.
Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional practice.
One aspect of my performance during this assessment that needs improvement is time management when collecting subjective data. The need to collect an extensive patient history in relation to the present illness, while at the same time seeking to minimize the time spent interviewing a patient can be particularly challenging. However, I realized that by efficiently documenting patient responses and providing empathic or educative feedback makes the process smoother and faster. This is because such personalized interaction makes it easier for the patient to provide detailed, yet specific responses regarding their problems. I intend to leverage this aspect of patient interviewing into my practice going forward.
References
Setya, A., Mathew, G. & Cagir, B. (2020). Fecal Impaction. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK448094/
Welcome to today’s presentation today. My name is……. and I shall be taking you through our topic today. We shall be focusing on Ethical and Policy factors in care collaboration in nursing homes, as is illustrated in the PowerPoint Presentation. Welcome!
Ethics applied in healthcare implies that healthcare practices adhere to morally and ethically acceptable norms within the health sector, and by extension, the society. They bring the best benefits to the patients and minimal to no harm, considering outcomes and consequences of healthcare practices. It also implies an unbiased manner of healthcare providers’ practice (Fink-Samnick, 2019).
The health policies are governments’ or responsible bodies’ regulations set to dictate care practice, safeguard staff and patients, and ensure quality care delivery. Health care policies play a role in determining healthcare standards, and most importantly, improving the health outcomes of patients. Health policy making process involves local, federal and state governments and other responsible organizations (Moore, 2018).
In the care collaboration process, ethical and policy factors are very essential. Ethical and policy aspects work hand in hand and promotes other crucial elements in adequate healthcare provision, such as collaboration and communication (Morley and Cashel, 2017). Relevant ethical and policy factors significantly impact the care planning process, a key element in care collaboration. For this reason, Moore (2018) contends that health practitioners and other stakeholders must integrate the pertinent ethical and policy factors in the delivery of healthcare.
Patient centered initiatives have been identified as significant contributors to care coordination success. The initiatives are an evolution from the previous hospital-centered care, which had the hospital as the focus of the care process (Fix et al., 2018). Successful effort in care coordination focuses on the patient and are directed towards benefiting and safeguarding the patient throughout healthcare delivery. The presentation’s primary focus is the nursing homes, which are healthcare institutions in need of care coordination to enhance healthcare delivery and the care continuum.
Nursing homes are special healthcare facilities in that they offer extended care beyond what an ideal hospital setting would. They provide holistic patient care that include areas outside healthcare. They provide services to a vast continuum of patients, among them, the elderly, the physically and mentally challenged, palliative care patients and other patients requiring special healthcare attention (Morley and Cashell, 2017). Care coordination and care continuum are very essential in the provision of quality healthcare to the patients.
Care coordination involves bringing together all factors and resources that are necessary to meet patients’ needs. Care continuum, on the other hand, involves all activities carried out to the patient, directed towards patient recovery or improved quality of life. Care continuum is offered in nursing homes, and thus, a care collaboration plan is essential. The plan, according to Morley and Cashel (2017), must adhere to ethical and policy guidelines to effectively deliver quality healthcare.
The government has significant input in the regulation of care coordination, as discussed in this presentation. One of the policies impacting care collaboration is the Affordable Care Act, even though the Act has been facing a degree of rejection. The act advocates for the public’s application of health insurance, which has had tremendous effects on the accessibility of health services to the public and, consequently, increased number of patients seeking care under the insurance cover. This has demanded increased care collaboration in nursing homes (Gaffney & McCormick, 2017).
Another policy is the Medicare which has enabled citizens to acquire insurance coverage specific to healthcare needs. The policy has been at work since the 1940s. In 1965, The U.S. President at that time, John F. Kennedy, ensured that senior U.S. citizens had insurance coverage (Garfield, Damico & Orgera, 2020), on that was relevant to our study focusing on nursing homes. The Medicaid policy, created in 1965, aimed at enhancing low-income individuals’ access to healthcare needs and providing them with insurance coverage.
Currently, about 80 million US citizens are beneficiaries of Medicaid (Garfield, Damico & Orgera, 2020). The frontline beneficiaries include uninsured mothers, the physically and mentally challenged and the temporarily unemployed. The policy has had vital success in insurance coverage and is critical to care coordination in healthcare delivery (Neuman & Jacobson, 2018).
The other important policy is the Health Insurance Portability and Accountability Act (HIPAA). The policy protects the citizens and allows them to retain their health insurance coverage during job shifts. The policy provides room for insurances changes in instances such as births, marriages, and deaths. The policy also ensures insurance coverage applicants are not discriminated against. The roles played by the policy have enhanced healthcare provision and, consequently, care collaboration (Edemekong et al., 2021).
Acts that protect the patient and health care providers from external threats is the Patient Safety Quality and Improvement Act. It also advocates for the confidentiality of patient information. It encompasses and promotes medical errors reporting, which has had a bearing on the conduct of healthcare providers, leading to improved quality of healthcare and care coordination (Canabal, 2018).
Lastly, we have the Certificate of Need Cost Containment Program. The policy enhances the quality of healthcare significantly in nursing homes. They do so by ensuring they are adequately regulated, and care coordination is effectively done (Canabal, 2018).
Ethical issues are present in policy provisions. Some healthcare policies have contributed significantly to ethical issues and ethical dilemmas in their creation and implementation (Fink-Samnick, 2019). Their effects have had a detrimental impact both on the economy and the population, as discussed below. These issues have impeded their implementation and, most importantly, their acceptability.
The Affordable Care Act of 2010, for instance, is one of the health policies with major ethical dilemmas impeding its implementation and acceptability. It has been debated over from its creation in 2010. The act aimed to ensure accessibility of healthcare services to all the US citizens. However, it has impacted negatively on income tax rate regardless of whether one purchased health insurance coverage. This has raised a vast ethical disparity in the act’s effectiveness (Gaffney & McCormick, 2017).
The Health Insurance Portability and Accountability Act (HIPAA) is not without ethical issues. Arguably, ethical issues impede the implementation of the act in nursing homes. For example, some mentally ill patients require a third party to handle their information.
The HIPAA act focuses on two significant aspects of healthcare, namely patient safety and confidentiality. However, since the act enshrines the essence of third-party involvement as far as sharing of patient data is concerned, it limits patient privacy (Edemekong et al., 2021). Thus, the HIPAA act cannot be fully implemented in nursing homes as it shall impede healthcare provision.
The International Council of Nurses globally controls nursing practice. Locally, the American Nurses Association (ANA) creates policies and codes of ethics that inform healthcare provision and ensure that nursing care conforms to the international code of ethics (Miller, 2017). Some of the provisions of ANA have direct impacts on care collaboration as discussed below.
Provision 2 of the ANA advocates for respect for humans and maintaining dignity (Gunny et al., 2017). Maintaining human dignity entails providing care that relays the highest degree of respect to the patients. These acts include informed consent before procedures, allowing for autonomy and atraumatic care. Patients’ dignity should be upheld at all times during healthcare provision. Nurses should tailor the care coordination plan to ensure patients are respected at all stages during the implementation process (Morley & Cashel, 2017).
Provision 5 expounds on duty to self and others. The provisions entail providing care from the patients’ perspective. It calls for healthcare providers to offer care based how they would like to be cared for when in a similar position. It calls for personal efforts for self-growth and also improvement of healthcare quality. Nurses must provide the best quality care as a duty to themselves and to their patients. For this reason, Gunny et al. (2017) argues that a care coordination plan should be tailored to enhance the achievement of healthcare quality goals and duty to self-growth.
Provision 8 advocates for patient safety and protects patients from denial of quality healthcare, discrimination and manipulation during healthcare. It states that everyone irrespective of age, race or status should have access to quality healthcare. The provision also advocates for the provision of unbiased care to all patients. There should be no discrimination or favoritism. A care coordination plan should encompass all individuals and not a segment of the population (Gunny et al., 2017).
The Healthy People 2020 is a policy whose main aim was that by the year 2020, healthcare practitioners were to be able to carry our standard healthcare practices in the right environment. However, as Finney-Rutten et al. (2019) observes, achievement of the Healthy People 2020 initiative is significantly determined by the social determinants.
These social determinants include and are not limited to the availability of social support, healthcare resources, healthcare accessibility, employment, social exclusion, stress factors, and social-economic status. Nursing homes are not limited to conventional care, and as such, social determinants are crucial in the achievement of necessary holistic care. Social determinants are vital aspects of care coordination and care continuum.
Ethical considerations and healthcare policies are indispensable in the process of quality and effective healthcare delivery. They are vital in nursing homes, especially in the planning and implementation of care coordination plan and care continuum. The policies put in place mediate for optimum health outcomes and quality healthcare delivery. The Nursing Code of Ethics is an essential tool in informing nurses’ practice. Social determinants of health provided by the Healthy People Initiative should also form an integral part in the provision of quality healthcare, in addition to enhancing care coordination.
Ethical decisions in designing patient-centered health interventions.
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For this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1. Present the plan to the patient in a face-to-face clinical learning session and collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan Ethical decisions in designing patient-centered health interventions..NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.
Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients Ethical decisions in designing patient-centered health interventions..
Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.
This assessment provides an opportunity for you to apply communication, teaching, and learning best practices to the presentation of a care coordination plan to the patient Ethical decisions in designing patient-centered health interventions..
You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
In this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the patient in a professional, culturally sensitive, and ethical manner.
To prepare for the assessment, consider the patient experience and how you will present the plan. Make sure you schedule time accordingly Ethical decisions in designing patient-centered health interventions..
Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
Note: You are required to complete Assessment 1 before this assessment.
For this assessment:
Reminder: The time you spend presenting your final care coordination plan must be logged in the CORE ELMS system. The total time spent in securing individual participation in this activity in Assessment 1 and presenting your plan in this assessment must be at least three hours. The CORE ELMS link is located in the courseroom navigation menu Ethical decisions in designing patient-centered health interventions..
Please be advised that the Volunteer Experience form requires that you provide the name and contact information for at least one individual with whom you worked as part of your direct clinical activity. Your faculty may reach out to this individual to verify that you have accurately documented and completed your clinical hours Ethical decisions in designing patient-centered health interventions..
Build on the preliminary plan document you created in Assessment 1. Your final plan should be 5–7 pages in length.
Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources.
The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.
Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.
You must submit your hours to the CORE ELMS system before you can complete this assessment and course.
Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course. Ethical decisions in designing patient-centered health interventions.
Jessica has been a nurse practitioner for nearly two decades. She has been providing primary care services to home bound and home limited patients since 2013 with an organization known as MD2U in Evansville, Indiana. In viewing the documentary, The Invisible Patient, Jessica presented herself as a disruptive innovator.
According to Hamric, Hanson, Tracy, & O’Grady, “disruptive innovation transforms an existing market or creates a new market by making processes simpler and improving access” (2014). Jessica took pride in carrying for individuals in the community that were faced with challenges Ethical Dilemma Case Study. In viewing the documentary, I was able to see many of them live in difficult situations.
Some are unable to travel to see a clinician at a doctor’s office for a lot of different reasons. They all had multiple chronic conditions, and all faced some form of poverty. Jessica mentioned several times that there are only a handful of people currently reviving primary health care in their homes. Jessica background was in renal and telemetry medicine at Yale New Haven hospital.
Prior to joining MD2U, she cared for the adult and geriatric population with dementia. She also spent a decade in traditional family practice prior to branching out. If Jessica did not provide her services many of her patients would have frequent admissions to the hospitals or require long term or skilled rehab services.
During the documentary, Jessica displayed respect and empathy to her patients while delivering high quality patient centered care Ethical Dilemma Case Study. Per Jessica, her services are also more cost efficient for the patients, especially since they were on a fix income.
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The ethical dilemma that stuck to to me the most while watching the documentary was the care Jessica provided to the 34-year male Roger Brown. He was diagnosed with muscular dystrophy at four years old. “Muscular dystrophy is a group of diseases that cause progressive weakness and loss of muscular mass” (“Muscular dystrophy”, 2018).
According to “Muscular dystrophy”, the genes are abnormal, and they mutate interfering with the production of proteins needed to form healthy muscle (2018). This disease is very common in young males Ethical Dilemma Case Study. There is no cure, but medications and therapy can try to help manage symptoms and slow the course of the disease.
The normal life expectancy is approximately twenty years, Roger exceeded this. Symptoms may include, “frequent falls, waddling gait, walking on the toes, large calf muscles, muscle pain/stiffness and respiratory complications” (“Muscular dystrophy”, 2018) Ethical Dilemma Case Study. The ethical dilemma faced here was informed consent, “Concerns that patients and their families have not been fully informed about there treatment or clinical prognosis is a common ethical concern for nurses” (“Muscular dystrophy”, 2018).
Often, patients feel more comfortable asking a nurse to decipher what their doctor say because of comprehension, especially with end life decision making. In one party of the documentary Jessica is faced to discuss end of life care with Roger and his mom due to the progression of his disease especially impacting his respiratory status Ethical Dilemma Case Study. Jessica conflict was Rogers age. Normally treating a person of his age, you would take aggressive measures.
But regarding Rogers health, his EF is 20%, fluid buildup, heart failure, kidney stones and generalized pain. He had multiple co-morbidities that Jessica knew if his heart stop beating, performing CPR to prolong his life would cause more harm to him. At first Roger wanted to continue aggressive measures so he could continue his life if he could Ethical Dilemma Case Study. Jessica had to find another approach to assist Roger and his mother to understand the progression of his disease. She helped him understand that he wasn’t getting better regardless of his treatment.
Aggressive measures and hospice/palliative care services are two different treatments. Jessica had a difficult time discussing this because she was fully aware Rogers time was near. She did a great job explaining to Roger and his mother what would happen once he starts to transition. Many people are faced with difficult decision regarding code status, hospice and palliative care services in their lifetime Ethical Dilemma Case Study. End of life should be a smooth transition, but it is often difficult because people find it hard to accept.
One important factor that affects ethical decision making is your personal belief system (Hamric, Hanson, Tracy, & O’Grady, 2014). Your life experiences over a period may change your personal values Hamric, Hanson, Tracy, & O’Grady, 2014). My personal beliefs are inline with Jessica with this ethical dilemma. I feel end of life patients should have pain and symptoms management.
I would also assist the patient and family through the dying and death process, so the anxiety and fear can be decreased like Jessica did Ethical Dilemma Case Study. Advocacy for the patient is key to me. For a person to give great end of life care appropriately, effective communication should take place.
Becoming an adult gerontology nurse practitioner, I will be the spokesperson for my patient and honor their rights and give them dignity. I will ensure my patients are informed on what advance directives and living wills are in case they ever are unable to make a sound decision and they wouldn’t want to put that burden on there love ones.
Everyone should honor a patient wishes as it is not causing any harm. Through education with end of life, DNR, palliative care services, hospice services and advance directives the tales will be eliminated, and anxiety/fear will be decreased (Hamric, Hanson, Tracy, & O’Grady, 2014) Ethical Dilemma Case Study.
One mechanism to overcome barriers is recognizing a patient needs and making patient and families aware of additional services such as palliative care Ethical Dilemma Case Study. It is for patient with life threatening illness. “Patient have better quality of life and live longer and cost the health system less”, with palliative care services (Perrin & Kazonowski, 2015). Barriers to palliative care consultation for patients in critical care include misunderstanding.
Palliative care undermines the focus of saving the patient life is what some feel. Providers often have difficult time determine when critically ill patients are approaching the end of life, often causing patients to die in pain. According to Perrin & Kazonowski, palliative care is an approach that improves the quality of life of patients and their families facing problems associated with life threatening illness (2015). APN can emphasize to families that symptom management care to the patient can improve a patient outcome.
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When the dying process is detected earlier, comfort focused treatment goals are initiated sooner. When appropriate, patients are moved to lower intensity care site (Perrin & Kazonowski, 2015) Ethical Dilemma Case Study. Length of stay in the intensive care unit is decreased (Perrin & Kazonowski, 2015).
Cost of care is reduced because realistic goals are established. Staff would receive support for patients and families. The need for repeat admission could be reduced because treatment goals have been clarified. And lastly, with palliative care the patient and families would have continuity of care with familiar faces because they would be followed from the hospital, to skilled/long term care or home.
Clinicians face ethical and professional dilemmas when they manage their clients who cannot financially afford their care. Actions taken during these situations determine patient’s satisfaction and care quality. Determinants of such actions include the organization’s billing policies, admission policies, and hospital organization among other factors. The case presented is of a young man, 27 years, who requires emergency attention for acute flare-ups of his Crohn’s disease.
However, he is concerned about the costs of the present care because he has not been able to afford the cost of previous prescription medications. The nurse leader has a responsibility to oversee the overall process of nursing care in the department and make critical decisions (Kiwanuka et al., 2020). This patient requires urgent care and my decisions as an advanced nurse practitioner are essential.
The health assessment information required for the diagnosis of this patient includes a subjective assessment of his symptoms and an objective analysis of the signs. Evaluation of symptoms such as pain, rectal bleeding, and vomiting (Burg & Riccoboni, 2017) should be elicited from the patient’s history. Assessment of his sociocultural background would be necessary but after the stabilization of the patient.
An objective analysis of the patient such as vital signs especially temperature and blood pressure, bowel movements, and focused abdominal exam is also required. Investigation of the patient’s electrolytes and electrocardiography would be vital in the emergency setting. Management of pain and administration of corticosteroids would be highly indicated in the patient.
The remaining issues about billing and costs for the care provided would be discussed when the patient is stable and cannot be considered an emergency case. In managing the case, the intervening nurse should consider the need to make a referral for further affordable care, health promotion and patient education, and understanding of the organization’s billing regulations. To promote ethical justice to the patient, consultation with the organization administration may be effective in this case. As Milliken (2018) observe, nurses have an ethical responsibility to be advocates for the patient. To promote affordable care, I would advise the patient about healthcare insurance and assurance policies that would take care of his medical needs at affordable costs.
Evaluation and Management E/M NRNP 6675
WAlden University, LLCStudent NameCollege of Nursing-PMHNP, Walden UniversityNRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
Pathways Mental Health
Psychiatric Patient Evaluation
Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, and has a hard time focusing and concentrating, affecting her job.
Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of a previous rape, isolates, fearful of going outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self, or engaging in anorexic behaviors. No self-mutilation behaviors.
GAD 7= 2 with symptoms rated as no difficulty in functioning
Interpreting the Total Score:
Total Score Interpretation ?10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety
MDQ screen negative
PCL-5 Screen 32
· Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015
· Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing)
· Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records
Any history of substance-related:
· Blackouts: +
· Tremors: –
· DUI: –
· D/T’s: –
· Seizures: –
Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings
.
Education: High School Diploma
Denied current legal issues.
· Suicide gestures in past – no
· Psychiatric diagnosis – yes
· Physical Illness (chronic, medical) – no
· Childhood trauma – yes
· Cognition not intact – no
· Support system – yes
· Unemployment – no
· Stressful life events – yes
· Physical abuse – yes
· Sexual abuse – yes
· Family history of suicide – unknown
· Family history of mental illness – unknown
· Hopelessness – no
· Gender – female
· Marital status – single
· White race
· Access to means
· Substance abuse – in remission
PROTECTIVE FACTORS FOR SUICIDE:
· Absence of psychosis – yes
· Access to adequate health care – yes
· Advice & help seeking – yes
· Resourcefulness/Survival skills – yes
· Children – no
· Sense of responsibility – yes
· Pregnancy – no; last menses one week ago, has Norplant
· Spirituality – yes
· Life satisfaction – “fair amount.”
· Positive coping skills – yes
· Positive social support – yes
· Positive therapeutic relationship – yes
· Future oriented – yes
Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied a history of self-mutilation behaviors
Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence. However, the risk of lethality increased under the context of drugs/alcohol.
No required SAFETY PLAN related to low risk
She denies any current suicidal or homicidal ideation. Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her insight is good.
She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal symptoms, has somatic concerns of GI upset and headaches.
At the time of disposition, the client adamantly denies SI/HI ideations, plans, or intent and has the ability to determine right from wrong and can anticipate the potential consequences of behaviors and actions. She is at low risk for self-harm based on her current clinical presentation and her risk and protective factors.
Double click inside this text box to add/edit text. Delete placeholder text when you add your answers.
· Continue with atomoxetine 80mg PO daily for ADHD. #30 1 RF
Instructed to call and report any adverse reactions.
Future Plan: monitor for decreased re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful
2) Education: Risks and benefits of medications are discussed, including non-treatment. Potential side effects of medications discussed. Verbal informed consent was obtained.
Not to drive or operate dangerous machinery if feeling sedated.
Not to stop the medication abruptly without discussing it with providers.
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings.
Discussed how drugs/ETOH affects mental health, physical health, sleep architecture.
3) Patient was educated about therapy and services of the MHC, including emergent care. Referral was sent via email to the therapy team for PET treatment.
4) Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to the nearest ER or call 911 if they become actively suicidal and/or homicidal.
5) Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand the discussion and appears to have the capacity for decision making via verbal conversation.
6) RTC in 30 days
7) Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago, and include lab results
Patient is amenable with this plan and agrees to follow treatment regimen as discussed.
Information Required in Documentation to Support DSM-5 and ICD-10 Coding
The documentation includes the symptoms of the condition the patient is suffering. The DSM-5 criteria have an 11 items checklist where the severity of patient symptoms is measured. The DSM includes descriptions, symptoms, and other diagnostic criteria for mental disorders (American Psychiatric Association, 2020). It generates consistent and trustworthy diagnoses used in mental disorder research and gives a common vocabulary for physicians to talk about their patients. These documents also allow the physicians to document any behavioral changes. The important aspect is that DSM-V aids doctors in diagnosing behavioral health conditions more precisely (Stewart & DeNisco, 2019). ICD-10, on the other hand, aids billing personnel in accurately coding and billing. Because of these distinctions, an EHR system for a behavioral health provider should have both types of coding.
Missing Information and How It Can Be Helpful to Narrow down Billing and Coding Options
There should be more information about the patient’s strategies to cope with stress and triggers. This information will ensure that if the strategy needs physicians or medication, they are documented for billing (Buppert, 2021). It is also essential to measure whether the patients’ support needs are. Suppose the patient needs more than a 30-day interval between support. It can be accounted for in billing. It will ensure that the patient appointments are appropriately supported. There should also be information on where the failed medication trial occurred and the adherence plan.
Explain How To Improve Documentation To Support Coding And Billing For Maximum Reimbursement
The use of technology will allow physicians to have accurate data collection methods. It is also essential to provide training to the physicians on the key coding compliances and ensure maximization of the reimbursement issues (Pohontsch et al., 2018). There also needs to be a clinical documentation improvement to enhance adequacy and accuracy.
American Psychiatric Association. (2020). Updates to DSM–5 criteria, text, and ICD-10 codes. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5
Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.
Pohontsch, N. J., Zimmermann, T., Jonas, C., Lehmann, M., Löwe, B., & Scherer, M. (2018). Coding of medically unexplained symptoms and somatoform disorders by general practitioners–an exploratory focus group study. BMC family practice, 19(1), 1-11.
Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.
Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.
For this Assignment, you will review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5 to ICD-10
Review this week’s Learning Resources on coding, billing, reimbursement.
Review the E/M patient case scenario provided.
Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.
Then, in 1 – 2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.
Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.
Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
Reimbursement and the appropriate coding to support it are of paramount importance to the business side of the medical field. When a service is provided, a code is used to extract billable information from the medical documentation, which results in insurance reimbursements to the provider. Reimbursement rates and medical coding can be almost as complicated as treating some mental illnesses, and you will need to understand how to accurately code services for documentation, billing, and reimbursement.
This week, you analyze the relationships among documentation, coding, and billing in advanced practice nursing as you practice applying diagnostic criteria and service codes to a case study. You will also evaluate the progress you made on the study plan that you created in NRNP 6665 and develop additional goals to help you prepare for your nurse practitioner national certification exam.
Students will:
Apply DSM-5 diagnosis criteria and ICD-10 codes to patient service documentation
Analyze the relationships among documentation, coding, and billing in advanced practice nursing
Required Readings (click to expand/reduce)
American Psychiatric Association. (2020). Updates to DSM-5 criteria, text and ICD-10 codes. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5
American Psychiatric Association. (2013). Insurance implications of DSM-5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Insurance-Implications-of-DSM-5.pdf
Clicking on this link will initiate the download of the PDF.
American Psychiatric Association. (2020). Coding and reimbursement.
https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement
American Psychiatric Association. (2013). Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM). In Diagnostic and statistical manual of mental disorders (5th ed.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.ICD10Num_list
Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.
Chapter 9, Reimbursement for Nurse Practitioner Services
Centers for Medicare & Medicaid Services. (2020). Your billing responsibilities. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Your-Billing-Responsibilities
Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.
Chapter 15, Reimbursement for Nurse Practitioner Services
Walden University Academic Skills Center. (2017). Developing SMART goals. https://academicguides.waldenu.edu/ld.php?content_id=51901492
Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
Chapter 4 Neuroanatomy, Physiology, and Mental Illness
Document: E/M Patient Case Study
Also Read: Controversy Associated with Dissociative Disorders NRNP 6665
LOE
Strengths/Weaknesses
Feasibility
Conclusion
Recommendation
Huygens, M. W., Vermeulen, J., Swinkels, I. C., Friele, R. D., Van Schayck, O. C., & De Witte, L. P. (2016). Expectations and needs of patients with a chronic disease toward self-management and eHealth for self-management purposes. BMC health services research, 16(1), 1-11. DOI 10.1186/s12913-016-1484-5To evaluate how eHealth is used to support patients in self-management especially in chronic care. Chronic patients need round the clock monitoring due to their chronic condition. eHealth has the capability of monitoring and sending timely messages to nurses and doctors concerning the condition of each patient that use the technology.Investigating the expectations of patients with chronic ailments and their willingness to use eHealth for self-management purposes.Five focus groups comprising individuals with diabetes (n=14) and heart disease (n=9) were used. The researchers also used a separate focus group from patients with chronic conditions. The researchers examined chronic disease impacts on life, patient opinion regarding self-management, and needs and expectations regarding the use of eHealth. The researchers adopted conventional content analysis to understand the data.Groups of people suffering from COPD (n=9), diabetes (n=14), were recruited from four primary care centers around Netherlands. All patients were adults (18 years and above)eHealth- the technology used in monitoring the health of patients with chronic conditions. COPD- Chronic obstructive pulmonary disease-an inflammatory disease that affects the lungs and obstructs air flow to the organ. Measuring of symptoms and the effects of the condition on daily lifeA verbatim transcription of was done for all focus groups. The verbatim transcription was checked against the audio recordings for discrepancies. Researchers independently evaluated each transcript from COPD, diabetes, and heart disease.30 participants between 50 and 80 years old participated in the focus group. Two groups evaluated people with diabetes, another 2 groups analyzed COPD. Most COPD participants had mild to severe case of COPD. 4 participants had high cholesterol and high blood pressureThere were different expectations from different patient groups concerning eHealth and self-management. The use of eHealth greatly depended on the willingness of the participants to use it.The researchers found that there were big differences in the needs and the expectations of patients meaning that the implementation of eHealth technology should be tailored for each group. Based on these differences, there cannot be a ‘fits-all’ solution for everyone hence the need to tailor the eHealth for each group.
Bashir, A., & Bastola, D. R. (2018). Perspectives of nurses toward telehealth efficacy and quality of health care: Pilot study. JMIR Medical Informatics, 6(2), e35. https://doi.org/10.2196/medinform.9080The purpose of this study is to evaluate the effect of telehealth technology on the quality of service delivered by nurses. The study seeks to analyze the evolving roles of nurses as they assume new responsibilities occasioned by the use of information technology.A survey was conducted from nurses through a survey instrument to evaluate the quality of service when telehealth is used.This study is important because it highlights the role that telehealth plays in the provision of quality care for patients.
Data was collected from nurses from a home care agency using interview questions. The researchers did follow-up interviews to ascertain and validate the interview questions.The Visiting Nurse Association-VNA of Omaha was the study site. 13 members of VNA telehealth nursing staff participated in the study.Positive facilitators of telehealth were the major variables in the study. The key variables include; responsiveness, reliability, assurance, and empathy. Measuring these parameters helped the researchers to evaluate the link between the quality of telehealth.Measurement of the variables was scored on the level of responsiveness of the participants.The perceived services and consumer expectations is the major component of the study and is measured by the willingness of consumers to use telehealth.
The study provided weblink for the survey which was given through email to all the VNA participant nurses. 13 nurses took part in the survey.The survey was generated using a Web-based software tool; Survey Monkey was used to generate a web-based software tool for the study. . The data were processed through SPSS version 22. The gaps, expectations, and perceptions, were calculated.
The results of the study were positive based on the mean differences between perception and expectation.In the past, SERVQUAL tools have been found as a reliable and valid measure of SQ. This is because of factors such as the dimensionality, item compositions, validity, and disconfirmation paradigm used in its measurement. The “type of technology” has a direct effect on barrier reduction, attitudes, and quality and quantity of communication.
SERVQUAL instrument proved to be the best criterion for assessing TNSQ. This tool not only estimated the level of satisfaction but also identified situations where perceptions exceeded expectations.Shea, S., Weinstock, R. S., Teresi, J. A., Palmas, W., Starren, J., Cimino, J. J., Lai, A. M., Field, L., Morin, P. C., Goland, R., Izquierdo, R. E., Ebner, S., Silver, S., Petkova, E., Kong, J., & Eimicke, J. P. (2009). A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study. Journal of American Medical Information Association, 16(4), 446–456. doi:10.1197/jamia.m3157 To find out if telemedicine technology can offer chronic patients with an effective case management service.Today, patients have an array of hospital-based technology from which they can get information on health matters. Through telemedicine and other technologies, patients have access to personal health records that they can directly access and utilize.The researchers performed a randomized and controlled test that compares telemedicine to the usual care services. A total of 1,665 recipients of medicare suffering from diabetes participated in the study. The participant chosen for the study were all aged 55 years and above. They were drawn from the federally designated areas of New York that are underserved medically.Diabetes was chosen as the ideal clinical target for the IDEATEL. The results would be determined by the consumption of the technology and how much it contributed to the health of the patients.Measuring the variable depended on how much information the participants gathered about their condition. The more information a participant had, the better the outcome of their health improvement.Covariance was used to determine and adjust appropriately the baseline values used in the clustering process. The heterogeneity of groups and all other residual variances were modeled to accommodate model assumptions. The researchers found that the usual care groups together with the intervention did not bear much difference to the baseline demographic. The researchers found that case management of diabetes delivered through telemedicine greatly improved the hemoglobin level.
The study took into consideration the comparison between treatments delivered through telemedicine and in-person delivery of diabetes treatment. The design of the study allowed it to be feasible given the expansive geographic span of New York.
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Clinical practice guidelines have numerous advantages for practicing nurses. Practice guidelines offer practicing nurses the opportunity to focus on the provision of quality healthcare. Besides, practice guidelines promote rational use of resources by clinical staff. Evidence-Based Practice Guidelines-CPG are unique statements created to help nursing practitioners to make effective decisions concerning the healthcare provided to patients. Today, EBP is a critical part of nursing practice because it impacts the provision of quality healthcare to patients.
CPGS not only reduce costs to patients but also impact patient outcomes (Brook, R., & Rajagopalan, 2018). This paper is a critique of the journal article Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association obtained from clinical practice guidelines and the National Guideline Clearinghouse
The purpose of this study was to create a clinical guideline for the assessment, control, and monitoring of factors that contribute to the severity of High blood pressure. The study also aimed at developing the appropriate pharmacologic treatment plan for the disease. Being the most common respiratory disease in the US, High blood pressure remains a dangerous chronic inflammatory disease that affects millions of people across America and Canada. This study contains a comprehensive description of what cancer is, its causes, and the best pharmacology treatment for the disease.
The study was conducted in Canada based on the Canadian Community Health Survey that revealed that close to 10% of Canadians suffer from some form of High blood pressure. The study was conducted among young and old Canadians to find out the prevalence of the disease in these demographic groups. The epidemiological evidence from the study showed that young people below 19 years and old people above 60 years are the most affected by this respiratory problem.
The study was conducted in Canada to evaluate the number of deaths caused by High blood pressure annually. Up to 10% of the Canadian population is affected by High blood pressure. A recent cohort study done in Ontario revealed that the prevalence of High blood pressure has increased to 55% from a low of 8.5% in 2003. High blood pressure is a respiratory problem that affects the airways causing difficulty in breathing. T helper cells are associated with High blood pressure and affect immune responses. There are many triggers for High blood pressure such as dust, dander from animals, cockroach residue, pollen from plants, and cold air in some people.
The research question is presented in the study. The authors pose the question, “do the prenatal risk factors increase the chance of High blood pressure attack in children”. To answer this question, the research identifies up to 5 clinical High blood pressure phenotypes that differ distinctly from a lung infection. There is the non-atopic phenotype that represents the groups of children that experience wheezing episodes.
In a research study, a population is defined as a set of elements (People or objects) that have similar characteristics as quantified by a researcher. On the other hand, the word sample in research refers to selected objects or elements chosen to participate in a study. This study sought to capture the experiences of older men and young children working in Ontario Canada. The study was conducted among 150 old adults and children in Ontario and the West South Central region of the United States of America.
This region is 443,501 square miles in size with a combined population of about forty-five million inhabitants. Owing to its huge size, it would be impossible to interview all the women in the oil and gas industry in the entire West South Central States. A total of 150 old people and children were randomly selected to participate in the study by way of an interview to collect and capture their lived and personal experiences with High blood pressure.
According to the American College of Cardiology-ACC and American Heart Association-AHA., the best methods for measuring the impact of Evidence-based practice Clinical guidelines is through scientific measurement of patient outcomes. The authors assert that the implementation of EBPCG can only work when it is practiced by nurses and patients. The impact factor, in this case, is measured based on the number of citations present in the research or paper. In this work, such metrics provide a reliable and effective method of measuring the impact that clinical guidelines have on scientific research on evidence-based practice.
However, the AHA and ACC point out that the growth of analytical tools used in harvesting information from online databases has helped the research on Evidence-based practice Clinical guidelines to take a multi-disciplinary approach such as sociological approach, scientific approach, structural approach, and technological approach. The two institutions continue to assert that “most importantly, discoveries in the basic science of AD would be entirely impotent without close collaborations with investigators in translational, clinical, and public health disciplines.’ (American College of Cardiology-ACC and American Heart Association, 2017). This statement is conclusive and takes into consideration the work of individual researchers as critical additions to research on EVPCG.
According to Victoria and her fellow researchers, this research is the first RCT-based test done to find out the efficacy usefulness of web-based online intervention programs for caregivers compared to face-to-face interventions. According to the authors, the results of the test were a great success because control implementation error was taken care of. The authors assert that by controlling the information viewed by caregivers in a specific schedule. Victoria and her fellow researchers further assert that the contents of the website continued to remain static for the period of the test which further eliminated any errors. According to Garity (2006), the stress in caregivers of people living with Evidence-based practice Clinical guidelines is the same irrespective of the approach used to educate them. Based on this argument, it is not acceptable for Victoria and her fellow researchers to conclude that their research is 100% fault-free.
According to Creswell (2009), the best research methods which should be used in qualitative research include observations, interviews, and review of existing literature (Creswell, 2017). Accordingly, this research used a combination of the three methods mentioned above to come up with comprehensive and valid research. Interviews by far are the most used method to capture data in qualitative studies. This study entailed the researcher going to the field to conduct interviews with the chosen participants.
Another source of data that this research relied on to a big extent is observation. Observation is important to this research as it accorded the researcher the opportunity to observe first-hand the subjects as well as their natural environment which in this case was their workplaces. The observation was done via watching and taking down notes and also video recording the interviews as well as the environment of the participants to get a feel of the environment.
The observation was important to this study because it helped to reduce any biases that may have been formed before interaction with the participants. Apart from interviews and observation, a review of existing documents or literature played a pivotal role in shaping the direction of this research. A review of the literature gave the researcher a deep understanding of the phenomena and giving the researcher the much-needed background information for the study.
In this article, the American College of Cardiology-ACC and American Heart Association asserts that the continued use of the evolved format to present guidelines contributes a chunk of knowledge to EBPCG. The authors provided that each modular presentation is effectively represented through a combination of tools such as tables and flow diagrams where appropriate. To become more valid, the presentation contains a table of associated recommendations, a synopsis of the problem, and recommendations that are specific to the case study.
Interviews, observation, and review of existing documents were chosen as the most appropriate for this study because of the numerous benefits they presented to the researcher. Top of the benefits list that made these methods the best fit for this research is the fact that the researcher was able to get first-hand information from the respondents themselves. The researcher got the opportunity to immerse themselves in the world of the women being interviewed and was able to observe both the subject as well as the environment within which the respondents operated from.
The observation was particularly pivotal for this research because it allowed the researcher to observe what was going on rather than just relying on what one has been told by the respondents which may be biased in opinion (Reboussin et al., 2018). These sources also allowed the researcher to be able to narrow down the research to be more specific which in turn helped the researcher to decide the direction of the research and be able to make amendments as necessary before final data could be gathered for analysis. Additionally, these methods were chosen over other methods because they come with a high degree of reliability. They are deemed reliable because the researcher relies on what he has observed and recorded.
The calculation of descriptive statistics was done from a pool of co-publications which also contained the total number of publications every year. The data obtained from the co-publication networks were then fed to a linear regression line of 0.9567 being the value of R2. Investigators lying within a certain ADC network were then linked to other researchers or investigators who published a book together with another investigator (Quirt et al., 2018). The researchers then observed the percent of all nodes connected to the largest network or cluster which according to them had recorded growth compared to individual researchers. Based on this metric, Hughes and his teammates concluded that the level of connectivity interaction between ADC co-authors publications has tremendously increased.
For this study, participants were put in two randomized offline parallel groups using a computer-generated list which uses blocking as well as stratification i.e. categorizing the caregivers as either being relatives on non-relatives of the people with Evidence-based practice Clinical guidelines. Each group was given ten-minute training on how to operate the website. Every week, each participant read through an entire session before printing out a questionnaire to indicate how satisfied they were with both the training and the website.
The study was used stress and coping theory by Lazarus and Folkman as well Bandura’s self-efficacy model to ascertain the stress levels, self-efficacy, burden, and health issues in such caregivers (Cristancho-Lacroix, et al, 2015). The findings did not reveal any significant difference in PSS-14 (self-perceived stress) which means that it still needs further research to bring it to acceptable levels. This pilot research aimed to evaluate what impact the Diapason program would have on caregivers as far as helping them to deal with stress is concerned. The program was meant to offer skills, information, training, and a forum for caregivers to find a valuable platform to help them reduce their stress and burden.
Intention-to-treat analysis was the method used to analyze all available data. Calculations for means and percentages or descriptive data were also calculated for each caregiver as the characteristics found in PWADS. Besides, Victoria and fellow researchers relied heavily on Mann-Whitney tests (popularly called t-tests) as well as Spearman correlations were the main method used for identifying correlations between the variables. Face-to-face interventions allow researchers to control the level of bias which is something Victoria and her co-researchers did not achieve with success in their online-based intervention (Whelton et al., 2015). Furthermore, due to the heterogeneous nature of caregivers, future studies must limit the criteria of inclusion.
The researchers concluded that as the number of High blood pressure rises in America, so does the number of collaborating researchers on Evidence-based practice Clinical guidelines. According to Hughes and his fellow researchers, the number of nodes linked to each cluster especially the major cluster is proof of collaboration between researchers. The researchers do agree that their research lacks adequately in the area of statistical power which could pose problems of efficacy to the research. This notwithstanding, the researchers believe that this research has been largely successful in providing an alternative method for providing information and education to caregivers of people suffering from Evidence-based practice Clinical guidelines, especially the informal caregivers.
The researchers believe that they have demonstrated with a success that online facilitation of caregivers can help them to acquire functionalities such as personalization, flexibility, socialization, and dynamism which are all important qualities in a caregiver given the stress levels associated with Evidence-based practice Clinical guidelines. Furthermore, the researchers conclude that there was a very limited acceptance of the online Diapason program by caregivers which is a pointer to the fact that the program needs to be rolled out in a structural manner that allows the caregivers to be able to interact with other professionals as well as the broader online community.
Caring for people using Evidence-based practice Clinical guidelines -EVPCG is cost-effective and increases patient outcomes. Over five million Americans and thirty-five million people worldwide suffer from High blood pressure meaning that these people require some form of caring whether formally or informally. Caring for people through Evidence-based practice Clinical guidelines -EVPCG is the best way to combat High blood pressure since people do not even have basic information on how to take care of people suffering from the disease.
Caring for people with High blood pressure people takes two approaches; formal and informal care. Authors Victoria Cristancho-Lacroix, Jeremy Wrobel, Inge Cantegreil-Kallen, Timothee Dub, Alexandra Rouquette, and Anne-Sophie Rigaud analyze the efficacy and acceptability of web-based educational programs intended for informal caregivers to people with Evidence-based practice Clinical guidelines using methods of research analysis.
According to Victoria Cristancho and her fellow researchers, the world has seen substantial growth in the number of High blood pressure which presents problems to nations. All of these people require round-the-clock care just to get by. By the year 2017 AHA indicated that over 12 million caregivers gave more than 17.5 billion hours of care (unpaid) which was equivalent to USD 216 billion. Presently, a majority of people with High blood pressure are cared for at home by their relatives which has also seen the emergence of chronic stress in such caregivers. Based on this, Victoria and fellow researchers researched to find out if a web-based intervention program for caregivers is just as good as face-to-face interventions.
Evidence-Based Practice-Clinical Guidelines is a critical tool used by nurses to assess patients and offer the best treatment plans that capture their problems. For ultimate results, both nurses and patients must practice EBPCG. Evidence-Based Practice-Clinical Guidelines guide practicing nurses to offer quality healthcare to patients. Besides, nurses that use Evidence-Based clinical guidelines have a better grasp of their duties and responsibilities meaning that they have a great impact on patient outcomes.
Intravenous line is an easy procedure which nurses encounter daily in practice. This occurs either during administration of medications or during fixing of intravenous lines. However, nurses are vulnerable to inappropriately preparing and pushing medications. This can be due to lack of knowledge and skills of IV drug preparation and safe use of IV lines. Also, lack of standards of IV-line insertion and usage and miscommunication between health care professionals is a contributing factor. This can lead to harm of the patients which is against the ethics of practice (Pezeshkmehr, 2021). As identified by Boström et al. (2020), some of the complications of IV lines include thrombophlebitis, limb ischemia due to a retained tourniquet in the arm of the patient and misconnection due to poor communication and documentation. Despite the presence of multiple guidelines on IV lines insertion and maintenance, nurses and other health care professionals still experience IV-line related complication which can bring in the individual factor in rates of IV-line related complications. Peripheral venous line complications account for up to 69% of premature access failure in hospitals (Ray-Barruel et al., 2019).
The proposal will aim to first identify how confident the nurses are that they have the required knowledge and skills to safely fix and use IV lines without causing adverse complications to the patient. The skills, according to Osti et al. (2018), include site identification, cleaning of the site, proper insertion technique, management of the line after insertion and possible complications of poor line insertion. In addition, it will identify the percentage of nurses who at one point in practice have experienced an infection at the site of line insertion and how they managed it. It will also assess the possible misconnections which they have experienced in their lifetime during practice. In addition, it will evaluate the importance of having a care plan in each hospital for IV lines.
The care plan includes assessing the patient which involves looking at the patient clinical status and educating the patient on care for IV line. The second part of the care plan is choosing correct IV line and site for insertion. Large IV lines have a possibility of rupturing small veins hence causing irritation while small IV lines are not best to give fast infusion or even blood due to the possibility of breakdown of blood products termed as hemolysis (Morgaonkar et al., 2017). Next is the intervention which involves cleaning IV lines before use, ensuring they are patent, and assessing them daily for signs of infections. The last part is evaluating whether the patient has understood the instructions and whether the site is developing infections.
Even though most nurses have knowledge of IV-line use and complications, some lack the necessary skills to insert and maintain an IV line without complications. Also, patient consent is sometimes neglected. In addition, nurses have at one time or another experienced insertion site infection and thrombophlebitis which can be avoided. It is an expectation that nurses should have the necessary knowledge and skills to fix IV lines and take care of them as it is central to evidence based nursing practice. In case some lack the required skills, measures can be made to help train them to better nurses who are competent.
The most appropriate data collection tool for this proposal will be interviews and checklist. Other tools which may be appropriate during the study will be questionnaires and reports and existing data. Interviews with a checklist is appropriate because it is simple and able to get the relevant information from the participants. Also, it is cheap and less time is required. From the data collected in the checklist during interviews, analysis can be done to come up with a conclusion hence leading a better and well-informed evidence-based practice. Interviews are reliable because you get the information directly from participant hence no second party information.
The statistical test of choice is multiple regression test. This is especially essential for quantitative data helping to know the effect of lack of enough knowledge and skills on the number of IV-line related complications amongst the nurses. This will help in coming into conclusion whether there is need for more training on IV lines protocols and the need for development of a standardized guidelines for IV-line use in all health care facilities (Feinsmith, et al., 2018). A chi square test can also be used to compare rates of IV-line related complications amongst those who feel they have enough knowledge and skills on IV lines and those who do not.
Using the checklist as the data collection tool, the methods which are planned to be used include using open or closed ended questions in interviews, observation by volunteer groups, following up patients on IV lines for possible complications and using online methods to reach clients. This will help reach a high number of nurses hence increasing the success rate and quality of the results collected. In addition, consent will be taken from the nurses so as to participate in the project with confidentiality maintained.
One will be the evaluation for the cause of the unexpected outcome including conflict of interests. This will then be reported early and possible plan for correcting it made. Also, it will involve evaluating the whole process taken in the project to identify reasons for the lack of expected outcomes hence mitigation measures to avoid it. Overall in case of lack of expected outcome, a recommendation for further research on the field to be done to help come up with better guidelines which are evidence based.
The proposed solutions to fixing the problem including developing a training schedule for nurses about IV lines and this include both during trainings in nursing training institutions and during practice. In addition, a proposed protocol for improving IV access include evaluation of the patient, intervention and reevaluation. When this process is used, less complications of IV lines will be experienced and if they happen, they will be recognized early. The plans will involve making policies in consultation with hospital managers to develop a standard guideline for IV drug use. This will help build a better plan which will last for future generations.
Additionaly, further research and evidence will help revise the guidelines and incase the recommendation needs to be stopped, it will be based on the evidence provided. The proposed solution can be discontinued in case a better proposal guiding IV-line insertion and usage is developed. To help extend the proposed solutions, changes can be made based on research to make it more applicable, affordable and easy to implement hence better patient outcome.
The underlying clinical question for the proposed study is that for children aged between 5 and 15 years, in severe acute asthma refractory to nebulization by SABA/LAMA combination, how effective is using IV methylprednisolone alone versus IV methylprednisolone and heliox at reducing respiratory difficulties over a period of one hour of admission? Severe acute asthma is a clinical condition that can easily be managed using various therapies.
Nonetheless, poor management of severe acute asthma in children can also cause death upon cardiorespiratory collapse. When managing severe acute asthma in children, the therapies often target to increase air passage through oxygen supplementation and bronchodilators dilation. As per Batabyal & O’Connell (2018), the different therapies for severe acute asthma in children of aged 5-15 years should enable the patient to achieve a stable breathing condition.
There are only limited treatment therapies for acute severe asthma refractory to SAA/LAMA combination because the other ones are either prohibitively expensive or unsafe. But because the patients must be treated, physicians are often left with the choice of either IV steroids with or without heliox. This explains why many pieces of research have focused on IV methylprednisolone and heliox as the two most feasible options for treating acute severe asthma in children of age between 5-15 years old.
Using corticosteroids as a treatment option for severe acute asthma in children has however been well-established. Several clinical trials have investigated the benefits of corticosteroids and have provided indications of early improvement in peak expiration flow rates, reduced hospital admission, reduced morbidity, and decreased use of beta agonists (Fishe et al. 2019a). Some practitioners strongly believe that when presented with acute asthma exacerbations, intravenous corticosteroids should be a number one option for achieving the desired pharmacologic effect. However, other piece literature has revealed that this should not be the case (Ferrante & La Grutta 2018, Kenyon et al. 2020).
Specifically, according to Doymaz et al. (2020), corticosteroids should not be a top of the list option for acuter severe asthma exacerbation because their early onset of pharmacologic effects have not been confirmed. Specifically, corticosteroids have been suspected to alter leukocyte function, decrease vascular permeability and inhibition of arachadon acid pathway (Fishe et al. 2019b). Henderson et al. (2018) observed that corticosteroids cause a leukocyte response peak effect within 4-6 hours after administration, which is a delayed pharmacologic response.
Published guidelines and expert opinion on the treatment of acute asthma exacerbations recommend the use of oral corticosteroids within the first 48 hours of treatment (Tesse et al. 2018). However, according to Indinnimeo et al. (2018), some practitioners are hesitant on using oral therapy. Ideally, this hesitation is attributable to a perceived delay in the action onset, a longer duration of hospitalization associated with the use of oral corticosteroids, and potentially decreased potency of the therapy (Leung, 2021).
Some other trials (Ferrante & La Grutta 2018, Kenyon et al. 2020) have demonstrated a few therapeutic equivalencies of intravenous and oral corticosteroids, demonstrating similar improvements in peak expiratory flow rates, and forced expiratory volumes within one second (FEV1) between intravenous and oral groups. However, only a few of the studies have assessed the clinical outcomes of these therapies such as length of hospital stay.
There is an established threshold in the management of acute severe asthma in children of age 5-15 years, that any therapy must be able to achieve. First, early treatment of asthma exacerbations is the best treatment strategy, and there are various important elements of early treatment that any therapeutic intervention must observe. For example, the therapy must be able to relieve hypoxemia when the patient is experiencing mild to severe exacerbations (Leung, 2021).
Similarly, according to Seliem & Sultan (2018), SABA must be able to reverse airflow obstruction, especially during severe exacerbations where additional inhaled ipratropium bromide is used. The corticosteroids must be able to reduce airway inflammation, especially in patients who fail to respond to SABA (Ferrante & La Grutta 2018, Kenyon et al. 2020). more importantly, the therapy must be able to prevent the relapse of exacerbation through follow-up care.
Since the 1940s, corticosteroids have been the widely used treatment of acute severe asthma. However, the long-term systemic use of corticosteroids such as IV methylprednisolone have been associated with adverse events such as adrenal suppression, and even cardiovascular disease (Ferrante & La Grutta 2018). As a result, clinicians have often questioned the mechanism of action of as well as their side effects to refute or support the use of IV methylprednisolone or heliox.
Typically, corticosteroids are synthetic analogue of the natural steroid hormones produced in the body within the adrenal cortex. Their synthetic compounds are like those of natural hormones and may have mineralocorticoid or glucocorticoid properties (Seliem & Sultan, 2018). According to Batabyal & O’Connell (2018), Mineralocorticoids affect ion transportation in the renal tubule’s epithelial cells and are majorly involve water balance and electrolyte regulation. On the other hand, glucocorticoids are primarily involved in protein and fat metabolism, with anti-proliferative, immunosuppressive, and anti-inflammatory properties.
Most of the immunosuppressive and anti-inflammatory actions of glucocorticoids are either directly or indirectly attributable to the interaction with the cytosolic glucocorticoid receptors, which changes the gene transcription to either repress or indue gene transcription in both structural cells and inflammatory leukocytes (Seliem & Sultan, 2018). Therefore, glucocorticoid have a clinical effect on asthma primarily by upregulating the transcription of anti-inflammatory genes to cause a downstream reduction in the number of pro-inflammatory chemokine and cytokine proteins, cell adhesion molecules and other important enzymes that initiate or maintain the host’s inflammatory response.
There are several side effects of systemic corticosteroids in children and adolescents that must be examined to evaluate whether IV methylprednisolone and/or heliox is effective in respiratory difficulties in children of age 5-15 years. For instance, the paediatric population receiving IV glucocorticoids such as IV methylprednisolone have been associated with growth suppression, which manifests in delay in growth among children with asthma as well as those with other diseases such as nephrotic syndrome (Leung, 2021). Evidence by Lew et al. (2021) also suggest that the final height of children with a history of glucocorticoid may have compromised final height.
An underlying hypothesis is that both IV methylprednisolone alone and IV methylprednisolone and heliox can reduce respiratory difficulties over a period of one hour of admission. However, considering the evidence on the side effects associated with systemic corticosteroids, practitioners must have evidence-based recommendations on how they can safely use the therapies to treat paediatric asthma.
But before any long-term use of systemic corticosteroids, the physician must have a thorough physical and patient history evaluation to examine the pre-existing conditions or risk factors that may be exacerbated by corticosteroids therapies including osteoporosis, affective disorders, dyslipidemia, and diabetes (Seliem & Sultan, 2018). According to Batabyal & O’Connell (2018), the use of corticosteroids must be preceded with thorough baseline measures such as height, body weight as well as blood pressure, alongside other important information such as blood glucose levels, pubertal status and nutritional status, lipid profile and complete blood count.
It is also important to assess the children’s exposure or symptoms of serious infections before the use of corticosteroids because they are usually contraindicated in patients with untreated systemic infections. According to Serebrisky & Wiznia (2019), patients without a history of chicken pox should avoid close contact to those with shingles or chicken pox, with a caution to seek immediate medical attention in case they do. Physicians should also be keen on concomitant use of other medications before initiating any corticosteroids therapy because existing research has shown drug interactions between corticosteroids and various drug classes.
IV methylprednisolone alone and IV methylprednisolone and heliox seem to be effective at reducing respiratory difficulties during acute asthma exacerbation in children of age 5-15 and may therefore be a good adjunctive therapy in for paediatric asthma management. However, while either IV methylprednisolone alone or IV methylprednisolone and heliox may be a viable constructive treatment option for emergency asthma treatment in children of age 5 – 15, physicians must be cautious of the various side effects associated with these therapies.
For example, IV glucocorticoids have been associated with a delay in growth among children with asthma as well as those with other diseases such as nephrotic syndrome. Also, systemic corticosteroids have been associated with perceived delay in the action onset, a longer duration of hospitalization associated with the use of oral corticosteroids, and potentially decreased potency of the therapy. The proposed investigation will delve into the benefits and side effects of IV methylprednisolone alone or IV methylprednisolone and heliox for managing acute severe asthma in children of age 5 – 15, before coming up with a comprehensive and evidence-based conclusion on which one among the two treatment regimens is more effective.