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Advanced Pharmacology Asthma Discussion Paper

Advanced Pharmacology: Asthma

Among the appropriate pharmacological therapies to be prescribed for Johnathan is STEP therapy as recommended by EPR3, which places him in step three, due to his known use of Albuterol that is in step 1. Further, with a viral asthmatic attack, an inhaled corticosteroid (ICS) is recommended, which could be administered via a nebulizer machine (Lizzo & Cortes, 2020). The above, in combination with a leukotrine receptor antagonist (LTRA) would increase the efficacy of ICS.

Asthma exacerbation presents as medical emergency, which necessitates prompt treatment. Jonathan and his mother will therefore need to understand the need for an ICS inhaler even while in school. She also needs to know the need to involve the teacher in the management of Johnathan’s condition, in case of an exacerbation in school. Spirometric indices such as forced exhalation volume are integral in the assessment of asthma especially among children. EPR3 recommends this test among children above 5 years to measure the lung functionality through breath volumes using a spirometer (Dinakar & Chipps, 2017).

Asthma is classified on frequency of exacerbations and severity (Oksel et al., 2018). Mild intermittent asthma presents mildly for less than 2 days a week, resolving spontaneously. This type does not hinder performance of daily activities and includes exercise-induced asthma. Mild persistent asthma presents symptomatically more than twice a week, with symptoms persisting more than a day. Moderately persistent asthma presents symptomatically in most days of the week and at least one night each week. Severe persistent asthma, the most chronic, presents almost every day and severally at night. This type does not respond well to medications.

Johnathan’s mother needs education on the need to change the inhaler to an ICS inhaler. She also should be made aware of benefits of including Johnathan’s teacher in care for Johnathan. This will ease the use and storage of the inhaler in school setup. She also should be educated on the need to prevent Johnathan from contracting URTI from family and friends due to his sensitivity and vulnerability. The plan of care for Jonathan will include pharmacological management and health education. Pharmacological therapy will address the attack as an emergency, as well as prevention of future occurrences.

References

• Dinakar, C. & Chipps, B. (2017). Clinical Tools to Assess Asthma Control in Children. Pediatrics. 139 (1) e20163438; DOI: https://doi.org/10.1542/peds.2016-3438
• Lizzo, J. M. & Cortes, S. (2020). Pediatric Asthma. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551631/
• Oksel, C., Haider, S., Fontanella, S., Frainay, C., & Custovic, A. (2018). Classification of Pediatric Asthma: From Phenotype Discovery to Clinical Practice. Frontiers in Pediatrics, 6(258), 258–. doi:10.3389/fped.2018.00258

Adoption Sample Paper

The biggest psychological issue of adoption on children is mental and emotional trauma. Younger children such as infants may not experience trauma from adoption because they may not recall the ordeal. However, older children often have vivid memories of the process and may experience the trauma associated with losing a parent or being separated from a biological parent. Another common psychological problem associated with adoption is the identity problem (Anthony et al., 2020). Adopted children have to forget their history and ‘rewrite’ new ones as they struggle to fit into their new environment.

Dealing with Mental/Emotional Trauma in Adoption

Being a traumatic experience for a child, adoption affects childhood brain development. If not dealt with early, the trauma may make a child resort to negative behavior such as truancy, risky sexual behavior, and drug use. The best method of dealing with adoption trauma is by providing a home environment that exudes stability, support and understanding, nurturance, and predictability. Such an environment, as Sargent (2019) opines, helps a child to heal and adapt to their new environment. The efficacy of this intervention method draws from the fact that it helps a child to erase their old memories gracefully while creating pleasant new ones. The only remedy for helping adopted children deal with adoption trauma is to ensure that they are happy in their new environment. Loving and happy environments help adopted children forget their past traumatic experiences.

Treatment Options available for Adopted Children and Adolescents

One of the best intervention/treatment options for adopted children is behavioral family therapy. This technique is superior to other therapies such as the standard psychodynamic therapy and client-centered therapy because it uses operant principles (Dowell et al., 2018). Operant conditioning is a technique where the consequence is used as a motivation for behavior. A foster parent can leverage this concept by demonstrating certain desired behaviors to an adopted child. The parent then motivates the child to follow the demonstrated behavior. At the same time, the parent makes it clear to the child that following the demonstrated behavior is rewarded positively while doing the opposite attracts punishment. This method depends heavily on positive reinforcement of behavior, punishment for wrong-doing, and rewards for doing right. Foster parents need to create a stable and loving environment for adopted children to nurture love and discipline.

Explain how Culture influence Adoption

Cultural beliefs influence adoption positively or negatively. In some societies, adopted children cannot hold the same statuses as biological children. For example, some cultures may not permit adopted children to inherit their parent’s wealth as would biological children. In some societies, adopted children are not permitted to take the name of their adopted parents due to a lack of blood relationship. These practices are not healthy for children because they lead to long-term emotional trauma (Ma, 2017). Another critical cultural factor in adoption is the cross-cultural response to adoption. Some cultures are not yet open to adopting children from different ethnic and racial backgrounds. Furthermore, cross-cultural adoption raises pertinent questions about culture, class, and race, an aspect that makes the issue of identity a critical factor for adopted children. Further, cross-cultural adoption exposes children to anxiety and stress as they try to fit in their new environment.

References

• Anthony, R., Paine, A., Westlake, M., Lowthian, E., & Shelton, K. (2020). Patterns of adversity and post-traumatic stress among children adopted from care. Child Abuse & Neglect, 104795. https://doi.org/10.1016/j.chiabu.2020.104795
• Dowell, T., Donovan, C., Farrell, L., & Waters, A. (2018). Treatment of Anxiety in Children and Adolescents. Current Treatment Options In Psychiatry, 5(1), 98-112. https://doi.org/10.1007/s40501-018-0136-2
• Ma, K. (2017). Korean Intercountry Adoption History: Culture, Practice, and Implications. Families In Society: The Journal Of Contemporary Social Services, 98(3), 243-251. https://doi.org/10.1606/1044-3894.2017.98.25
• Sargent, J. (2019). 8.4 ADOPTION: WORKING WITH FAMILIES TO PROMOTE CONNECTIONS AND COMPETENCE. Journal Of The American Academy Of Child & Adolescent Psychiatry, 58(10), S145-S146. https://doi.org/10.1016/j.jaac.2019.07.675

Advanced Pharmacology Discussions

Discussion 1

Howard appears to have chronic pain which needs multidisciplinary approach. All clients presenting with chronic pain require an extensive physical evaluation including neurological, cardiovascular, renal and mental status examination to try and identify underlying etiologies and associated features such as decreased overall physical and mental function, depression, sleep disturbances and fatigue (Henry et al., 2017). In addition, Howard complains of previous ulcer problem hence pain medications that cause gastric irritation such as Non-Steroidal Anti-inflammatory Drugs (NSAIDs) should be avoided.

Five schedules of controlled substances exist in their decreasing order of potential risk for addiction and dependence according to the united Nations classification of drugs (Uzuegbu-Wilson, 2019). Schedule 1 medications include Marijuana, Heroine, Methaqualone, Mescaline, Lysergic acid etc. Schedule 2 medications are the opioid class, including morphine, meperidine, fentanyl, hydromorphone and barbiturates such as pentobarbital. Schedule 3 medications are easily prescribed and include ketamine and anabolic steroids. Schedule 4 medications include benzodiazepines and tramadol. Finally, schedule 5 drugs are less likely to be misused and include drugs with codeine less than 200mg per 100 ml, pregabalin.

A long-acting narcotic will be a valuable prescription to this patient over the short acting. This helps to improve compliance, reduces opioid overdose and dependence associated with habit forming potential of the short acting drugs.

Discussion 2

Howard can benefit from analgesics such as paracetamol and adjuncts of pain management such as corticosteroids, antidepressants, anticonvulsants and skeletal muscle relaxants (Weyker & Webb, 2018). For such, advise the patient on the side effects of the above drugs and advise the patient to take the drugs as instructed by the physician.

According to WHO analgesic ladder and opioid crisis, which specifies treatment on pain intensity, Step 1 entails Non-opioid alongside optional adjuvant analgesics, which are recommended for mild pain. Step 2 entail Weak opioid medications alongside non-opioid and adjuvant analgesics, recommended for mild to moderate pain. Step 3 entail Strong opioid medications alongside non-opioid and adjuvant analgesics recommended for moderate to severe pain. For this patient, I would recommend step 2 and even step 3 depending on the response.

Discussion 3

Screening tools available include abnormal urine testing and opioid risk tool score. The former being most reliable because the sample is collected from the patient and subjected to laboratory testing (Kaye, 2017).

Substance abuse problem is a complex but manageable condition that affect the brain behavior and function. At first, I will consider a rehabilitation program for Howard. Howard will also benefit from counselling services and behavioral therapies. In addition, I will constantly evaluate his mental status and treat any underlying anxiety and depression. Withdrawal medications and devices for treatment of withdrawal symptoms cannot be ignored. Long term follow-up strategies to prevent relapse is ideal as well (NIDA, 2019).

I will refer Howard to a psychiatrist to try and institute cognitive behavioral and psychotherapy. Howard will also see a neurologist and a physician to assess his neurological health status and prescribe any withdrawal medications.

Discussion 4

The use of epidural injections as a way of managing chronic pain permits the use of smaller doses of other analgesics including opioids to reduce their toxicity (Weyker & Webb, 2018). This, therefore means that I will prescribe smaller doses of narcotics to Howard.

Howard can also be given alpha-2 adrenergic agonists such as clonidine, botulinum toxin and neuroleptics such as haloperidol and fluphenazine. Acupuncture, cognitive and behavioral therapy, heat and cold, assistance with vocational training, exercises, music, hypnosis, relaxation and biofeedback techniques (Gokhale, 2017) will all be of help to Howard.

Discussion 5

Substance abuse programs for Howard include family therapy, cognitive behavioral therapy, group therapy, individual therapy in addition to harm reduction model and inpatient addiction treatment (Miller, 2021). The nurse practitioner must be licensed under the respective state laws to prescribe schedule 3-5 drugs for pain, must have completed not less than 24 hours of appropriate education through a qualified provider and demonstrates the ability to treat and manage opioid disorder through training and experience (“Buprenorphine Waiver Management”, 2021).

The patient enrolled in a medication assisted opioid treatment program requires a consent for treatment, a plan for relapse prevention, a procedure through which the patient can discuss the treatment and doses with a staff at request and a regular assessment.

References

• Buprenorphine Waiver Management. ADVOCACY. (2021). Retrieved 21 April 2021, from https://www.asam.org/advocacy/practice-resources/buprenorphine-waiver-managementhttps://www.asam.org/advocacy/practice-resources/buprenorphine-waiver-managementhttps://www.asam.org/advocacy/practice-resources/buprenorphine-waiver-management.
• Gokhale, S. (2017). “Non-Pharmacological Methods for Pain Management”. JOJ Nursing & Health Care, 4(4). https://doi.org/10.19080/jojnhc.2017.04.555642
• Henry, S., Bell, R., Fenton, J., & Kravitz, R. (2017). Goals of Chronic Pain Management. The Clinical Journal Of Pain, 33(11), 955-961. https://doi.org/10.1097/ajp.0000000000000488
• Kaye, A. (2017). Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse: Part 1. Pain Physician, 2(20;2), s93-s111. https://doi.org/10.36076/ppj.2017.s111
• Miller, L. (2021). Types of Addiction Treatment Programs. Drug Rehab Options. Retrieved 21 April 2021, from https://www.rehabs.com/addiction/types-of-treatment-programs/.
• NIDA. (2019). Treatment Approaches for Drug Addiction DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction
• Uzuegbu-Wilson, E. (2019). Narcotics Drug Use in West Africa and Its Impact on Human Security. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.3456528
• Weyker, P., & Webb, C. (2018). Comprehensive Pain Management in the Rehabilitation Patient. Anesthesia & Analgesia, 127(1), 299. https://doi.org/10.1213/ane.0000000000003390

Advanced Pharmacology Gastrointestinal Drugs DQ 5

Advanced Pharmacology Gastrointestinal Drugs DQ 5

As an advanced practice nurse, you will likely encounter patients who will present with symptoms affecting the gastrointestinal (GI) tract. Of particular note is the consideration that most symptoms concerning the GI tract are non-specific, and therefore, diagnosing diagnoses of the GI tract requires thoughtful and careful investigation. Similarly, hepatobiliary disorders may also mirror many of the signs and symptoms that patients present when suffering from GI disorders.

How might you tease out the specific signs and symptoms between these potential disorders and body systems? What drug therapy plans will best address these disorders for your patients?

This week, you examine GI and hepatobiliary disorders. You will review a patient case study and consider those factors in recommending and prescribing a drug therapy plan fo your patient.

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Chapter 64, “Drugs for Peptic Ulcer Disease” (pp. 589–597)
Chapter 65, “Laxatives” (pp. 598–604)
Chapter 66, “Other Gastrointestinal Drugs” (pp. 605–616)
Chapter 80, “Antiviral Agents I: Drugs for Non-HIV Viral Infections” (pp. 723–743)
Chalasani, N., Younossi, Z., Lavine, J. E., Charlton, M., Cusi, K., Rinella, M., . . . Sanya, A. J. (2018). The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance fro

Advanced Pharmacology Gastrointestinal Drugs DQ 5 ASSIGNMENT:

Gastrointestinal (GI) and hepatobiliary disorders affect the structure and function of the GI tract. Many of these disorders often have similar symptoms, such as abdominal pain, cramping, constipation, nausea, bloating, and fatigue. Since multiple conditions can be tied to the same symptoms, it is important for advanced practice nurses to carefully evaluate patients and prescribe a treatment that targets the cause rather than the symptom.

Once the underlying cause is identified, an appropriate drug therapy plan can be recommended based on medical history and individual patient factors. In this Assignment, you examine a case study of a patient who presents with symptoms of a possible GI/hepatobiliary disorder, and you design an appropriate drug therapy plan.

To Prepare

•  Review the case study assigned by your Instructor for this Assignment
• Reflect on the patient’s symptoms, medical history, and prescribed drugs.
• Think about a possible diagnosis for the patient. Consider whether the patient has a disorder related to the gastrointestinal and hepatobiliary system or whether the symptoms result from a disorder from another system or other factors, such as pregnancy, drugs, or a psychological condition.
•  Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
• Write a 1-page paper that addresses the following:
•  Explain your diagnosis for the patient, including your rationale for the diagnosis.
•  Describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
•  Justify why you would recommend this drug therapy plan for this patient. Be specific and provide examples.

This week we will discuss the gastrointestinal and hepatobiliary systems and drugs used to treat those disorders. We will specifically focus on nausea/vomiting, gastroesophageal reflux disease, peptic ulcer disease, constipation, diarrhea, irritable bowel syndrome, inflammatory bowel disease, and cirrhosis.

CASE STUDY: Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs:

• Synthroid 100 mcg daily

ORDER THROUGH BOUTESSAY

Advanced Pharmacology Pharmacological Management of Respiratory Illness

Pharmacological Management of Respiratory Illness

JD presents with signs and symptoms suggesting an upper airway tract infection. However, there is a productive cough with greenish sputum suggesting a lower respiratory tract infection as well. The frontal headache, sinus tenderness, and nasal congestion are classical sinus presentations in acute rhinosinusitis. He thought that these symptoms would subside on their own but progressed instead.

Missing Information and Need for Treatment

Chest examination revealed bilaterally clear lungs but this does not rule out concurrent pneumonia. A piece of subjective information ruling out chest pain with difficulty in breathing would be needed. A chest plain radiograph finding would be required to rule out lung consolidation as the source of the productive cough. JD’s immune status and presence of comorbidities such as diabetes and hypertension are missing and would be used to rule out the possibility of fungal sinusitis (Husain et al., 2018) in the patient. Information about recent antibiotics use would also be essential (American Academy of Family Physicians, 2020). Nevertheless, JD would require treatment because his symptoms had lasted more than 10 days with postnasal discharge.

Pharmacotherapy

JD has had severe sinusitis symptoms for more than 10 days (NICE, 2018) and this warrants medical treatment. The ideal prescription would be Augmentin 875 mg PO TID. Augmentin prevents cell wall synthesis in bacteria while inhibiting beta-lactamase enzymes. Its excretion is predominantly renal with hepatic components for the clavulanic acid. This mediation may cause fatal anaphylactic reactions in those allergic to penicillin (Food and Drug Administration, n.d.).

If JD were a child, say 10 years old and weighing 78lbs, the medication would not change but alterations would be made to the dosage quantities. It would be essential to monitor the patient for allergy symptoms and educate him properly regarding medication adherence. Monitoring his response to antibiotic treatment would be essential in his further treatment.

Conclusion

JD most likely has acute bacterial rhinosinusitis requiring antibiotic treatment due to the severity of his symptoms lasting more than 10 days. The best choice of antibiotics would be Augmentin since he has reported no known food or drug allergies. This medication choice would be maintained even if JD were a child weighing 78 pounds. However, monitoring for possible allergic reaction would be necessary.

References

• American Academy of Family Physicians. (2020). Adult Sinusitis. Aafp.Org. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/adult-sinusitis.html
• Food and Drug Administration. (n.d.). Augmentin Label – FDA. Fda.Gov. www.accessdata.fda.gov
• Husain, S., Amilia, H. H., Rosli, M. N., Zahedi, F. D., Sachlin, I. S., & Development Group Clinical Practice Guidelines Management of Rhinosinusitis in Adolescents & Adults. (2018). Management of rhinosinusitis in adults in primary care. Malaysian Family Physician: The Official Journal of the Academy of Family Physicians of Malaysia, 13(1), 28–33. https://www.ncbi.nlm.nih.gov/pubmed/29796207
• NICE. (2018, April 3). NICE sinusitis (acute): antimicrobial prescribing. Guidelines.Co.Uk; Guidelines. https://www.guidelines.co.uk/infection/nice-sinusitis-acute-antimicrobial-prescribing/454117.article

Advanced Pharmacology Sample Paper 2

What would you add to the current treatment plan? Why?

Based on Mr. EBR’s presenting symptoms and a history of CAD, he is most likely suffering from stable angina. In addition to the current treatment plan for the patient, I would recommend an ECG to evaluate his cardiac condition. The immediate intervention would be to reduce or eliminate the patient’s anginal chest pain. Further, I would refer him to a cardiologist for stress test and, possibly, cardiac catheterization if needed.

Would you discontinue any of the currently prescribed medication? Why or why not?

I would not recommend the discontinuation of any of Mr. EBR’s current prescriptions as they crucial in managing his blood pressure, type 2 diabetes and hyperlipidemia. The patient is already on beta blockers which serve to decrease myocardial contractility, in addition to decreasing both heart rate and conduction velocity. Beta blockers also work by reducing the systemic vascular resistance as well as blood pressure (Laurent, 2017). Put together, the medication serves to reduce myocardial oxygen demand, thus relieving the patient’s anginal pain. Aspirin, at a dose of between 81mg and 162 mg per day is recommended for patients with angina as it also serves to reduce mortality rates among those suffering from CAD.

How does the diagnosis stage 3 chronic kidney disease affect your choices?

Gabapentin is the preferred medication for diabetic neuropathy among patients with no chronic kidney disease (CKD). With Mr. EBR’s stage 3 CKD, gabapentin is discouraged due to the elevated risks of high toxicity. Further, as Lefebvre et al. (2020) observe, for patients with such comorbidities as CKD, CHF, liver cirrhosis, etc., drug combinations that include renin-angiotensin blockers, NSAIDS and diuretics can result in acute renal failure.

How is the patient prescribed more than one antihypertensive?

            Current hypertension therapy guidelines recommend combined therapies with separate agents or fixed-dose combinations that are more effective in lowering blood pressure within a short time, while at the same time minimizing possible adverse effects. Further, studies have shown that different classes of hypertensive drugs can work to offset the adverse reactions associated with either. Additionally, the fact that most hypertensive patients require more than one antihypertensive agent, more so when there are comorbid conditions, makes it easier to understand Mr. EBR’s case. For instance, for hypertensive patients, particularly those at elevated risks of coronary disease, current treatment recommendation includes diuretics, beta-blockers, and angiotensin-converting enzyme inhibitors (Cuspidi et al., 2018).

What is the benefit of the aspirin therapy in this patient?

Aspirin, being an antiplatelet agent, reduces the ability of blood to clot. This makes blood flow easier in narrowed arteries. With Mr. EBR’s history of CAD and MI, reducing the risks of blood clot formation in his arteries is crucial to managing his conditions. For this, Aspirin is recommended.

References

• Cuspidi, C., Tadic, M., Grassi, G., & Mancia, G. (2017). Treatment of hypertension: The ESH/ESC guidelines recommendations. Pharmacological Research, 128(), 315-321. doi:10.1016/j.phrs.2017.10.003
• Laurent, S. (2017). Antihypertensive drugs. Pharmacological Research, 124(), 116-125. https://doi.org/10.1016/j.phrs.2017.07.026
• Lefebvre, C., Hindié, J., Zappitelli, M., Platt, R. W., & Filion, K. B. (2019). Non-steroidal anti-inflammatory drugs in chronic kidney disease: a systematic review of prescription practices and use in primary care. Clinical Kidney Journal, 13(1), 63-71. https://doi.org/10.1093/ckj/sfz054

Advanced Pharmacology Sample Discussion

Discussion 1

1. What pain relieving medications would you prescribe? Defend your choice.

For patients with acute musculoskeletal and soft tissue injuries, the most appropriate treatment choice for pain remains NSAIDs. However, since this patient reports being intolerant to NSAIDs and aspirin, the alternative medication would be a topical NSAID, such as diclofenac. While topical NSAIDs have been subject to extensive studies on efficacy with varying results, Busse et al. (2020) for non-low back musculoskeletal injuries, topical nonsteroidal anti-inflammatory agents offer the greatest benefits, “followed by oral NSAIDs and acetaminophen with or without diclofenac.” Unlike ordinary NSAIDs that must be used with caution in patients with a history of GI and Kidney problems, or intolerance, topical NSAIDs are safe alternatives. This is because they have a small amount of systemic absorption and yet offer pain relieving and anti-inflammatory benefits to patients.

2. How would you prescribe them?

Prescribe Diclofenac 1.3% topical system. Diclofenac Topical Dosage (2019) recommends application of 1 topical system to the area with most pain, twice daily, for up to 7 days.

3. What side effects should you educate the patient about?

Inform the patient that while this is a topical NSAID as opposed to an oral one, such side effects as GI symptoms may occur. Further, with application on the skin, irritation or rash may occur, prompting the need to notify the provider should it worsen. Educate the patient on proper usage as well, especially on the need to apply it on a clean dry skin, and not to wear the patch when showering. Inform the patient to always secure the patch with tape whenever it begins to peel off.

4. Does the age of the patient influence what your choice?

The patient’s age to an extent influences the choice of treatment. Topical diclofenac is recommended for patients aged >6 years. However, there are no other age limitations associated with this medication.

Discussion 2

Metabolism and excretion of NSAIDs occur in the liver and through the kidney respectively. As such, these are the organs that are likely to incur damage. For this reason, it is important to assess liver and skin function prior to administering NSAIDs. Further, as Rakoski et al. (2018) observe, there is need to decrease the dosage when administering the drugs to patients with cirrhosis since they are likely to experience increased unbound drug levels and reduced clearance. Further education should regard patients with heart conditions as they are at increased risks of developing renal insufficiency, hence the need for close monitoring. Also, educate the patient on the risks of fluid retention caused by NSAIDs, which may result in changes in BP. Equally important is to educate the patient on the interaction between NSAIDs and other prescription medications, especially since many drugs tend to interact negatively with NSAIDs.

Taking too much aspirin can affect the liver. As such, it is advisable to monitor LFTs and continually assess the patient for liver dysfunction symptoms and jaundice. Patient education regarding aspirin use should cover self-monitoring of liver dysfunction signs and GI problems, especially GI bleeding (Lavie et al., 2017). To minimize the risks of GI bleeding, recommend the use of enteric coated aspirin. Educate the patient to monitor for such toxicity symptoms as tinnitus, impaired hearing and dizziness. The patient should stop Aspirin prescription immediately upon noticing the said symptoms.

3 Diagnoses for which NSAIDs would be appropriate:

• Muscle or Join pain following a sprain or strain
• Arthritis
• Postpartum pain

3 Diagnoses for which Aspirin would be ideal:

• Coronary Artery Disease
• Transient Ischemic Attack
• Angina Pectoris

References

• Busse, J. W., Sadeghirad, B., Oparin, Y., Chen, E., Goshua, A., May, C., Hong, P. J., Agarwal, A., Chang, Y., Ross, S. A., Emary, P., Florez, I. D., Noor, S. T., Yao, W., Lok, A., Ali, S. H., Craigie, S., Couban, R., Morgan, R. L., … Guyatt, G. H. (2020). Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries: A Systematic Review and Network Meta-analysis of Randomized Trials. Annals of Internal Medicine, 173(9). https://doi.org/10.7326/M19-3601
• Drugs.com. (2019). Diclofenac Topical Dosage. Accessed April 1st 2021 from https://www.drugs.com/dosage/diclofenac-topical.html
• Lavie, C. J., Howden, C. W., Scheiman, J., & Tursi, J. (2017). Upper Gastrointestinal Toxicity Associated With Long-Term Aspirin Therapy: Consequences and Prevention. Current Problems in Cardiology, 42(5), 146–164. doi:10.1016/j.cpcardiol.2017.01.006
• Rakoski, M., Goyal, P., Spencer-Safier, M., Weissman, J., Mohr, G., & Volk, M. (2018). Pain management in patients with cirrhosis. Clinical Liver Disease, 11(6), 135–140. https://doi.org/10.1002/cld.711

Advanced Practice Nurse Role In Facilitating End-Of-Life Care

Cruz-Oliver et al. (2017) defines end of life care as the type of care offered to patients in their final hours or days of life, as well as to patients who are suffering from advanced terminal illnesses or diseases, and whose conditions have progressed to the level of being incurable. Nurses play a significant role in ensuring that this type of health care is available and delivered effectively by performing a variety of small tasks that ensure the patient is cared for holistically.

The most important role of an advanced practice nurse in facilitating Mrs. D’Angelo’s end-of-life care is to identify her needs (Abelsson & Willman, 2020). These needs range from basic dietary requirements to advanced emotional, spiritual, psychological, and even economic requirements. The involved nurse should strive to identify these needs and reason out possible ways to meet them, and if possible, involve Mrs. D’Angelo’s family. These needs can be identified by asking Mrs. D’Angelo about her thoughts on the subject, conducting a physical examination, analyzing her medication profile and allergies, observing her coping abilities, assessing support needs, and screening for implementation needs (Morioka et al., n.d.). By identifying the needs, the nurse in charge is able to plan how to meet those needs in the best interests of the patient.

Making decisions is an important part of the end-of-life process (Abelsson & Willman, 2020). The nurse(s) in charge play an important role in assisting Mrs. D’Angelo in making decisions such as whether to continue or discontinue the current chemotherapy regimen, whether to make plans to receive care somewhere other than at home, whether to discuss her wishes for care and treatment planning with her family, and whether to appoint someone to be her substitute decision maker. This helps in clarifying unsure concerns, avoiding distress or upset, eliminating concerns about negative outcome, helping Mrs. D’Angelo on being sure on what to do next and avoid cases her being preoccupied with the decision made.

Advance practice nurses also play important role in promoting meaningful interactions between Mrs. D’Angelo and her significant others (Abelsson & Willman, 2020). By encouraging Mrs. D’Angelo to make informed decisions, she will find it easier to decide what to discuss with a specific family member or significant other. Time is an important consideration. In the event that she develops advanced pancreatic cancer, which significantly reduces her life expectancy, she can discuss and plan with her family on how to manage the available family resources. By ensuring that the correct information is shared with Mrs. D’Angelo’s family, the family members can interact without fear of losing their loved one at any time, especially if the pancreatic cancer is not in an advanced stage and a cure can be achieved through surgery. This reduces the likelihood of emotional instability interfering with Mrs. D’Angelo’s expected interaction with her significant others.

Advanced practice nurse plays a role in controlling Mrs. D’Angelo’s symptoms and, in the event that she does not recuperate from the adverse reaction to chemotherapy or the cancer, facilitates a peaceful death (Abelsson & Willman, 2020). Nurses first do the assessment of Mrs. D’Angelo before coming up with a nursing diagnosis. They then come up with a plan on how to alleviate the patient’s symptoms before implementing the plan. Implementation includes psychological care, eliminating any form of fear, be it of pain, of feeling meaningless or fear of loneliness and abandonment. I the event that Mrs. D’Angelo’s cancer turns out to be non-curable, the nurses help in ensuring that she is able to make proper arrangements for whoever or whatever is going to be left behind, enjoy her final moments and, live a satisfactory final moments. This help in facilitating peaceful death.

Advance Directives

Advance directives, according to Dalmau-Bueno et al. (2021) are legal documents that outline formal preferences on actions that caretakers or doctors should take if the individual’s health deteriorates to an extent that they are no longer able to make appropriate decisions about self. The goal and objectives of advance directives is to ensure patient autonomy during end-of-life care, thereby enabling the caregivers to prioritize the patient’s medical care preferences, which must be within reasonable clinical options. Advance directives come in a various types and include a living will, durable power of attorney, advanced healthcare directive, preferred intensity of care(PIC) form and, do not resuscitate (DNR) order (Dalmau-Bueno et al., 2021).

A living will is a legal document that outlines an individual’s needs and wishes when they are unable to make competent decisions on their own. The living will, unlike the other forms, does not allow the patient to name someone to make decisions for him or her. In addition, unlike the other forms, two witnesses who are not related to the patient are required for validation. A durable power of attorney, on the other hand, is a legal device that allows one person, known as the “principle”, to delegate authority to another person, known as the “attorney-in-fact”, to act on his or her behalf (Dalmau-Bueno et al., 2021).

As a result, the decision is based on what the “attorney-in-fact” believes is appropriate for the “principle”. Unlike the appointed “attorney-in-fact”, the appointed “attorney-in-fact” is limited by their own knowledge of legal matters and finances, leaving room for error. The durable power of attorney is used for financial matters, whereas the advanced healthcare directive is used for medical matters.

The advanced healthcare directive specifies who you want to make healthcare decisions for you and only becomes active if the patient is unable to make decisions or is unconscious. In the event of a medical emergency, the PIC form is typically used to specify what should and should not be done. The DNR order is a form that requests that cardiopulmonary resuscitation not be performed if the patient’s heart stops beating or if he or she stops breathing (Dalmau-Bueno et al., 2021).

Mrs. D’Angelo will need an advanced directive if she wants to legally protect herself from unwanted medical procedures, such as when she does not want to be resuscitated in the event of cardiac failure (do not resuscitate order). In addition, if her cancer is advanced and she is unlikely to recover, the directives may specify the type of care she prefers, such as whether she wants to continue with chemotherapy or discontinue it. Advanced directives will also be useful if she wishes to receive a specific type of treatment regardless of how ill she is. Mrs. D’Angelo will also be able to relieve her family of the need to sit down and make difficult decisions about her care.

How To Approach The Topic Of Advanced Directive With A Patient.

The first step is to disclose all information about pancreatic cancer to Mrs. D’Angelo in a way that she understands, including the stage and the options for treatment available (Gieniusz et al., 2018). In the event that the cancer is at an advanced stage, explain to her the terminality of the condition. Also, explain to her the side effects of the available treatment modes. After the above disclosure of information, always give the patient hope, but not false hope. Explain to her the probable outcomes in case of ongoing treatment. Listen actively, assist her with medical decision making and also ensure effective communication with all individuals involved in her care and her family members. If she resents grieving, allow her to finish grieving until she gets to the acceptance phase.

Once she does accept her condition (s) and the possible outcomes, explain to her the prospect of advanced directives and allow her to make her own decision with your help on what she wants about her health and her financial capability. You can allow her to consult with a legal team if she has one. Help her select a directive that is in accordance with her religion, financial ability and, culture or ethnicity. Once she has decided on an advance directive, she can fill out the form in the presence of witnesses if necessary and present it to her advocate or legal team.

Ethical Principles and Legal Challenges related to End-of-life and Palliative Care.

Ethical Principles

Beneficence: This is the balance between what is good and what is harmful to the patient (Brodtkorb et al., 2017). The nurse and the involved healthcare officer should make decisions and take actions that will improve Mrs. D’Angelo’s life rather than worsen it. If, for example, the use of chemotherapy causes more harm than benefit in the form of adverse reactions, it can be discontinued and the Whipple procedure performed without initiating chemotherapy.

Autonomy: It is defined as the right of self-governance (Sprung et al., 2019). In this situation, it is allowing Mrs. D’Angelo to decide for herself the type of treatment she is to receive and also have a final say in her financial and family matters. This can be done through advanced directives.

Legal Challenges

Limitation to patient autonomy: Mrs. D’Angelo cannot demand a treatment that is not in their best interests. Further, the intervening doctors and the doctors need not to strive to preserve life.

Withholding and withdrawing treatment: If Mrs. D’Angelo and the doctor agree that there is no benefit of continuing chemotherapy they can stop it (Sprung et al., 2019). The doctor and Mrs. D’Angelo should agree to withdraw or discontinue the chemotherapy prior to the Whipple procedure.

Effective Communication Strategy for End-of-life Care

Mrs. D’Angelo is entitled to bad news if her condition worsens and she is diagnosed with a terminal illness. However, there may be some good news in between the bad news, and what is most important is how the advance practice nurse communicates the same news to Mrs. D’Angelo. This necessitates a communication strategy that includes skills for communicating with the seriously ill as well as responding to serious questions with sensitivity.

Upon diagnosing an individual with a serious or life-threatening illness and noticing that the individual is nearing the end of their life, effective communication is critical. As Anderson et al. (2019) notes, good and timely communication can help alleviate stress and distress, in addition to enabling the patient and the caregiver to discuss and plan for advanced care. The best known approach is the 9-Step Approach (Anderson et al., 2019).

To begin, the meeting must be convened. This entails gathering the members of the medical professional and Mrs. D’Angelo’s family in a private and quiet location and having all members introduce themselves to establish a good rapport. Second, it entails reaching an agreement on the meeting’s purpose. Update everyone on Mrs. D’Angelo’s health from your perspective, breaking the news about her health. After that, discuss the decision with the appropriate members. Help anyone who may require emotional or psychological support.

Third, find out what the patient or family knows and assess their level of understanding, language they understand better, potential misconceptions or misinformation, and the last time they were updated. Fourth, find out what information they need to make a decision and show them how much you appreciate them in the process. This includes the diagnosis, likely course of action, and prognosis.

Fifth, share the necessary information with them and try to get them to agree on their common desires in a peaceful manner. Try to evaluate them to discover their goals, hopes, expectations and, fear with the hope of understanding their “history”. Try to address their needs as per their financial capability and for the best interest of the patient. Create a plan for them that include when to break the bad news to them, decision-making and anticipated decisions, and the necessary support to assist them and Mrs. D’Angelo in coping and reducing potential fears. Finally, schedule a follow-up with them, inviting them to share any unresolved concerns and, in doing so, normalize their experience (Anderson et al., 2019)

References

• Abelsson, A., & Willman, A. (2020). Caring for patients in the end-of-life from the perspective of undergraduate nursing students. Nursing Forum, 55(3), 433–438. https://doi.org/10.1111/nuf.12448
• Anderson, R. J., Bloch, S., Armstrong, M., Stone, P. C., & Low, J. T. (2019). Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence. Palliative Medicine, 33(8), 926–941. https://doi.org/10.1177/0269216319852007
• Brodtkorb, K., Skisland, A. V.-S., Slettebø, Å., & Skaar, R. (2017). Preserving dignity in end-of-life nursing home care: Some ethical challenges. Nordic Journal of Nursing Research, 37(2), 78–84. https://doi.org/10.1177/2057158516674836
• Cruz-Oliver, D. M., Little, M. O., Woo, J., & Morley, J. E. (2017). End-of-life care in low- and middle-income countries. Bulletin of the World Health Organization, 95(11), 731. https://doi.org/10.2471/BLT.16.185199
• Dalmau-Bueno, A., Saura-Lazaro, A., Busquets, J. M., Bullich-Marín, I., & García-Altés, A. (2021). Advance directives and real-world end-of-life clinical practice: a case-control study. BMJ Supportive & Palliative Care. https://doi.org/10.1136/bmjspcare-2020-002851
• Gieniusz, M., Nunes, R., Saha, V., Renson, A., Schubert, F. D., & Carey, J. (2018). Earlier goals of care discussions in hospitalized terminally ill patients and the quality of end-of-life care: A retrospective study. The American Journal of Hospice & Palliative Care, 35(1), 21–27. https://doi.org/10.1177/1049909116682470
• Sprung, C. L., Ricou, B., Hartog, C. S., Maia, P., Mentzelopoulos, S. D., Weiss, M., Levin, P. D., Galarza, L., de la Guardia, V., Schefold, J. C., Baras, M., Joynt, G. M., Bülow, H.-H., Nakos, G., Cerny, V., Marsch, S., Girbes, A. R., Ingels, C., Miskolci, O., … Avidan, A. (2019). Changes in end-of-life practices in European intensive care units from 1999 to 2016. JAMA: The Journal of the American Medical Association, 322(17), 1692–1704. https://doi.org/10.1001/jama.2019.14608

Advanced Pharmacology Sample Paper 3

Contraception

            For various reasons such as unwanted pregnancies and spaced births, people opt for different contraceptive methods. Colquitt and Martin (2017) classify the methods as hormonal, barrier, natural, surgical, and intrauterine or emergency contraception. Due to the diversity of individuals, the choice for contraceptive methods is influenced by various reasons including costs, side effects, availability, and the cultural and religion acceptance (Colquitt & Martin, 2017). This forms the basis of discussion in this paper by inferring to the case study provided.

Contraceptive Options

            The options, as aforementioned, are influenced by a variety of factors, side effects being among them. Being that Margaret is at risk for cardiovascular events; contraceptives that do not contain estrogen are recommended. For her case, progestogen-only contraception is feasible. This form of contraception can be in the form of pills or injectable for those who have difficulty with pills (Bansode, Sarao & Cooper, 2020). Further, the Depo-Provera, an injectable progestogen-only contraception confers a 12-13 weeks of birth control and further reduces the risks for premenstrual syndrome (Bansode et al., 2020). The third option for progestogen-only method is the sub-dermal patches (Implanon) that is highly effective and provides long term contraception.

Additionally, intrauterine devices (IUD) can be considered. These devices can either be copper or hormonal; however devoid of estrogen therefore making it safe for the patient. Even though she is separated from her spouse, she is sexually active; she can use cheaper and widely available barrier methods such as female or male condoms. Moreover being that she is approaching menopause, and has two children, an ideal number of children according to the majority (Petrowski, Cappa & Gross, 2017), she can opt for sterilization techniques such as bilateral tubal ligation.

Contraindicated Options

            From the health history, use of combined oral contraceptive pills is contraindicated. An absolute contraindication for COC includes circulatory diseases or risk factors for cardiovascular events (Gomez-Tabares, 2020). Margaret is hereditarily susceptible to cardiovascular diseases as both of her parents are hypertensive. Additionally, her paternal grandfather died of hypertension, type 2 diabetes and coronary artery disease making her genetically vulnerable. Further, she is overweight (BMI of 28.6) and has systolic hypertension, risk factors for cardiovascular diseases. Moreover, the patient is an active smoker, a habit attributed fully to her stressful life events. Women who smoke cigarettes and use COCs are at an increased risk for peripheral arterial diseases (Gomez-Tabares, 2020).

Patient Education

            It is for the best interest of the patient to quit smoking. Concomitant use of COCs alongside smoking is associated with adverse cardiovascular events as aforementioned. Besides the cardiovascular related risks, pulmonary diseases such as lung cancer can ensue. Further, being that she is overweight, education on the importance of weight management and physical activity is crucial. Additionally, the patient reports not to eat well; therefore, nutritional counseling is equally important. The patient leads a stressful life as evidenced by her failed marriage, need to work for extra time and her adolescent sons. She therefore needs counseling from a psychiatrist. Since she is sexually active, safe sex education is necessary should she opt to look for another partner. Finally, regular blood and glucose measurement and breast cancer screening is vital due to her inherent risk for hypertension and diabetes type 2, and the association of breast cancer with COCs.

Normal Pelvic Exam and the Influence on Decision Making

            Even though the pelvic examination reveals normal findings, there is a minimal whitish non odorous vaginal discharge. Use of COCs has been associated with cystitis, a condition that can present with a whitish vaginal discharge (Judge et al., 2018). Further test are therefore required to rule out the condition before contraception is chosen. Further, the whitish discharge can be a sign of a sexually transmitted disease which would contraindicate the use of an IUD (Matorras et al., 2018).In the presence of the STD; an IUD can cause a pelvic inflammatory infection. Treatment is therefore required before IUD insertion

References

• Bansode, O. M., Sarao, M. S., & Cooper, D. B. (2020). Contraception. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK536949/#_NBK536949_pubdet
• Colquitt, C. W., & Martin, T. S. (2017). Contraceptive methods: A review of nonbarrier and barrier products. Journal of Pharmacy Practice, 30(1), 130–135. https://doi.org/10.1177/0897190015585751
• Gomez-Tabares, G. (2020). Complications caused by combined oral contraceptives. Thromboembolic events. Ginecología y Obstetricia de México, 88(S1), 140–155. https://www.medigraphic.com/cgi-bin/new/resumenI.cgi?IDARTICULO=93720
• Judge, C. P., Zhao, X., Sileanu, F. E., Mor, M. K., & Borrero, S. (2018). Medical contraindications to estrogen and contraceptive use among women veterans. American Journal of Obstetrics and Gynecology, 218(2), 234.e1-234.e9. https://doi.org/10.1016/j.ajog.2017.10.020
• Matorras, R., Rubio, K., Iglesias, M., Vara, I., & Expósito, A. (2018). Risk of pelvic inflammatory disease after intrauterine insemination: a systematic review. Reproductive Biomedicine Online, 36(2), 164–171. https://doi.org/10.1016/j.rbmo.2017.11.002
• Petrowski, N., Cappa, C., & Gross, P. (2017). Estimating the number of children in formal alternative care: Challenges and results. Child Abuse & Neglect, 70, 388–398. https://doi.org/10.1016/j.chiabu.2016.11.026

Advanced registered nurse roles with regard to ethical guidelines

Advanced registered nurse roles with regard to ethical guidelines

Compare two different advanced registered nurse roles with regard to ethical guidelines.

Are there any differences in the ethical guidelines that govern these roles?

What situations might require one role to respond differently, depending on the ethical guidelines?

ORDER THROUGH BOUTESSAY

Advanced registered nurse roles with regard to ethical guidelines

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. Advanced registered nurse roles with regard to ethical guidelines

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.

Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.

One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.

Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).

Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.

As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.

It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice.

We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

• Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
• Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Advanced registered nurse roles with regard to ethical guidelines