BACKGROUND INFORMATION

The client is a 32-year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to the PMHNPs office for an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.

SUBJECTIVE

During today’s clinical interview, the client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago but has been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is casually dressed. His speech is clear but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. The effect is somewhat constricted but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. The PMHNP administers the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).

Decision Point One

Begin Zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

• The client returns to the clinic in four weeks
• Reports a 25% decrease in symptoms
• The client is concerned over the new onset of erectile dysfunction

Decision Point Two

Add augmenting agent such as Wellbutrin IR 150 mg in the morning

RESULTS OF DECISION POINT TWO

• The client returns to the clinic in four weeks
• Client stated that depressive symptoms have decreased even more and his erectile dysfunction has abated
• Client reports that he has been feeling “jittery” and sometimes “nervous”

Decision Point Three

Change Wellbutrin to XL 150 mg orally daily in AMThe PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended-release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.

Examine Case Study: An Elderly Hispanic Man With Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

• At each decision point stop to complete the following:
  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also, include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

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Locate an article from a peer-reviewed nursing journal where a practice change was made based on research, preferably a change that could relate to your area of practice or organization. Note: You are seeking to find an evidence-based article that describes some change in practice that was based on research; this is all about applying research, not doing research. Thus, you are not looking for a research article, but you are looking for an article that uses evidence from research to make a change.

1.      Describe the change made and comment on the strength of the research evidence utilized and the whether the change led to improved patient outcomes.

2.      Note any barriers to change that were identified and how they were overcome.

3.      End your discussion with a reflection on how this article is useful to you as you consider your role as an advanced practice nurse leading others to use the best evidence to strengthen nursing practice and improve nursing-sensitive patient outcomes.

 Note: This is an evidence-based topic of master degree program. Text book by Melnyk and Fineout 2015, Evidence based practice in nursing and healthcare.

 Eight Steps for Successful Change: Your Personal Example

1.      Post your personal example about change here for peer and instructor feedback.

2.      Refer to the Practice area in Reading.

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PLEASE USE APA STYLE, ATTACHED IS THE RUBRICS, THIS PAPER WILL GO THRU TURNING, PLEASE NO MORE THAN 15% OF SIMILARITY. ANY QUESTION FEEL FREE TO ASK

QUESTION ( PLEASE DO 6 PAGES FOLLOWING THE RUBRICS )

The purpose of this assignment  is to provide a concise description and appraisal of the American Association of Colleges of Nursing (AACN) Essentials of Master’s Education in Nursing.  Following APA guideline , provide a brief explanation on each of the essentials reflecting on each essential affects the clinical practice and the author’s interpretation on each essential. Make sure to include a (Title page, abstract, introduction, body, conclusion, and reference page). Please submit it via Turnitin .

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Peer replies

1-Alberto :

Polypharmacy is an area of concern for many patients, especially the elderly.  Elderly patients are at a greater risk for adverse drug reactions (ADRs) because of the reduced drug clearance associated with aging and because of metabolic changes (Boris, Cafiero & Smith, 2014).  Some risk factors associated with polypharmacy are potential of drug-drug interactions because it is further increased by use of multiple drugs.  Another risk factor is hip fractures, associated with adverse drug reactions and losing balance or fainting (Boris, Cafiero & Smith, 2014).  Polypharmacy may sometimes lead to “prescribing cascades.”4 Prescribing cascade is said when signs and symptoms (multiple and nonspecific) of an ADR is misinterpreted as a disease and a new treatment/drug therapy is further added to the earlier prescribed treatment to treat the condition (Piere & Farrell, 2012).

       In my practice working with the elderly population, to reduce the incidence of polypharmacy medication, patients are evaluated on a monthly basis.  Additionally, a single drug is be prescribed instead of multiple drugs for the treatment of a single condition, if possible.  Another strategy we use is staring medication with the lower drug dosage and slowly increasing as indicated.

           A strategy that seems to be effective, according to research, is prescribe drugs that can be given once or twice a day instead of prescribing drugs that require to be taken three times a day (Thomas, Liao, & McCliar, 2016).  The reasoning behind this is to lower the risk of forgetting to take the medication or taking the medication together with other drugs.  Another strategy that can be employed is that if the drug taken has no therapeutic beneficial effect or clinical indication it should be eliminated. Unessential drugs should be identified and eliminated prescribed by different health care providers for the same condition/disease (Thomas, Liao, & McCliar, 2016).

2-maceda 

Polypharmacy refers to the effects of taking multiple medications concurrently to manage coexisting health problems, such as diabetes and hypertension (Piere & Farrell, 2014).  Too often, polypharmacy becomes problematic, such as when patients are prescribed too many medications by multiple healthcare providers working independently of each other. Also, drug interactions can occur if no single healthcare provider knows the patient’s complete medication picture. Nurses have a unique opportunity to help identify patients at risk for inappropriate polypharmacy and to educate patients and families about risk reduction. Nurses can use strategies such as patient teaching and consistency in care plan (Piere & Farrell, 2014). 

Some of the risk factors of polypharmacy are age and chronic conditions.  The elderly are more sensitive to the effects of certain drugs, particularly those that affect the central nervous system.  As a consequence, drug classes such as benzodiazepines should be used with caution, and if absolutely necessary, then at a reduced dose to minimize the risk of falls and other adverse events (Thomas, Liao & McCliar, 2016). In addition, age is associated with decreased regulatory functions, therefore anti-hypertensives can more easily result in postural hypotension and opiates in respiratory depression.  Communication barriers often go undetected in health care settings and can have serious effects on the health and safety of patients. Limited literacy skills are one of the strongest predictors of poor health outcomes for patients (Thomas, Liao, & McCliar, 2016).  If the patient is deaf, can’t see or is illiterate there are various strategies the nurse can use for example, advise the patient to bring someone with them to the visit.  Nurses who are responsible for checking patients in should be friendly and helpful. The length and number of forms patients are asked to fill out should be limited.

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