Answer the questions in both scenarios in your own words. Answer these questions as if you were talking to a peer, unless otherwise indicated.

Shock Case Studies

Scenario #1

K.L., a 25-yr-old Korean American, was not wearing his seat belt when he was the driver involved in a motor vehicle crash. The windshield was broken and K.L. was found 10 ft from his car. He was face down, conscious, and moaning. His wife and daughter were found in the car with their seat belts on. They sustained minor injuries and were very frightened and upset. All passengers were taken to the emergency department (ED). The following information pertains to K.L.

Subjective Data

• States, “I can’t breathe”
• Cries out when abdomen is palpated

Objective Data

Physical Examination:

• Cardiovascular: BP 80/56 mm Hg; apical pulse 138 but no palpable radial or pedal pulses; carotid pulse present but weak
• Respiratory: respiratory rate 35 breaths/minute; labored breathing with shallow respirations; asymmetric chestwall movement; absence of breath sounds on left side
• Trachea deviated slightly to the right
• Abdomen: slightly distended and left upper quadrant painful on palpation
• Musculoskeletal: open compound fracture of the lower left leg

Diagnostic Studies

• Chest x-ray: Hemothorax and six rib fractures on left side
• Hematocrit: 28%

Interprofessional Care in the ED

• Intraosseous access in right proximal tibia placed prehospital
• Left chest tube placed, draining bright red blood
• Fluid resuscitation started with crystalloids
• High-flow O2via non-rebreather mask

Emergency Surgical Procedures

• Splenectomy
• Repair of torn intercostal artery
• Repair of compound fracture

Discussion Questions

1. What types of shock is K.L. experiencing? What clinical manifestations did he display that support your answer?
2. What were the causes of K.L.’s shock states? What are other causes of these types of shock?
3. Priority Decision: What are the priority nursing responsibilities for K.L.?
4. Priority Decision: What ongoing nursing assessment parameters are essential for this patient?
5. What are his potential complications?
6. Patient-Centered Care: K.L.’s parents arrive. English is their second language. They are very anxious and asking about their son. What can you do to provide culturally competent family-centered care?
7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses?
8. Teamwork and Collaboration: Identify the tasks that could be delegated to unlicensed assistive personnel (UAP).
9. Evidence-Based Practice: You are orienting a new graduate RN. He asks you why crystalloids are used instead of colloids for fluid resuscitation. What is your response?
10. Examine therapeutic nursing interventions associated end-of-life decision-making.

 The following is information that will assist you in answering the question associated with scenario #2

Septic shock is

“A life-threatening organ dysfunction caused by a dysregulated host response to infection” (McCance & Huether, 2019, p. 1550).

The infectious process starts with an infectious agent entering the bloodstream and causing bacteremia either directly from the site of infection or indirectly by releasing toxic substances into the bloodstream. Some of the most common causes of septic shock are gram-negative or gram-positive bacteria, viruses, and fungi. The most common sites of infection are the lungs, bloodstream, intravascular catheters, intra-abdominal, urinary tract, and surgical wounds (McCance & Huether, 2019).

Normal Physiology

In normal physiology, when a pathogen invades the body, the body will react with local and systemic responses.

• Our first line of defense is the body’s natural physical, mechanical, and biochemical barriers such as the epithelial cells and surfaces of the skin. These defenses prevent microorganisms from getting into tissues and also have the ability to remove infectious microorganisms. The surfaces of the skin and mucous membranes of the body also contain normal microbiomes (“normal flora”) that also protects the body by releasing chemicals to prevent pathogens from being colonized (McCance & Huether, 2019).
• The body’s second line of defense is the inflammatory response. Inflammation causes a vascular response that makes vessel walls become leaky and more permeable and makes white blood cells adhere to vessel walls and migrate out into the tissues. Symptoms usually produced by inflammation are the heat, redness, edema and pain. The goal of inflammation is to prevent and limit infection and interact with components of the adaptive immune system as well as prepare the body for healing (McCance & Huether, 2019). 

There are three important plasma protein systems involved to provide an active barrier against invading pathogens in the inflammatory response.

• One is a complement system which destroys pathogens directly and work with other components of the immune responses by three pathways: (1) classic, (2) lectin and (3) alternative. The main functions of these are to induce rapid mast cell degranulation, attract white blood cells to pathogens, and “tag” pathogens for destruction (McCance & Huether, 2019).
• Second is the clotting or coagulation system which forms blood clots that include a meshwork of protein strands at the injured or inflamed site to stop bleeding, trap pathogens to prevent the spread of infection, and provide a framework for repair and healing (McCance & Huether, 2019).
• The last important inflammatory response is from the kinin system which activates and assists inflammatory cells by the release of mainly bradykinin which causes dilation of blood vessels, pain, smooth muscle contraction, increase vascular permeability and leukocyte chemotaxis (McCance & Huether, 2019). 

There are also many biochemical mediators of the innate immune system that secrete cytokines responsible for activating other cells such as interleukins, chemokines, interferons, and other molecules. These chemicals are important to the vascular changes that occur during the inflammatory process (McCance & Huether, 2019).

Along with the cellular mediators are the cellular components such as platelets, phagocytes (neutrophils, eosinophils, monocytes, macrophages, and dendritic cells), natural killer cells, and lymphocytes. The components respond to the site of the injury together to limit the tissue injury, kill pathogens, remove the debris, and prepare for healing and tissue repair (McCance & Huether, 2019). 

Septic shock begins when the pathogen enters the bloodstream. This stimulates the release toxic substances called the triggering molecules, which triggers the body to activate the proinflammatory responses and release proinflammatory cells such as leukocytes, macrophages, monocytes and platelets as well as proinflammatory mediators such as cytokines (interleukins, tumor necrosis factor alpha and other mediators). Cytokines along with the vasoactive peptides cause vasodilation causing hypotension, relative hypovolemia, and decreased in oxygen delivery to the tissues. The release of proinflammatory cytokines also activate plasma protein systems of the complement, coagulation and kinin systems (McCance & Huether, 2019).

Dysfunction of epithelial cells cause further capillary leaking and microvascular thrombus, tissue hypoxia and apoptosis. Due to tissue hypoxia, the body will start breaking down carbohydrates to make ATP or energy for the body. As more anaerobic cells are being used for energy, the more lactic acid is produced. Without correction, the accumulation will lead to metabolic acidosis causing further damage to the tissues (McCance & Huether, 2019).  

As the responses of proinflammatory and anti-inflammatory mediators intensify the body experiences persistent low arterial pressure, low tissue perfusion, low systemic vascular resistance which will profoundly affect the circulatory, cellular, and metabolic systems. These responses will lead to multiple organ dysfunction syndrome (MODS) due to dysfunction of the kidneys, liver, intestines, lungs, and brain as a result of tissue hypoxia and lack of tissue perfusion (McCance & Huether, 2019). 

Tools

Septic shock is measured by the SOFA score and assessing different systems in relation to the severity of the organ failure. The quick SOFA criteria include a respiratory rate equal or greater than 22 per minutes, altered mentation and systolic blood pressure less than 100 mmHg. The standard SOFA scoring includes respiration, coagulation of platelets, bilirubin level of the liver, mean arterial pressure, Glasgow coma scale score, creatinine level, and urine output.

Clinical manifestations

Clinical manifestations of septic shock usually include fever, chills, sweating, warm progressing to cool skin, respiratory distress, altered mentation, decreased urine output, hypotension, elevated liver enzymes, and decreased platelet counts (McCance & Huether, 2019). 

Scenario #2

Mr. S. S. is a 56-year-old, white male with a right diabetic foot ulcer. He was at his podiatrist’s office for a wound check and was referred to the emergency department (ED) due to increasing purulent drainage and necrotic tissue in the wound. Mr. S.S. noticed the drainage getting worse over the last week and has experienced fevers up to 102 degrees F for two days. He also complains of diaphoresis, fatigue, abdominal pain, and general malaise. He states he just does not feel like himself.  

Past Medical History:

Allergic to Penicillin and shellfish

Uncontrolled Type 2 Diabetes Mellitus 

Hyperlipidemia

Hypertension [baseline 140/90]

Obesity [BMI=32]

Cholecystectomy, age 32 years

Left Above the Knee Amputation (AKA), age 54 years

Pertinent Family History:

Mother- Hyperlipidemia, Hypertension, CABG x2 vessels

Father- Prostate Cancer, age 63 years

Pertinent Social History:

Active Smoker (2 packs/day)

History of Alcoholism

Previous history of homelessness

Emergency Department

In the ED, assessment reveals moderate foul odor, purulent drainage from right foot ulcer, and capillary refill of four seconds on upper and lower extremities. Patient is alert and oriented but short-term memory appears to be impaired and the patient is asking abnormal questions. Two peripheral IVs and an indwelling foley catheter are placed, a 1000mL bolus of IVF is initiated, wound and blood cultures are obtained, and the patient is started on broad spectrum antibiotics. An x-ray of his right foot demonstrates soft tissue inflammation and concern for osteomyelitis, so an MRI was completed of his foot. The patient is transferred to MICU for further management. 

ED Vitals:

Temperature: 101.6 degrees F

Heart Rate: 117 bpm

Respiration Rate: 24 breaths/min

Blood Pressure: 92/45 mm Hg (MAP 61)

Blood glucose: 315 mg/dL

SpO2: 91% on 2L NC

ED Labs:

WBC: 26,000

Lactate: 6.0 mmol/L

C-reactive Protein: 11mg/L

Creatinine: 1.4 mg/dL

pH: 7.32

Medical Intensive Care Unit

Upon admission to MICU, Mr. S.S. is lethargic and flushed. Further assessment demonstrates bounding pulses and right lower extremity edema. His heart rate increased and blood pressure dropped despite the liter bolus. The patient is started on vasopressors to maintain his blood pressure and intubated to protect his airway.

Pertinent Vitals:

Temperature: 101.4 degrees

Heart Rate: 154 bpm

Respiration Rate: 30 breaths/min

Blood Pressure: 72/34 (MAP 47)

SpO2: 86% on 2L NC

1. All of the options below are the most common causes of septic shock except for: 
   1. Gram-negative bacteria
   2. Gram-positive bacteria
   3. Viruses
   4. Cancer
2. Which of the following criteria would you expect to see from a patient with septic shock?
   1. Elevated lactate level
   2. 30 ml/hr of urine output
   3. Respiration of 18 rate per minute
   4. Patient is alert and oriented 
3. Which of the following are measurable components of the quick SOFA? Select all that apply.
   1. Respiration rate
   2. Temperature
   3. Heart rate
   4. Systolic blood pressure 
   5. Mentation
4. The patient wants to know more about sepsis asking if he or any of his family members would be at higher risk for sepsis. You tell the patient that most vulnerable patients for this problem would be: (Select all that apply)
   1. Children younger than one
   2. Patients who have received recommended vaccinations
   3. Adults 65 years old and older
   4. People with weakened immune systems
   5. People with chronic diseases
   6. People have been traveled outside of the United States
5. Discuss why septic shock is one of the leading causes of death in the intensive care units.
6. Examine therapeutic nursing interventions associated end-of-life decision-making.

For the middle-aged adult, exercise can reduce the risk of various health problems. Choose two at-risk health issues that regular physical exercise and activity can help prevent and manage. Discuss the prevalence of each of these health problems in society today. Describe measures that you would take as a nurse to assist patients with health promotion measures to incorporate exercise and physical activity into their lives. Include the kind of activities you would recommend, the amount of exercise, and the approach you would use to gain cooperation from the patient. Support your response with evidence-based literature.

Examine 
Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

· Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

· Which decision did you select?

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

· Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Case

BACKGROUND

Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.

The parents give the PMHNP a copy of a form titled 
“Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.

Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.

SUBJECTIVE

Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”

Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.

MENTAL STATUS EXAM

The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

RESOURCES

§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners' Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.

Decision Point One

Begin Wellbutrin (bupropion) XL 150 mg orally daily

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Katie’s parents inform you that they stopped giving Katie the medication because about 2 weeks into the prescription, Katie told her parents that she was thinking about hurting herself. This scared the parents, but they didn’t want to “bother you” by calling the office, so they felt that it would be best to just stop the medication as they would be seeing you in two weeks

Decision Point Two

Educate the parents that Bupropion sometimes causes suicidal ideation in children and that this is normal, and re-start the drug at the previous dose

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Katie's parents again report that after about a week of treatment with the Bupropion, Katie began telling her parents that she wanted to hurt herself and began having dreams about being dead. This scared her parents, and they stopped giving her the medication At this point, they are quite upset with the results of their daughter’s treatment and are convinced that medication is not the answer

Decision Point Three

Refer the parents to a pediatric psychologist who can use behavioral therapy to treat Katie’s ADHD.

Guidance to Student

Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.

At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.

In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.

The PMHNP should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow the PMHNP to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.

 Due 10/13/23 @ 1600 EST

Respond by sharing ideas for how shortcomings discovered in their evaluations and/or their examples of incivility could have been managed more effectively. 

using APA, at least 2 scholarly references 

 

WORKPLACE ENVIRONMENT ASSESSMENT

I recently conducted a Work Environment Assessment to evaluate workplace civility in the acute psychiatric inpatient unit. The results of the assessment painted a mixed picture. On the positive side, most staff members consistently exhibited professionalism and respect in their interactions with colleagues and patients. Team collaboration during shift handoffs and interdisciplinary meetings was generally effective and respectful.

.However, the assessment also revealed challenges. There were instances of incivility during high-stress situations, such as patient crises or when dealing with challenging patients. Communication breakdowns occurred when staff members were overwhelmed, leading to frustration and occasional conflicts. Some employees expressed concerns about a lack of adequate resources, contributing to heightened tensions ((Abt et al.,2021)

.Overall, the workplace in the psychiatric inpatient unit could be characterized as moderately civil. While there were numerous examples of professionalism and respect, the high-stress nature of the environment occasionally led to lapses in civility. In my personal experience, I encountered incivility during a team debriefing following a challenging patient case. The charge nurse became frustrated with a staff member she believed had not followed protocol during the crisis, leading to a heated argument in front of the team.

This situation needed urgent action to stop any further deterioration. The parties could speak freely and with less hostility because of this one-to-one discussion. The clinical supervisor subsequently mediated the process, delving into the underlying issues to devise an alternative means of communication between the two parties. The latter included conflict resolution/communication training that was introduced in advance. An acute psychiatric inpatient unit is a high-stress healthcare setting where it is essential to deal with incivility simultaneously to maintain a therapeutic and civil working environment (Mabona et al.,2022).

References

Abt, M., Lequin, P., Bobo, M., Vispo Cid Perrottet, T., Pasquier, J., & Ortoleva Bucher, C. (2021). The scope of nursing practice in a psychiatric unit: A time and motion study. Journal of Psychiatric and Mental Health Nursing, 29(2), 297–306. https://doi.org/10.1111/jpm.12790Links to an external site.

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00684-2Links to an external site.

Mabona, J. F., Van Rooyen, D., & Ten Ham-Baloyi, W. (2022). Best practice recommendations for healthy work environments for nurses: An integrative literature review. Health SA Gesondheid, 27. https://doi.org/10.4102/hsag.v27i0.1788