In this Assignment, you will identify an issue or opportunity for change within your healthcare organization and propose an idea for a change in practice supported by an EBP approach.

To Prepare:

• Reflect on the four peer-reviewed articles you critically appraised in Module 4, related to your clinical topic of interest and PICOT (attached below)
• Reflect on your current healthcare organization (Behavioral health hospital-children services/adults) and think about potential opportunities for evidence-based change, using your topic of interest and PICOT as the basis for your reflection (attached below)
• Consider the best method of disseminating the results of your presentation to an audience. 

The Assignment: (Evidence-Based Project)

Part 4: Recommending an Evidence-Based Practice Change

Create an 8- to 9-slide PowerPoint presentation in which you do the following:

• Briefly describe your healthcare organization (Behavioral health hospital), including its culture and readiness for change. (You may opt to keep various elements of this anonymous, such as your company name.)
• Describe the current problem or opportunity for change (psychiatric related). Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.
• Propose an evidence-based idea for a change in practice using an EBP approach to decision making. Note that you may find further research needs to be conducted if sufficient evidence is not discovered.
• Describe your plan for knowledge transfer of this change, including knowledge creation, dissemination, and organizational adoption and implementation.
• Explain how you would disseminate the results of your project to an audience. Provide a rationale for why you selected this dissemination strategy.
• Describe the measurable outcomes you hope to achieve with the implementation of this evidence-based change.
• Be sure to provide APA citations of the supporting evidence-based peer reviewed articles you selected to support your thinking.
• Add a lessons learned section that includes the following:
  • A summary of the critical appraisal of the peer-reviewed articles you previously submitted (attached below)
  • An explanation about what you learned from completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template (1-3 slides) (attached below)

  Rubric (please follow and read):

  Part 4: Disseminating Results/ Create a, 8-9-slide narrated PowerPoint presentation of your Evidence-Based Project: Briefly describe the following: your healthcare organization and culture, current opportunity for change, scope of issue, and EBP best practice recommendation. Explain how you would plan knowledge transfer and dissemination. Describe measurable outcomes with the implementation of EBP best practice. Summarize lessons learned.
  -The narrated presentation fully integrates at least two outside resources and two or three course-specific resources that fully support the presentation.
  -The presentation is professional; images are appropriately attributed; images are clear. The presentation text is readable. Presentation flows well and is presented in a logical order.

Unit 7 Discussion Case Study —2 Peer Response 600w. Due 10-20-23

Please read and respond to at least two of your peers' initial postings. You may want to consider the following questions in your responses to your peers:

· Compare and contrast your initial posting with those of your peers.  

· How are they similar or how are they different?

· What information can you add that would help support the responses of your peers?

· Ask your peers a question for clarification about their post.

· What most interests you about their responses? 

Please be sure to validate your opinions and ideas with citations and references in APA format.

Unit 7: Initial Discussion-Case Study RM

· A 70-year-old woman has scheduled an initial evaluation with you. Her medical diagnoses include hypertension, hyperglycemia, mild obesity, and hyperlipidemia. Her psychiatric diagnoses include anxiety and depression. Her current medications are atorvastatin 20 mg daily for seven years, Ozempic 1 mg injection weekly for three years, lisinopril 10 mg daily for 10 years, and Abilify 5 mg daily for six years. 

· Labs: Fasting Blood Glucose – 115, HbgA1C – 6.9, Total Cholesterol – 200, LDL – 100, HDL – 37. Her height is 5’2” and her weight is 176 pounds. Her blood pressure was 146/83 upon arrival at the office.  

· During your interview, she explains she became depressed following the death of her husband seven years ago. She became anxious about performing everyday tasks without him present.  After starting Abilify, she gained 25 pounds and required an increased dose of atorvastatin and Ozempic. She has been unable to lose the weight she gained and tries to closely monitor her dietary intake due to her persistently elevated glucose but reports still craving carbohydrates.  Her depression has improved slightly but she is still anxious to go out alone, so she no longer goes for daily walks to exercise. 

Subjective: 

CC: initial evaluation 

HPI: A 70-year-old female presents to the clinic for initial evaluation. She is a new patient in the practice. She reports a current history of hypertension, hyperglycemia, mild obesity, and hyperlipidemia. She also reports currently being diagnosed with anxiety and depression. She reports taking atorvastatin 20 mg daily for 7 years for hyperlipidemia, Ozempic 1 mg injection weekly for three years for hyperglycemia, lisinopril 10 mg daily for 10 years for hypertension, and ability 5 mg daily for 6 years for depression. 

PMH: Hypertension, hyperlipidemia, hyperglycemia, mild obesity, anxiety, and depression.  

Allergies: none reported 

Medications: atorvastatin 20 mg daily for 7 years for hyperlipidemia, Ozempic 1 mg injection weekly for three years for hyperglycemia, lisinopril 10 mg daily for 10 years for hypertension, and Abilify 5 mg daily for 6 years for depression. 

SH: Patient lost her husband seven years ago and became depressed. The patient reports her anxiety increased to perform everyday tasks without her husband. The patient states, that after starting Abilify she gained 25 pounds and required an increased dose of atorvastatin and Ozempic.  She has been unable to lose the weight she gained and tries to closely monitor her dietary intake due to her persistently elevated glucose but reports still craving carbohydrates.  Her depression has improved slightly but she is still anxious to go out alone, so she no longer goes for daily walks to exercise. 

FH: N/A 

Health promotion and maintenance: N/A 

ROS:  

Constitutional	reports weight gain of 25 lbs.
Head	N/A
Eyes	N/A
Ears, Nose, Mouth, Throat	N/A
Neck	N/A
Cardiovascular/Peripheral Vascular	N/A
Respiratory	N/A
Breast	N/A

Gastrointestinal	Reports increased cravings for carbohydrates.
Genitourinary	N/A
Musculoskeletal	N/A
Integumentary	N/A
Neurological	Alert and oriented x 3.
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)	Reports anxiety to go out of her house alone and depression slightly improved
Endocrine	Reports persistent elevated glucose and carbohydrate cravings.
Hematologic/Lymphatic	N/A
Allergic/Immunologic	N/A
Other

Objective:   

Her height is 5’2” and her weight is 176 pounds. Her blood pressure was 146/83 upon arrival at the office.  Labs: Fasting Blood Glucose – 115, HbgA1C – 6.9, Total Cholesterol – 200, LDL – 100, HDL – 37. 

·
What advice or modifications to his treatment regimen would you recommend for your new patient? (Discuss a minimum of two). Please support your answer with research-based evidence.  

This 70-year-old female patient presents with diabetes as evidenced by a FBS of 115 

and a HgbA1C of 6.9. A HgbA1C level equal to 6.5% or greater indicates a diagnosis of diabetes mellitus 

(Centers for Disease Control and Prevention, 2023). The patient is currently at considerable risk for cardiovascular disease due to her borderline total cholesterol level of 200, LDL of 100, and HDL 37. The patient’s height is 5’2″ and weight is 176 lbs, BMI is 32.2 as per CDC (Centers for Disease Control) guidelines patient is obese which also contributes to cardiovascular disease (Centers for Disease Control and Prevention, 2022). The normal weight for the height of this patient is between 101lbs-136lbs (Centers for Disease Control and Prevention, 2022). According to Healthline, total cholesterol levels should be less than 200, LDL less than 100, HDL greater than 60, and triglycerides less than 149 for adult patients (2021). The patient has also been experiencing high blood pressure, BP 146/83 upon arrival. The patient has currently been taking lisinopril 10 mg daily for hypertension, atorvastatin 20 mg daily for 7 years for hyperlipidemia and Ozempic 1 mg injection weekly for three years for hyperglycemia. 

The patient has also been taking Abilify 5 mg daily for 6 years for depression. During this time, the patient gained twenty-five pounds and required an increased dose of Ozempic and atorvastatin. The patient has been unable to lose the weight she gained and reports closely monitoring dietary intake due to persistently increased glucose levels and carbohydrate cravings. The patient’s states depression slightly improved, however, anxiety has not improved and now the patient is having trouble leaving the house alone.  

According to the patient’s assessment, my treatment plan would be to continue Ozempic 1 mg injections weekly for diabetes management and add metformin IR 500mg PO BID with meals (Corcoran & Jacobs, 2023). Patient to check finger stick blood glucose levels 1-2 times daily on an empty stomach. Recommend the patient to a diabetes education program. To manage her cholesterol levels, I would titrate her atorvastatin from 20 mg to 40 mg PO daily. Re-check patient's lipid levels in 2-4 weeks (Drugs, 2023). To manage her high blood pressure, I would increase her lisinopril to 10 mg PO BID as a study shows that prescribing lisinopril twice daily vs once daily shows more improvements in SBP. Mean adjusted SBP reduction was 10.2 mm Hg greater in the twice‐daily cohort compared with the once‐daily cohort (Tsai et al., 2017). The patient will be coming back for follow-up in 2-4 weeks for further treatment outcome and if necessary, treatment plan adjustment.  

The patient has chronic depression that has improved slightly; however, she does voice increased anxiety and new symptoms of fear of going out alone since her husband died seven years ago. The patient is now restricting herself from going out for walks and exercise. She is starting to exhibit symptoms of agoraphobia. The patient is currently taking Abilify 5 mg PO daily for 6 years. Typically, second-generation antipsychotics are not the first line of treatment for depression, they are used once they have tried many antidepressants with no effect. I suggest treatment augmentation with an antidepressant. Zoloft is an SSRI that does not counteract Abilify, start Zoloft at 25 mg PO daily and increase the dose weekly as needed. Zoloft is used for depression and social anxiety disorder (Psych Central, 2021). The patient will also benefit from psychopharmacology, psychotherapy, cognitive behavioral therapy. 

Lastly, lifestyle change recommendations include diet and exercise modification. Work your way up to 150 minutes of moderate-intensity aerobic activity each week. This could be brisk walking 30 minutes a day, 5 days a week. Or you could do 75 minutes of vigorous-intensity aerobic activity each week, such as swimming laps. Regular physical activity provides immediate and long-term 

health benefits.Links to an external site.
 Physical activity and weight loss will Improve sleep quality, reduce high blood pressure, and reduce risk for type 2 diabetes, heart attack, stroke, and 

several forms of cancerLinks to an external site.
. It can help reduce arthritis pain and associated disability, reduce the risk for osteoporosis and falls, and reduce symptoms of depression and anxiety (Centers for Disease Control and Prevention, 2023). 

·
If you suggested additional medication, look up your state’s prescribing laws. Are PMHNP’s able to prescribe the medication you recommended?  

 Yes, as a practicing PMHNP for the state of Pennsylvania, prescribe drugs, devices, and Schedule II-V controlled substances if there is a written collaboration agreement with a physician (Pennsylvania Coalition of Nurse Practitioners, n.d.).  

References: 

Balaram, K., & Marwaha, R. (2023). Agoraphobia.
 NIH. 

https://www.ncbi.nlm.nih.gov/books/NBK554387/Links to an external site.
 

Centers for Disease Control and Prevention. (2022). Adult BMI calculator. CDC. 

https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.htmlLinks to an external site.
 

Centers for Disease Control and Prevention. (2023). Diabetes tests. 
CDC. 

  

https://www.cdc.gov/diabetes/basics/getting-tested.htmlLinks to an external site.
 

Centers for Disease Control and Prevention. (2023). Physical activity for a healthy weight. 
CDC. 

https://www.cdc.gov/healthyweight/physical_activity/index.htmlLinks to an external site.
 

Corcoran, C., & Jacobs, T.F. (2023). Metformin. 
NIH. 

https://www.ncbi.nlm.nih.gov/books/NBK518983/Links to an external site.
 

Drugs. (2023). Atorvastatin dosage. 

https://www.drugs.com/dosage/atorvastatin.html#Usual_Adult_Dose_for_HypertriglyceridemiaLinks to an external site.
 

Pennsylvania Coalition of Nurse Practitioners. (n.d.). Scope of Practice. PACNP. 

https://www.pacnp.org/page/ScopeofPractice#:~:text=In%20Pennsylvania%2C%20an%20NP%20may,collaboration%20agreement%20with%20a%20physicianLinks to an external site.
. 

Psych Central. (2021). Zoloft: What you want to know? 

https://psychcentral.com/drugs/zoloft#basicsLinks to an external site.
 

Tsai, T., Kroehl, M. E., Smith, S. M., Thompson, A. M., Dai, I. Y., & Trinkley, K. E. (2017). Efficacy and 

safety of twice- vs once-daily dosing of lisinopril for hypertension. 
Journal of clinical hypertension (Greenwich, Conn.), 
19(9), 868–873. https://doi.org/10.1111/jch.13011 

Unit 7 Discussion Case Study MV

What would be your approach to managing this patient’s weight concern? (Discuss at least two aspects of your approach). Support your answer with research-based evidence.

In managing this patient's weight concern, a comprehensive approach that addresses both behavioral and pharmacological aspects would be necessary. First and foremost it's crucial to evaluate if the patient is prepared to make changes and how motivated she is to lose weight. We can use motivational interviewing techniques to delve into her reasons, for wanting to shed pounds and uncover any obstacles or difficulties she might encounter (Bischof et al., 2021). To address her worries, about how her weight might affect her ability to care for her child it could be advantageous to involve a team of professionals that includes a registered dietitian, an exercise specialist and a psychologist or therapist. The dietitian can work with the patient to develop a personalized meal plan that takes into consideration her busy schedule and frequent eating out habits. Emphasizing portion control, incorporating healthier food choices, and encouraging mindful eating practices have been shown to be effective in managing obesity (Foster et al., 2018). In terms of physical activity, an exercise specialist can help the patient create an individualized exercise routine that is feasible given her current responsibilities as a stay-at-home mother. Promoting regular physical activity has been found to aid in weight loss so finding activities that she enjoys and can incorporate into her daily routine will enhance adherence maintenance (Posadzki et al., 2020).

What would be our approach to the sexual side effects she is experiencing?

Regarding the sexual side effects experienced by the patient, it is crucial to address these concerns openly and compassionately. It's important to determine whether the issues are primarily caused by medication use or if they're influenced by factors, like stress or relationship dynamics. It might be beneficial to educate the patient about how fluoxetine and olanzapine can affect sexual functioning. If it is determined that the medication is causing these problems switching from fluoxetine to another antidepressant that has a less impact on sexual function could be considered. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine have been linked to sexual dysfunction (Yuan et al., 2021). Bupropion, which is an atypical antidepressant, with a lower likelihood of causing sexual side effects could be an alternative option worth exploring (Montejo et al., 2019).

If you suggest additional medication, look up your state’s prescribing laws. Are PMHNPs able to prescribe the medication you recommend?

Before suggesting any additional medication options such as Bupropion, it is essential to review prescribing laws specific to Illinois. As a PMHNP prescribing additional medication for the above concerns would depend on state laws. According to the Illinois Nurse Practice Act (2017), advanced practice registered nurses (APRNs) including PMHNPs have prescriptive authority. However, there are specific conditions and restrictions outlined in the Act (AANP, 2022). Therefore, it is necessary to review the current regulations and guidelines set forth by the Illinois Department of Financial and Professional Regulation (IDFPR) to ensure compliance with prescribing laws when considering Bupropion as a treatment option for this patient (Kleinpell et al., 2023). Psychiatric Mental Health Nurse Practitioners (PMHNPs) in Illinois have prescriptive authority to reduce practice. Illinois state law requires a career-long regulated collaborative agreement with a psychiatrist in order for the NP to prescribe medication. The nurse practitioner-psychiatrist collaborative practice agreement outlines their working relationship. It describes the categories of care, treatment, and procedures the nurse practitioner expects to perform (AANP, 2022). In Illinois, psychiatrists are not required to be physically present with the PMHNP. The psychiatrist must be available for consultation whether in person or by phone. A collaborating psychiatrist and PMHNP are required to meet at least once a month (AANP, 2022).

Include the subjective and objective information in this post.

Subjective information:

The patient reports concerns about her weight and its impact on her ability to care for her disabled child after her husband's death. She has tried numerous 'fad diets' without long-term success, losing only 15 pounds at most and maintaining it for three months. The patient expresses feelings of shame related to sexual dysfunction, specifically difficulty achieving orgasm during intimate moments with her husband.

Objective information:

The patient's objective data include being morbidly obese at 340 pounds with a height of 5'5″. She also has type II diabetes, hypertension, and hyperlipidemia. Additionally, she eats out frequently due to her children's busy schedules and leads a sedentary lifestyle with no regular physical activity.

References

American Association of Nurse Practitioners (2022). State practice by type. Retrieved from https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment/66-legislation-regulation/state-practice-environment/1380-state-practice-by-typeLinks to an external site.

Bischof, G., Bischof, A., & Rumpf, H.-J. (2021). Motivational interviewing: An evidence-based approach for use in medical practice. Deutsches Ärzteblatt international. https://doi.org/10.3238/arztebl.m2021.0014Links to an external site.

Foster, D., Sanchez-Collins, S., & Cheskin, L. J. (2018). Multidisciplinary team–based obesity treatment in patients with diabetes: Current practices and the state of the science. Diabetes Spectrum, 30(4), 244–249. https://doi.org/10.2337/ds17-0045Links to an external site.

Kleinpell, R., Myers, C. R., & Schorn, M. N. (2023). Addressing barriers to aprn practice: Policy and regulatory implications during covid-19. Journal of Nursing Regulation, 14(1), 13–20. https://doi.org/10.1016/s2155-8256(23)00064-9Links to an external site.

Montejo, A., Prieto, N., de Alarcón, R., Casado-Espada, N., de la Iglesia, J., & Montejo, L. (2019). Management strategies for antidepressant-related sexual dysfunction: A clinical approach. Journal of Clinical Medicine, 8(10), 1640. https://doi.org/10.3390/jcm8101640Links to an external site.

Posadzki, P., Pieper, D., Bajpai, R., Makaruk, H., Könsgen, N., Neuhaus, A., & Semwal, M. (2020). Exercise/physical activity and health outcomes: An overview of cochrane systematic reviews. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-09855-3Links to an external site.

Yuan, S., & Deban, C. E. (2021). Ssri-induced hypersexuality. American Journal of Psychiatry Residents' Journal, 16(3), 9–12. https://doi.org/10.1176/appi.ajp-rj.2021.160305Links to an external site.

Given the critical role of fluid, electrolyte, and acid-base balance in maintaining overall health, how can nurse practitioners effectively assess and identify subtle imbalances in their patients?

Student Instructions for i-Human Virtual Simulation

NR325/NR330 Maggie Naganashe Scenario 2

PURPOSE:

The following information is to be used in guiding your preparation and participation in the virtual simulation scenario for this course. This document will provide applicable course outcomes in preparation for your simulation.

SCENARIO OVERVIEW:

Maggie Naganashe is a 62-year-old American Indian female with chronic renal failure. She also has a 15-year history of type II diabetes mellitus and a history of hypertension, and hyperlipidemia. She lives on an American Indian reservation and is a proud member of the Odawa tribe. Mrs. Naganashe reports that she was unable to go to her dialysis treatment this week because her husband had to use their only car for a job interview. She was admitted for shortness of breath, swelling, weight gain and fatigue.

LEARNER OBJECTIVES:

1. Utilize clinical reasoning skills to perform a health history and physical assessment on an adult patient. (CO 1, 2, 3, 4)

2. Construct a plan of care based by prioritizing assessment findings and nursing diagnoses (CO 4, 5, 6, 7)

3. Evaluate patient outcomes to determine the effectiveness of nursing interventions and need for ongoing care (CO 4, 8)

4. Communicate and collaborate with the patient, family, and interdisciplinary healthcare team members (CO 3, 6)

STUDENT ROLES DURING SIMULATION:

You are the staff nurse at the hospital who will be conducting a comprehensive assessment. After completing your assessment, you are expected to document your findings as a nurse’s note in SBAR format.

KEY FEATURES OF i-HUMAN:

· As the nurse, you are expected to complete the case scenario using the following tabs: EHR, History, Physical, Analyze, Actions, Nursing Notes, Summary

· There are required questions and/or additional information provided related to this case. The questions, information, and videos must be completed/reviewed prior to progressing to the next tab.

· Nursing Notes: At the end of the simulation, you will document your assessment findings using ISBAR.

CONFIDENTIALITY:

To preserve the educational value, integrity, and safety of the learning environment, you agree to maintain strict confidentiality about the proceedings of the simulation session, details of the training scenarios and the performance of all participants. You acknowledge that this expectation aligns with the guidelines related to the Health Insurance Portability and Accountability Act (HIPAA) as well as laws governing Protected Health Information (PHI) in client care environments.  You will not view, discuss, share, record or disclose any confidential information pertaining to the session. You understand that lapses in confidentiality are considered academic misconduct and could result in dismissal from the academic program. 

FICTION AGREEMENT:

You will suspend judgment of realism for any given simulation in exchange for the promise of learning new knowledge and skills, treating the simulated patients with the same care due an actual patient, act with a genuine desire to learn even when it may be difficult to do so.  

DUE DATE:

The virtual simulation is assigned to be completed during

Week 4
prior to your scheduled debriefing with faculty/peers.

SIMULATION TIMING:

· Pre-simulation preparation: 30-60 minutes

· Pre-brief: 15 minutes

· Run Time: 2.75 hours

· Debriefing: 60 minutes

ASSESSMENT & EVALUATION

Faculty will utilize your participation measurements in the i-Human case, and debriefing discussions to identify areas of opportunity for enhancement of your clinical growth. Your experiences in i-Human will contribute to your overall completion of clinical requirements for the course as documented on the Clinical Learning Evaluation tool.

i-Human Evaluation – What does my total score mean?

REVIEW AND COMPLETE PRIOR TO THE START OF THE VIRTUAL SIMULATION:

In order to prepare for the simulation, you are
required to complete the pre-simulation questions below and submit this prework to the faculty via uploading your responses in Canvas prior to the start of the virtual simulation. If you do not complete the pre-simulation questions and upload them, you will

not
be able to access or participate in the simulation.

1. Describe the fluid and electrolyte imbalance that occur with chronic renal failure.

2. What are key patient education concepts related to chronic kidney disease?

3. Explore the CDC Tribal Data, Information, and Resources at
www.cdc.gov/tribal/data-resources and read the following article.

Mitchell, F. (2012). Reframing diabetes in American Indian communities: A social determinants of health perspective.
Health & Social Work, 37(2):71–79.

[Note: This article can be located through the Chamberlain University Library.]

4. Describe risk factors and conditions that lead to health disparities for American Indians.

Immediately following the completion of the virtual simulation, you will complete the evaluation of the simulation using the link provided.

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