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.

Adeyanju Bello

11/10/23, 2:49 PM NEW

The nurse and the patient must be aware of the interactions between medications and nutrients. The nurse must be able to ensure that the correct dose is given and that no negative interactions occur when showing the drug or explaining how to take it. The patient must comprehend and follow instructions correctly.

Fentanyl is a drug that interacts with nutrition. Fentanyl is used to treat “breakthrough” pain by altering the brain's and nervous system's response to pain. Grapefruit and grapefruit juice should be avoided because they increase the amount of medicine in the body, which can lead to an overabundance of fentanyl.

Warfarin is a blood thinner that prevents blood clots from forming or developing in the blood or blood arteries. Warfarin interacts with foods when you eat a constant amount of vitamin K. Broccoli, spinach, and kale are green, leafy vegetables that can make the drug less effective.

Linezolid is another medication that interacts with nutrition. This drug treats infections (such as pneumonia) and prevents bacteria from growing. If the patient is taking linezolid, tyramine-containing meals should be avoided. Cheese, excessive chocolate, caffeine, yogurt, raisins, bananas, sour cream, and sausage are all examples. The interaction can cause blood pressure to rise dangerously.

The interactions should be explained during client education so that the patient understands the importance of following the medication directions. An important point to remember about fentanyl medication is that increasing the dosage can increase the risk of overdosing and severe side effects (respiratory failure). The takeaway for warfarin is that the vitamin K level must be monitored and consistent for the medication to work correctly—finally, the importance of avoiding tyramine-containing foods while on linezolid should be thoroughly explained.

Amy Sanchez

11/9/23, 11:18 PM 

NEW

Top of Form

 1: Warfarin and Vitamin K

Interaction: Warfarin is a blood thinner that works by blocking the action of vitamin K, which is needed for blood clotting. Consuming foods high in vitamin K can interfere with the effectiveness of warfarin.

Foods to avoid: Foods high in vitamin K include leafy green vegetables (kale, spinach, cabbage), broccoli, Brussels sprouts, and liver.

Client education: Patients taking warfarin should be advised to maintain a consistent intake of vitamin K-rich foods. They should not completely avoid these foods but rather consume them in moderation to have a consistent balance of vitamin K intake. Regular monitoring of the blood clotting time is crucial in preventing complications.

Interaction 2: Monoamine oxidase inhibitors (MAOIs) and Tyramine

Interaction: MAOIs are used to treat depression, but they can interact with tyramine, a compound found in certain foods. MAOIs block the action of the enzyme that breaks down tyramine, leading to its accumulation, which can cause a sudden increase in blood pressure.

Foods to avoid: Foods high in tyramine include aged cheeses, cured meats (sausages, pepperoni), fermented foods (sauerkraut, soy sauce), and some alcoholic beverages.

Client education: Patients taking MAOIs must be informed about the potential risks of consuming foods high in tyramine, as it can lead to hypertensive crisis. They should be educated on the importance of avoiding these foods, especially during the early stages of MAOI treatment. Awareness of alternative food choices is crucial to ensure a safe diet.

Interaction 3: Calcium and Tetracycline antibiotics

Interaction: Calcium can bind to tetracycline antibiotics in the gastrointestinal tract, forming insoluble complexes that reduce the absorption of the medication.

Foods to avoid: Dairy products (milk, cheese, yogurt), calcium-fortified orange juice, and high-calcium foods like spinach and kale.

Client education: Clients on tetracycline antibiotics should be advised to avoid calcium-rich foods or supplements for several hours before and after taking the medication. It is important to emphasize the significance of adhering to the recommended dosing schedule to ensure optimal absorption and effectiveness of the antibiotics.

Bottom of Form

Based on your clinical practice area and location. What are some of the greatest cultural issues and trends that are frequently encountered? How do we as professional nurses rise to these challenges? Provide examples of cultural recognition while implementing evidence-based standards of care.

Sections of the assignment must include:

• Introduction
• Focus points covered in the discussion posts 
• Any arguments and rationales for your stance
• Conclusion or Summary

The components of your APA  Assignment includes the following:

• Your APA Assignment must include a title pg (Refer to Purdue OWL). 
• All in-text citations must be used when paraphrasing or quoting a previous author.
• All references must reflect the in-text citations used. 
• All reference sources must be within the past 5 years unless it is the works of a nurse theorist or a significant reference material. 
• The length of the assignment must be 750-1000 words. Please pay attention to spelling and grammar. Points will be deducted for repeat offenders. 
• Upon completion of the assignment, you must submit it via Turnitin.com, and please note that your plagiarism score should be no more than 20%.  If you score higher, please make adjustments. 

HUM 1050 – Introduction to Literature

Week 6 – Peers replies

 

Return to the forum on a second day this week read your peers’ posts Power Points. Respond to at least two of your peers. These posts should be substantive and add to the discussion. This could include asking a probing question or relating your own experience with whatever they have posted. 

Please see the two peers power point presentations attached to develop the two peers replies.