Reflective question answers. mreen

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Read the following case study and answer the reflective questions.  Please provide evidence-based rationales for your answers.  APA, 7th ed. must be followed. 

EVIDENCE BASE IN DESIGN

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Maria Hernandez

Main Post:

H.R. 977- Patient Access to Higher Quality Health Care Act of 2023.

 

Description: When a patient has health insurance, depending on which premium, they are made to use providers or hospitals that are “in-network” to avoid higher costs of services. This can often be an issue for patients because some providers are not in network with their health insurance, specifically Medicare recipients. The Patient Access to Higher Quality Health Care Act would “repeal changes made by health care reform laws to the Medicare exception to the prohibition on certain physician referrals for hospitals” (Congress.gov, 2023).

Background: According to the American Hospital Association, “For decades, the Ethics in Patient Referrals Act (“Stark Law”) has protected the Medicare program from the inherent conflict of interest created when physicians self-refer their patients to facilities and services in which they have a financial stake” (AHA, n.d.). At one point, physicians were allowed to make referrals to hospitals with ownership within the entire facility; this gap was closed in 2010 when the Affordable Care Act was passed.  

Social Determinant: One social determinant is access to health care and quality care. Patients, regardless of their socioeconomic status, should receive high-quality care. The American Hospital Association states, “The Government Accountability Office (GAO), the Centers for Medicare & Medicaid Services and MedPAC all found that physician-owned hospitals’ patients tend to be healthier than patients with the same diagnoses at general hospitals” (AHA, n.d.). This would lead those with serious illnesses to rely on general hospitals for healthcare services.

Evidence: The growth of Physician-owned hospitals was prohibited in 2010 after the passing of the Affordable Care Act. According to Ehrenfeld, “a systematic review of 30 years of research demonstrating that physician-owned specialty hospitals or so-called “focused factories” offer higher-quality care at comparable or lower cost, while physician-owned community hospitals are no worse than their counterparts” (Ehrenfeld, 2023). If H.R. 977 is passed into law, it would allow physicians of physician-owned hospitals to extend their services to the community by opening new hospitals that would provide high-quality, efficient care and be affordable to patients. This would place competition against general hospitals at risk of losing market share, leading them to reform their services to stay in competition. This would benefit patients in being able to seek assistance in a variety of hospital or hospital-owned facilities. 

 

References:

American Hospital Association. (n.d.). Fact sheet: Physician self-referral to physician-owned hospitals. https://www.aha.org/fact-sheets/2023-02-27-fact-sheet-physician-self-referral-physician-owned-hospitals

Congress.gov. (n.d.). H.R.977 – 118th Congress (2023-2024): Patient Access to Higher Quality Health Care Act of 2023. https://www.congress.gov/bill/118th-congress/house-bill/977?q=%7B%22search%22%3A%5B%22HR+977%22%5D%7D&s=1&r=1

Ehrenfeld, J. M. (2023, August 10). End restrictions on physician-owned hospitals to expand Quality Care. American Medical Association. https://www.ama-assn.org/about/leadership/end-restrictions-physician-owned-hospitals-expand-quality-care

Discussion 500 words. Make sure you provide 2 references and utilize APA style.. . Discussion Rubric

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Epidemiology and the stages of disease prevention

In this activity, you will apply the concept of prevention in terms of stages to a chronic disease control strategy in your country and consider the ways in which epidemiology can inform public health intervention.

Step 1: Review Table 6.1 “Levels of prevention” found on page 104 in this resource: Basic Epidemiology. (see attachment here) 

WHOBasicEpidemiology.pdf

Step 2: Choose one non-communicable chronic disease that is either prevalent in your community and one that you should know about as an APN.  

Step 3: Briefly describe several actions the APN, the state and US could take to contribute to primary, secondary, and tertiary prevention of your chosen chronic disease.  

Please address each of the following points in 200 to 300 words:

Primary: Briefly research (using online resources from a government, university, or professional association) and summarize the common risk factors for your chosen disease. Explain one or more actions your state/country could take to reduce the population’s exposure to one or more of these risk factors. (Note: Specify if you are recommending a strategy that targets the entire population or only high-risk individuals. ‘Population strategy’ and ‘High-risk individual strategy’ are described on pages 105-108 of the activity resource.)

Secondary: Briefly describe at least one common screening test for your chronic disease, and one or more actions your state/country could take to increase access to or increase public awareness of the benefits of this test. (Government websites are often a good place to get information about screening programs in your country. For example, information on cancer screening in the U.S.A. can be found here: http://www.cancer.gov/cancertopics/pdq/screening/)

Tertiary: Summarize one or more actions the healthcare system in your state/country could take to reduce the progression or complications of the disease you chose to focus on. (For example, you could describe the treatment, rehabilitation, or any other approaches that would help people, with the chronic disease, live longer and healthier lives).

Please be sure to adhere to the following when posting your weekly discussions:

1. Students are to write their name and the appropriate discussion number/discussion title in the title bar for each discussion. For example Discussion 1: Micheal Cabrera or Discussion 3: Sheila Smith. This is important in identifying that students are submitting original posts as well as response posts as required.

2. Students are to submit their discussions directly onto Blackboard Discussion Board Attachments submitted as discussion board posts will not be graded.

3.  As a reminder, all discussion posts must be minimum 500-550 words, references must be cited in APA format 7th Edition, and must include minimum of 3 scholarly resources published within the past 5-7 years (not part of the classroom coursework).  

FOCUSED CASE STUDY 2

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 Marie, A 58-year-old woman with a complicated history which includes chronic low back pain, bipolar disorder, mixed anxiety, and depressive disorder presents to her PCP, a PA, complaining of constipation for several months 

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Initial Post

Foundational Neuroscience

The term foundational neuroscience refers to a three-course series that explores the structure and function of the nervous system – from the inner workings of a single nerve cell to the staggering complexity of the brain and the social interactions it enables (Harvard Edu. 2020)

According to studies, cases of mental and psychiatric conditions have been on the increase. As a result of this crisis, there is a need for quality psychiatric health care that encompasses appropriate knowledge by health practitioners of dealing with these issues (Harvard Edu. 2020). This involves a deep understanding of the pathophysiology of psychiatric disorders and understanding the impact of certain drugs on a specific disorder. It has been advocated those psychiatric patients be referred to as clients as it is more favorable for mental health. This discussion will address the agonist and antagonistic agents, g- g-couple proteins and ion-gated channels, and the role of epigenetics in psychopharmacology.

The agonist-to-antagonist spectrum of action of psychopharmacologic agents.

 Also known as the agonist spectrum, describes the range of effects that can be exerted by psychopharmacological agents. For example, it describes how some medications/drugs can stimulate receptors in the brain just like natural neurotransmitters and how other drugs can block/prevent this action (Stahl, 2013). For example, benzodiazepines (Valium) increase/mimic the GABA neurotransmitter (agonist) and Flumazenil decreases/blocks this neurotransmitter (antagonist).  The agonist-to-antagonist spectrum psychopharmacologic agents work at the sites of neurotransmission and conduct their effects based on a spectrum of agonist-to-antagonist (Stahl, 2013). The spectrum ranges from true agonist to inverse agonist. Some examples of effects between the two ends are partial agonist, silent antagonist, and partial inverse agonist.

Agonist

Agonist is a chemical substance that binds to and activates certain receptors on cells. Agonistic drugs are drugs that modify or change the state of receptors to trigger a biological response. Oxycodone, morphine, heroin, fentanyl, methadone, and endorphins are all examples of opioid receptors (Stahl, 2013). According to Stahl (2013), a full agonist allows the receptor to fully open the ion channel which allows the downstream signal transduction to occur maximally. An agonist is any drug that activates specific brain receptors, thereby causing the full effects of the drug to take place

Partial Agonist

A partial agonist is any drug that acts as an agonist, but the degree of receptor activation is reduced. The receptor has a resting state. When a partial agonist is in contact with the receptor in a resting state, the ion channel will partially open, allowing some downstream signal transduction (Stahl, 2013).

Antagonist

Antagonistic drugs refrain or stop minimizing any biological response by blocking any presenting receptors (Camprodon et al., 2016). The antagonist will return the receptor to a resting state (Stahl, 2013). Constitutive activity still occurs in the presence of an antagonist, which is the minor ion flow despite being in a resting state (Stahl, 2013). When a drug is classified as an antagonist, it means that it blocks the receptors, so they are not able to bind to the agonist. In the realm of opioids, an example of an agonist is Heroin, the antagonist is Naloxone, while the the partial agonist is Buprenorphine. To illustrate this example, Heroin is an addictive agonistic substance. In the case of heroin overdose, Naloxone, an antagonist can be used to reverse the binding and block receptors from binding with free-floating Heroin. The pharmacological treatment for heroin addiction often includes the partial agonist, Buprenorphine. Buprenorphine allows partial binding to opioid receptors, thus reducing withdrawal symptoms and curving drug cravings (Camprodon et al., 2016).

Inverse Antagonist

Inverse agonists are the last type on the spectrum. Inverse agonists cause receptor changes, leading to the closing of the ion channels and eventual inactivation if not reversed (Stahl, 2013).

G Couple Proteins and ion-gated channels

G couple proteins and ion-gated channels are both major membrane receptors. The binding of a signaling molecule to a G-coupled protein receptor results in G protein activation, which in turn triggers the production of any number of second messengers, leading to G-coupled proteins helping to regulate a person’s immune system, growth, taste, smell, behavior, and mood (Rosenbaum et.al, 2009). Gated ion channels are proteins that open to allow ions such as Na+, K+, Ca2+or Cl- to pass through the cell membrane in response to a ligand such as a neurotransmitter (Stahl, 2013).

Comparison between G-couple protein and ion-gated channel and their actions

 The ion-gated channels, commonly known as, ligand-gated channels consolidate rapid postsynaptic responses while G-proteins consolidate slow postsynaptic responses (Camprodon et al., 2016). In terms of structure, the ion-gated channels are pores that open and close at the ligand binding while G-proteins include a single polypeptide. The G-protein receptors interact with proteins while ion channels regulate the flow of ions. G Couple Proteins and Ion-Gated Channels. Neurotransmission occurs not only electrically such as with ion-gated channels but also occurs chemically at receptors. G-protein linked receptors have seven transmembranes that each have a receptor to bind a neurotransmitter (Stahl, 2013). The first messenger is an extracellular neurotransmitter, and it passes the message to the second messenger system (Stahl, 2013). When the first messenger binds to the receptor, it changes the shape allowing the binding of the G protein, which then changes confirmation to allow binding with an enzyme (Stahl, 2013). Once bound, cyclic adenosine monophosphate is synthesized leading to the second messenger continuing neurotransmission to other messengers (Stahl, 2013).

Explain how the role of epigenetics may contribute to pharmacologic action.

Epigenetics not only has a role in the development of psychiatric and mental health disorders, but it can also affect the way medications work for each person. DeSocio (2016) describes synaptogenesis as the development of new neuronal connections that occur more rapidly during childhood but continue through adulthood as well. When stress hormones are present at high levels, there is a decrease in synaptogenesis (DeSocio, 2016).  Epigenetics can be defined in many ways, but the basis is that gene function can be altered without changing the DNA and RNA code. This functional change in the gene can also be inherited (Camprodon & Roffman, 2016, p. 64). As a result, epigenetics can determine how a medication works and what illnesses an individual may develop. If a medication works on a specific gene, but that gene has an altered function, the drug’s efficacy may change. For example, individuals with altered dopamine formation and receptor binding may have an affinity toward drug addiction or a degree of natural tolerance (Saad et al., 2019, p. 1534). For non-addictive substances, this logic holds as to why some medications work for one person, but not another individual.

Explain how this information may impact the way you prescribe medications to patients. Include a specific example of a situation or case with a patient in which the psychiatric mental health nurse practitioner must be aware of the medication’s action.

The above concepts of foundational neuroscience analyses will have an impact on how and what a psychiatric mental health nurse practitioner will prescribe to all clients. The knowledge learned will enable the provider to determine exactly which medication will help each client the most for their illness whether it be short-term or long-term. The PMHNP will be made more aware of the effectiveness of all medications used and their action for the client’s individual needs. Examples of the effects and actions are used to treat clients with anxiety and insomnia such as benzodiazepines which have an immediate effect on clients. Benzodiazepines can act as a full agonist on a positive allosteric modulator (PAM) by exhibiting an anxiolytic, hypnotic, anticonvulsant, amnestic, and muscle relaxant action (Stahl, 2013). Benefit-risk assessments must be considered by all providers when prescribing specific drugs to certain groups of clients. Extra care should be considered for clients, such as pregnant women, children, and the elderly because of their vulnerable states (Alshammari, 2016). An advanced psychiatric mental health nurse practitioner must be able to match the client’s symptoms with the correct medication to sometimes control their difficult symptoms (Laureate Education, 2016).

References

Alshammari, T. M. (2016). Drug safety: The concept, inception, and its importance in patients’ health. Saudi Pharmaceutical Journal, 24 (4), 405-412. doi: 10.1016/j.jsps.2014.04.008

Camprodon, J. A., & Roffman, J. L. (2016). Psychiatric neuroscience: Incorporating pathophysiology into clinical case formulation. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 1-19). Elsevier.

DeSocio, J. E. (2015). Epigenetics: An Emerging Framework for Advanced Practice Psychiatric Nursing. Perspectives in Psychiatric care/Volume 52, Issue 3/.201-207. https://doi.org/10.1111/ppc.12118Links to an external site.

Harvard University (2020). Fundamentals of Neuroscience: Electrical Properties of the Neuron. Retrieved September 4, 2023, from https://www.edx.org>lrstn>harva…

Laureate Education (Producer). (2016i). Introduction to psychopharmacology [Video file]. Retrieved from https://class.waldenu.eduLinks to an external site.

Rosenbaum, M. J., Clemmensen, L. S., Bredt, D. S. et al. Targeting receptor complexes: a new dimension in drug discovery. Nat Rev Drug Discov 19, 884-901 (2020). https://doi.org/10.1038/s41573-020-0086-4

Saad, M. H., Rumschlag. M., Guerra, M. H., Savonen, C. L., Jaster, A. M., Olson, P. D., Alazizi, A., Luca, F., Pique-Regi, R., Schmidt, C. J., & Bannon, M, J. (2019). Differentially expressed gene networks, biomarkers, long noncoding RNAs, and shared responses with cocaine identified in the midbrains of human opioid abusers. Scientific Reports, 9, pp. 1534. Retrieved from https://www.nature.com/articles/s41598-018-38209-8

Stahl, S. M. (2013). Stahl’s Essential Psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

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List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

When assessing this patient, it's important to ask questions that will help the provider understand the underlying causes and potential treatment options. Given the patient's recent loss and significant life changes, it's crucial to approach the assessment with sensitivity. Here are three questions I'd like to ask, along with their rationales:

1. Have you observed any changes in your sleep pattern, mood, or feelings since your husband passed away?

Rationale: This question allows the patient to provide insight into the nature and duration of her sleep disturbances and changes in her mood or feelings. Understanding the onset and progression of depression symptoms can related to her recent bereavement following her husband's passing.

2. Could you describe your emotions and have you ever experienced thoughts of self-harm or suicide?

Rationale: This question aims to comprehend a person's emotional state and evaluate the presence of suicidal thoughts or self-harm ideation. It's important to ask such questions without delay in treatment. Since the patient has a history of major depressive disorder (MDD), and her depression has worsened, it's crucial to explore her emotional state.

3. How have you been coping with the loss of your husband, and have you sought support or counseling to help you through this difficult time?

Rationale: Inquiring about coping strategies and support systems is essential for assessing the patient's resilience and identifying potential sources of assistance. Grief counseling or therapy can be invaluable in helping individuals navigate the complex emotions associated with loss. Additionally, it's important to assess whether the patient has been utilizing any resources to manage her depression.

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Identify people in the patient's life you would need to speak to or get feedback from to further assess the patient's situation. Include specific questions you might ask these people and why.

To gain a more comprehensive understanding of the patient's situation and evaluate her social support network, I would identify individuals in the patient's life, such as family members or close friends. Engaging in conversations with these individuals can be beneficial because they may have insights into the patient's emotional well-being and daily functioning. I would ask Questions like: “Could you please share any observations regarding alterations you may have noticed in the patient's behavior, mood, or sleep patterns following her husband's passing?” Family members and close friends are often the first to detect significant shifts in a person's behavior and emotional state. Their observations can offer valuable insights into the patient's emotional condition and the way the loss of her husband has affected her daily life.

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Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

In evaluating a 75-year-old patient with a chief complaint of insomnia and depression, diabetes (DM), and hypertension (HTN), a thorough assessment should include both physical exams and diagnostic tests: A physical examination should include checking blood pressure, heart rate, heart sounds, peripheral pulses, respiratory rate, and temperature. It should also involve assessing the patient's overall appearance and evaluating their general health.  In addition, assessing mental status, cognitive function, and neurological signs can help identify any neurological issues that may be contributing to sleep disturbances. Consider arranging a sleep study, also known as polysomnography (PSG). This medical test monitors various physiological functions while a person sleeps.

Diagnostic Tests include the following Blood Tests: Complete Blood Count (CBC) will check for anemia or other blood-related issues that can affect sleep and overall health; a Comprehensive Metabolic Panel (CMP), assess kidney and liver function, electrolytes, and glucose levels; The HbA1c (Glycated Hemoglobin) test can monitor her long-term blood glucose control, can provide valuable insights into her diabetes management. The results of these exams and tests will inform a comprehensive treatment plan tailored to the patient's specific needs.

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List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

When assessing a patient with insomnia, along with chronic medical conditions like diabetes and hypertension, this patient likely has Major Depressive Disorder (MDD). She had no history of MDD before her husband's passing, and the current worsening of her depression may be attributed to his death. Although anxiety can cause insomnia problems, MDD with Bereavement seems most likely. However, we need to ensure there aren't other underlying causes, such as sleep problems or medical issues. To do that, we should conduct thorough assessments and laboratory tests. She needs to seek help from both her regular doctor and a mental health professional to find the right treatment and support.

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List two pharmacologic agents and their dosing that would be appropriate for the patient's antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

When selecting pharmacologic agents for this 75-year-old patient, the choice of antidepressant therapy should consider pharmacokinetics and pharmacodynamics. Reduced kidney and liver function in elderly individuals can potentially affect both pharmacokinetics and pharmacodynamics.

SSRIs, such as sertraline (Zoloft) and escitalopram (Lexapro), are two preferred for elderly patients. They are generally well-tolerated and have a lower risk of certain side effects, such as sedation or anticholinergic effects, which can be problematic for older adults. Sertraline (Zoloft) 150mg once daily or Escitalopram (Lexapro) 20 mg daily would be appropriate for this patient.

The patient has been taking Sertraline (Zoloft), her start dose was 100mg daily; increase slowly, no more than a maximum Dose of 200 mg once daily; sertraline increases serotonin levels and can be effective in treating depression. Escitalopram is considered perhaps the best-tolerated SSRI, with the fewest cytochrome P450 (CYP450)-mediated drug interactions. (Stahl, 2021). Escitalopram (Lexapro) 20 mg daily is also the appropriate choice.

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For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?

When prescribing antidepressant therapy, it's important to consider drug contraindications and alterations. For the selected antidepressant, escitalopram (Lexapro), don't use it with MAOIs or within 14 days after stopping an MAOI to prevent serotonin syndrome. This is a contraindication due to the risk of serotonin syndrome, a potentially life-threatening condition characterized by agitation, confusion, rapid heart rate, and other symptoms. Escitalopram is primarily metabolized in the liver; it should be used with caution in patients with severe hepatic impairment or elderly with decreased liver function. In such cases, a lower initial dose and slower titration may be considered, as drug clearance may be reduced.

In all cases, ethical prescribing involves a thorough assessment of the patient's medical history, medication history, and potential contraindications. Dosing adjustments, when necessary, should be made to maximize therapeutic benefits while minimizing risks and adverse effects.

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Include any “checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

In depression treatment, scheduled follow-up appointments are vital for assessing progress, managing side effects, and adjusting treatment. Common intervals are every 4 weeks. At the checkpoint, like follow-up data at weeks 4, 8, 12, etc., make treatment decisions based on the patient's response, side effects, and goals. If there's significant improvement with few side effects, stick with the current dose. If there's limited improvement or major side effects, consider increasing the dose (if not already at the maximum) or trying a different antidepressant. In cases of long-term remission with a low risk of recurrence, think about tapering or discontinuing the medication.

At Week 4 (four weeks after initiating treatment), it's the time to evaluate the patient's initial response to medication. Inquire about changes in mood, sleep patterns, energy levels, and any side effects.

At Week 8 (eight weeks after starting treatment), it's time to reassess the patient's mood and overall well-being. Keep an eye on side effects, whether they're taking the medication as prescribed, any changes in their medical conditions, and any suicidal ideation.

At Week 12 (12 weeks after starting treatment), continue monitoring the patient's mood and how they're responding to treatment. Check for any signs that their depression might be coming back or getting worse.

Ongoing Follow-up (Regularly, every 3-6 months): Continue to monitor the patient's mental health, medication adherence, and any emerging side effects. Evaluate the need for ongoing treatment.

 


Reference:

Levenson JC, Kay DB, Buysse DJ. The pathophysiology of insomnia. Chest. 2015 Apr;147(4):1179-1192. doi: 10.1378/chest.14-1617. PMID: 25846534; PMCID: PMC4388122.

Stahl, S. M. (2021). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.

Lexapro Labeling-508; Reference ID: 4036381 https://www.fda.gov/media/135185/download

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A 41-year-old male presents to the doctor’s office you work at complaining of a sore throat and headache. Upon examination, he is diagnosed with a virus that is currently prevalent in the area he works. He is told to rest and drink liquids until the virus has run its course. He becomes irate and tells you he wants an antibiotic.

  1. How could you explain to him why he does not need an antibiotic?
  2. What are some alternatives you could consider for a patient who demands an antibiotic?

Instructions: It is a discussion post so 1 page to 1 1/2 pg is good enough. Apa format. Must have 3 references.

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Module 09 Written Assignment – Cultural Factors and Their Influence on Medication

In this written assignment, select one cultural factor such as health beliefs, language, perception of time, environment control, etc. (see textbook reading) and apply it to a selected ethnic group. The paper will include the following:

1. One impact on medication preparation. Explain.

2. Two impacts on medication administration. Explain.

3. Two potential adverse reactions. Explain with rationale.

4. One possible issue in adherence to medication regimen. Explain how this can be overcome.

The paper should be no more than 3 pages. Use APA Editorial Format for all citations and references used.

Submit your completed assignment by following the directions linked below. Please check the 
Course Calendar
 for specific due dates

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NOTE

Strictly APA, CITATION,AND REFERENCING,PLAGIARISM-CHECK

Proposed Project Interventions

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Please read the attachment for the instructions

Discussion Week 2 Nursing Theory

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Making judgement as to whether a theory could be adapted for use in research is very important.  Describe the internal and external criticism that is used to evaluate middle range theories.