Devry NR601 Week 2 Discussion (dq1+dq2) Latest 2019 MAY Question # 00603242 Course Code : NR601 Subject: Health Care Due on: 07/18/2019 Posted On: 07/18/2019 05:21 AM Tutorials: 1 Rating: 4.9/5

NR601 Primary Care of the Maturing and Aged Family

Week 2 Discussion

DQ1 Polypharmacy

Polypharmacy
is a common concern, especially in the elderly.

List the
definitions of polypharmacy you encounter in your assigned reading. Include an
additional reference from an evidence based practice journal article or
national guideline.

Discuss
three risk factors that can lead to polypharmacy. Explain the rationale for why
each listed item is a risk factor. Risk factors are different than adverse drug
reactions. ADRs can be a result of polypharmacy, and is important, but ADRs are
not a risk factor.

Discuss
three action steps that a provider can take to prevent polypharmacy.

Provide an
example of how your clinical preceptors have addressed polypharmacy.

Discussion
Guiding Principles

The ideas
and beliefs underpinning the discussions guide students through engaging
dialogues as they achieve the desired learning outcomes/competencies associated
with their course in a manner that empowers them to organize, integrate, apply
and critically appraise their knowledge to their selected field of practice.
The use of discussions provides students with opportunities to contribute
level-appropriate knowledge and experience to the topic in a safe, caring, and
fluid environment that models professional and social interaction. The ebb and
flow of a discussion is based upon the composition of student and faculty
interaction in the quest for relevant scholarship. Participation in the
discussion generates opportunities for students to actively engage in the
written ideas of others by carefully reading, researching, reflecting, and
responding to the contributions of their peers and course faculty. Discussions
foster the development of members into a community of learners as they share
ideas and inquiries, consider perspectives that may be different from their
own, and integrate knowledge from other disciplines.

DQ2 ACC/AHA
Guidelines Discussion

Chief
complaint: medication refill “ran out of medicine”

HPI: BJ, a
68-year-old AA female presents to the clinic for prescription refills. The
patient also indicates that she has noticed shortness of breath which started
about 3 months ago. The SOB gets worse with activity, especially when she is
playing with her grandchildren but it goes away once she sits down to rest. She
reports that she is also bothered by shortness of breath that wakes her up at
night, but it resolves after sitting upright on 3 pillows. She also has lower
leg edema which started 1 week ago. She also indicates that she often feels
light headed and faint while going up the stairs, but it subsides after sitting
down to rest. She has not tried any OTC medications at home. She never filled
her prescriptions, which she received at her checkup 6 months ago, she did not
think it was important.

PMH:

Hypertension

Previous
history of MI in 2010

Surgeries:

2010-Left
Anterior Descending (LAD) cardiac stent placement

Allergies:
Amoxicillin

Vaccination
History:

She
receives an annual flu shot. Last flu shot was this year

Has never
had a Pneumovax

Has not had
a Td in over 20 years

Has not had
the herpes zoster vaccine

Social
history:

High school
graduate, a widow with one son who loves out of state. She drinks one 4-ounce
glass of red wine daily. She is a former smoker that stopped 20 years ago.

Family
history:

Both
parents are deceased. Father died of a heart attack; mother died of natural
causes. She had one brother who died of a heart attack 20 years ago at the age
of 52.

ROS:

Constitutional:
Lightheaded and faint with exertion.

Respiratory:
Shortness of breath with exertion (playing with grandchildren and stairs). +
Orthopnea

Cardiovascular:
+ leg and ankle swelling x 1 week

Psychiatric:
Not taking medications for 6 months – “ran out”

Physical
examination:

Vital Signs

Height: 5
feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 oral P 100 R 22,
non-labored;

HEENT:
normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower
dentures in place a fitting well. No tinnitus

NECK: Neck
supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable

LUNGS:
inspiratory crackles

HEART:
Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic
murmur noted at the right upper sternal border without radiation to the
carotids.

ABDOMEN:
Normal contour; active bowel sounds all four quadrants; no palpable masses.

PV: Pulses
are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting
edema to her knees noted bilaterally

GENITOURINARY:
no CVA tenderness; not examined

MUSCULOSKELETAL:
Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral
knees on flexion and extension with tenderness to palpation medially at both
knees. Kyphosis and gait slow, but steady.

PSYCH:
normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.

SKIN:
Sparse hair noted on lower legs and feet bilaterally with dry skin on her
ankles and feet.

Labs:: Hgb
12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL
190, TSH 3.7, glucose 98 BUN 12 Cr 0.8

A:

Primary
Diagnosis:

Congestive
Heart Failure (CHF) (150.9)

Secondary
Diagnoses:

Primary
Hypertension (I10)

Depression
F32.3:

Obesity
(E66):

Osteoarthritis
(OA) (715.90)

Differential
Diagnosis:

Peripheral
Vascular Disease (PVD) (173.9)

P:

Medications:

Sertraline
25 mg. Take 1 tab PO QD disp#30, 1 refill

Tylenol 650
mg PO Q4 hours as needed for arthritis pain

Labs: UA;
Brain natriuretic peptide (BNP); LFTs and TSH.

12-lead
EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index

Education:

Congestive
heart failure is caused by the inability of your heart to pump blood
effectively enough to meet the demands of your body. If you think of your body
as any other pump, if fluid does not move well through the system, then it will
back up into other spaces. When blood backs up it puts a lot of pressure on the
blood vessels, which forces fluid to leak out into the nearby tissue. With CHF,
this fluid usually moves into your lungs, legs, or abdomen.

The signs
of worsening CHF include decreased energy level, shortness of breath during
your normal routine, increased swelling to your legs and feet, your clothes
feel tight, or a wet sounding cough. Call the office if these symptoms occur.

Weigh
yourself every morning at the same time. If you have a 3 pound weight gain in
24 hours, or a 5 pound weight gain over a week, you should call the office.

Exercise
and maintaining a normal weight is very important. You should try to exercise
at least 20-30 minutes a day, more if possible. Start slow with walking.

Decrease
your salt intake. Do not add any extra salt to foods. Salt makes you retain
fluid, and it makes you want to drink more fluid. Avoid fast food and prepared
food as they are usually very high in sodium.

If you notice
your legs swelling, elevate them up and rest. Do not drink alcohol and continue
to avoid smoking or second hand smoke.

Take your
medications as directed, with water. Do not stop them abruptly or skip doses.

I have
started you on a medication for depression. It can take 2 weeks to start to
feel it working and up to a month until you can fell the real benefits.

If you
start to feel more depressed, like you want to harm yourself or others, please
contact me right away or got to the ER.

Referrals:
may refer based on lab results

Follow up:
return to office in 2 weeks to review lab results and adherence to treatment
plan.

Additional
lab results:

Echo
results: LVEF 39%

BNP – 682
pg/ml

Questions:

According
to the ACC/AHA Guidelines, what is BJ’s heart failure stage? Include the
pertinent positives (the signs and symptoms AND the objective data) to support this finding. Cite your reference.

According
to the ACC/AHA Guidelines, what medications should BJ be prescribed? Include
the drug class and rationale statement for each medication listed. Cite your
reference for each medication.

Given her
history of MI, what additional medications will you prescribe? Include the drug
class and rationale statement for each medication listed. Cite your reference
for each medication, prescribed or OTC .

Write her
complete prescriptions using the prescription writing format.