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CLINICAL CASE DECISION INSTRUCTIONS

1. Your comments should be substantiated and substantive. Postings require two citations from 1 scholarly journal and/or 1 outside textbook. Textbooks assigned to this course may be used for an additional citation only.   
2. Each of the two references must be from a different reference source.
3. To gain full credit for the assignment, the response must be a full page, but no more than three (3) pages in length, which includes the reference list.
4. Students are required to use APA format, proper citations, and references.  Students using direct quotes from referenced sources in the body of the paper must include quotations.
5. Students will be assigned to a question.

Clinical Decision Case study.

Begin with a Head-Toe assessment, you decide if it should be treated as episodic with rationale.

You have been assigned two (2) cases to provide analysis. All cases should include the following

a. Pathophysiology and pharmacology of the disease

b. Expected signs and symptoms of the disease.

c. Nursing Diagnosis with a plan of care.

d. All questions pertaining to the case as listed under each case. 

You have been assigned two (2) cases to provide analysis. 

C1.  Mr. Bush, a 45-year-old middle school teacher arrives at the emergency department by EMS ground transport after he experienced severe mid-sternal chest pain at work. On arrival to the ED,

a.  What priority interventions you would initiate?

b. What information would you require to definitively determine what was causing Mr. Bush’s chest pain?

C2. Explain how diuretics, receptor antagonists, angiotensin converting enzyme antagonists, and angiotensin receptor antagonists reduce blood pressure in individuals with primary hypertension.

Pleas ONLY place bid if you can get done in 18 hrs from the time the deposit is given. 

Instruction: 

Min: 1500 words, APA Format. 

1. Identify and briefly discuss the body system selected for the topic of this paper ( Endocrine system, diabetes in particular) 
   1. Discuss the physiology (structure and function) of the body system including details about the major organ systems (if applicable)
   2. Discuss relevant health history questions (subjective data) pertaining to the body system
   3. Discuss an overview of the objective data and expected normal physical examination findings for this body system
   4. Discuss special physical assessment examination techniques or procedures specific to assessing this body system
   5. Discuss how you might adapt your physical assessment skills or techniques to accommodate each of the following specific populations:

 i.  Infant/pediatric

 ii.  Pregnancy

 iii.  Geriatric

1. Identify onemajor disease or disease process that may significantly impact this body system ( DIABETES)
2. Discuss the expected abnormal physical examination findings that may be associated with this disease or disease process
3. Summarize the key points 

– Scholarly Article sources. 

– Please no plagiarism 

 Pediatric: Undescended Testes Case Study. Please follow instruction and respond each part, be clear and specific. Apa format and low similarity. My condition that I choose is undescended testicle

Instruction: 

1. Your chosen disease/condition
2. Population most affected (ex: Older Adults, Middle Adults, Young Adults, Teenagers, Child, Infants)
3. Age related milestone for your chosen population
4. Socio-Demographic/Risk factors for getting the disease/condition
5. Impact on QOL
6. Current/new/recent research/EBP that will benefit/support this patient with the specific disease (If there are none please state so)
7. Recommendation for treatment or Gold standards for treatment if any (can be tied into the current research as above) (If there are no gold standards then please state so, but there should be some recommendations)
8. Please tell what/how you (speak in the first person) as the FNP caring for this patient with this specific disease can make a difference in his/her care and incorporate patient care/self-help teaching that can help him/her minimize disease symptoms.
9. Red flags for this condition (what specific S/S require urgent/ER care) or when should you refer patient to specialist.

Again, please follow the directions of what I am looking for and keep it to the point, as simple/concise as possible.

Points will be taken of for incorrect grammar and incorrect APA format/citations.

Assignment:
Locate a nursing study that examines the effects of an intervention


Describe Your task


New task 
Type of Service


coursework
Urgency 8 to 12 hours 
No. of Pages/Wordcount 6 page(s)/1650 Words




Citation Style


APA Style


Sources must be within the last five years only


2015, 2016, 2017, 2018 and 2019


Detailed Description/Explanation


Assignment:
Locate a nursing study that examines the effects of an intervention. Provide a summary of the study, focusing primarily on the intervention. 


Was the development and implementation of the intervention described in detail? Based on a theoretical framework? Did the design of the study promote investigation of the effects of the study—for example, was there comparison of experimental and control groups? Were there variables that could have impacted the findings that were not part of the intervention? Was there evidence of efforts to monitor the safety of participants? Are there any ways that the study could have been improved?


Locate a nursing study that utilizes some aspect of the internet (for instance, for recruitment, delivery of an intervention, or completing online assessments. What challenges did the researchers face, and how were these challenges overcome (or not)? How could future research efforts be improved?
Using your computer’s office tools, develop a pie, bar, or plot chart to represent the following population estimates:
Population Percentage
European American 20
African American 30
Native American 20
Hispanic American 30
The assignment should be between 1500 and 2000 words in length and contain at least two scholarly sources, in addition to the textbook and provided material. Please submit your assignment in one APA formatted document.






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these are examples of feedback I received on my other previous assignments, as well as several low grades. Please send me a paper that is original, has references that are within five years, and a really great formatted paper with a clear Introduction, clealr labled and a organized conlusion, thanks,




1.) Thank you for your submission. I’ve provided feedback and scoring. All required content was discussed, minus a clearly labeled and discussed conclusion. The introduction was brief and did not provide a clear purpose. See all comments to improve.


Organization Weight: 25%: Introduction is brief and requires a purpose statement. There is no clearly labeled and discussed conclusion as required. See all comments.
Support Weight: 20%: Multiple errors. See comments. 
Quality of Written Communication Weight: 10%: All papers written within this course need to be in third person.  




2.) Thank you for your submission. I’ve provided feedback and scoring. There are many areas to work on and improve. Please see all of my comments. 








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Please make sure this assignment is ORIGINAL and REFERENCES ARE WITHIN FIVE(5) years.
This is some feed back I received on some previous assignments, as well as low grades. Please make sure the assignment is correct, thanks








-Thank you for earlier submission. I’ve provided feedback and scoring on previous tasks and you need to read them . All required content was discussed, minus a clearly labeled and discussed conclusion. The introduction was brief and did not provide a clear purpose. See all comments to improve.
Organization Weight: 25%: Introduction is brief and requires a purpose statement. There is no clearly labeled and discussed conclusion as required. See all comments.
Support Weight: 20%: Multiple errors. See comments. 
Quality of Written Communication Weight: 10%: All papers written within this course need to be in third person. 


 -Thank you for your submission. I’ve provided feedback and scoring. There are many areas to work on and improve. Please see all of my comments. 
Content Weight: 30%: It appears that some of the topics are discussed. Each paper requires a properly labeled heading to help organize the information presented as well as lets me know as the reader that you covered all required content. This was put out within course announcements. 
Organization Weight: 25%: The introductory paragraph needs a purpose statement. see comment. In addition, there is disorganization as there are no other headings organizing the required content being discussed. 
Support Weight: 20%: Errors present. See comments. 
Quality of Written Communication Weight: 10%: All papers are to be written in third person and no reference to “I”.

Students will complete an APA paper about the following case study.  The provided case study represents ethical issues of historical interest.

Case Study

A nurse has sued Memorial Hospital, charging that she was demoted after complaining about a heart surgeon tossing bloody tissue at her during an operation. The eight-page complaint filed Friday in U.S. District Court by Sonja Morris alleges that Dr. Bryan Mahan tossed the 4-by-6-inch piece of tissue at her, hitting her on the leg during an open-heart surgery in August 2008. She contends Mahan made a joke about it to the other surgeons, saying, “Oh (expletive), I hit her. Can we get cultures on that?” Morris said she felt humiliated as the other surgeons chuckled. Mahan could not be reached for comment Friday afternoon.

Morris claims that the incident was part of a pattern of harassing behavior by Mahan toward her. She also alleged that in June 2008, Mahan came up behind her and hit her in the head. She told him to stop, but two weeks later, he did it again, the suit alleged. Again she asked him to stop.

Chris Valentine, a spokesman for the hospital, declined to comment on the lawsuit. “Obviously, because it’s in legal hands, we’re not in a position to comment,” he said. Mahan is the chairman of cardiac and thoracic medicine at Memorial. He is not named as a defendant in the lawsuit. Morris has worked at the hospital as a nurse since June 1999. She has been a member of the heart surgery team since October 2007.

The incident with the bloody tissue occurred on Aug. 28, 2008, after normal working hours during an operation in which doctors were doing a procedure known as a pericardiectomy. The surgery involved removing a protective layer of tissue from the heart. Morris contends that was the bloody tissue that Mahan tossed at her. She said she was standing at a work station about 15 feet away from the operating table. Because the operation was still in progress, she was unable to immediately clean the part of her leg that the tissue hit. She filed a complaint about the incident but said that resulted in no disciplinary action.

On Dec. 10, she filed a notice of claim against Mahan and the hospital. Her complaint to the U.S. Equal Employment Opportunity Commission alleged that she was subjected to a hostile work environment because of her gender. Seven days later, she said hospital administrators removed her from the heart surgery team, considered a prestigious position, and transferred her to the main operating room. The suit alleged that this action violated her First Amendment rights to petition the hospital to correct something she considered wrong.

Ensslin, J.C. (2009, June 6). Nurse sues Memorial, claims surgeon threw human tissue at her. The Gazette. Retrieved from http://gazette.com/nurse-sues-memorial-claims-surgeon-threw-human-tissue-at-her/article/57418

Morris v. City of Colorado Springs, 666 F.3d 654 (2012)  LINK

Answer the following questions:

1. What are the facts of the case? This should include: what do we need to know, who is involved in the situation, where does the ethical situation take place, and when does it occur?
2. What is the precise ethical issue in regards to autonomy, nonmaleficence, beneficence, fidelity, and justice?
3. Identify the major principles, rules, and values of the case.  Values are sets of beliefs about good and bad, right and wrong, and about many other aspects of living and interacting in the society with others. A principle is a personal rule that governs personal behavior. A rule is generally imposed by a figure of authority, and used to guide and govern people.
4. Is there legal ground for this case, if so what? Who is at fault? What legal action should be taken?
5. Are there alternative to the actions completed in this case by both the nurse, physician, and healthcare facility? Do you feel the physician and nurse were following hospital protocol?
6. If you were a member of the ethics committee at this facility, what actions or changes would you recommend changing? Why?

For the case study, an APA formatted paper should be used, and needs to include a title page, level headings, references and citations. This assignment should include at least 2 references and should be at least four pages in length. Students should address the proposed questions providing ample detail, examples, and additional support.

Assignment Expectations: 

• Length:
  • At least four pages in length; answers must thoroughly address each question in a clear, concise manner;
• Structure:
  • Reference page required
  • address each question in a numbered list
• References:
  • At least 2 references required
• Format:
  • save your assignment as a Microsoft Word (.doc or .docx), Open Office (.odt) or rich text format (.rtf) file type

Reply to Amanda 

Do you take any medications?

Some medications (Lithium) are notorious for causing hypothyroid.

Have you ever been diagnosed with a thyroid disorder?

Surgeries to the thyroid may result in hypothyroid.

Are you allergic to anything?

Relevant to treatment regimen.

Have you experienced any significant life changes? Additional stress etc?

Depression may manifest similar symptoms.

PE:

Hypothyroidism is six times more common in women than men, and is most common in older women (Carson, 2009). A thorough physical assessment should be completed. Clinical signs and symptoms may include paleness, brittle appearing hair and skin, elevated blood pressure, and bradycardia (Carson, 2009). The patient may have a “puffy” appearance to her face, irregular periods, and report sustained fatigue (Roberts et al, 2009).

Differential Diagnoses

Anemia, Depression

Diagnostics

           TSH – Will be elevated in Hypothyroid

           Free T4 – Result will be low in Hypothyroid

           Cholesterol – Often elevated with Hypothyroid

           CBC – To rule out anemia

           CMP – To monitor other electrolytes

           EKG – to assess for any blocks, prolonged QRS, or electrolyte abnormalities

Treatment

           Patients with symptomatic hypothyroidism should be treated to prevent long-term complications (Roberts et al, 2004) Depending on the results of her TSH & T4 I would initiate a daily regimen of Levothyroxine. 4-6 weeks after the initiation of Levothyroxine I would recheck the patients TSH. After the TSH has reached a therapeutic level – I would recheck it again in 6 months.

References

Carson, M. (2009). Assessment and management of patients with hypothyroidism. Nursing Standard (through 2013), 23(18), 48-56; quiz 58. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/219883523?accountid=167104 (Links to an external site.)Links to an external site.

Roberts, C. G. P., & Ladenson, P. W. (2004). Hypothyroidism. The Lancet, 363(9411), 793-803. doi:http://dx.doi.org/10.1016/S0140-6736(04)15696-1

reply to Quiana

1. What additional questions should you ask the patient and why?

Some questions include:

• How much weight has been gained? What kinds of meals/foods do you typically take? Do you exercise?
• Quantifying the amount of weight provides perspective. A gain of 5 lbs does not carry the urgency that a 20 lb weight gain does. Asking about her lifestyle habits can offer some insight into factors that can aggravate what sounds like hypothyroidism. This creates teachable opportunities for improving lifestyle habits.
• Are you still menstruating and if so, how regularly?
  • This can rule out pregnancy or hormone changes that precipitate menopause. Also, with hypothyroidism, this condition can disrupt a normal menstrual cycle. For a woman in menopause, hypothyroid symptoms can be masked or ignored when it is assumed that it is a lack of ooestrogen that is causing her concerns (Baisier, Hertoghe, & Eeckhaut, 2000).
• Bowel habits, specifically any problem with constipation?
  • (Chaker, Bianco, Jonklaas, & Peeters, 2017)
• Any hx of depression?
  • Her reported complaints are common findings for hypothyroid but they can also be related to depression. Though the rate of depression in hypothyroid patients is >60% (Bathla & Singh, 2016), the patient should be screened for depression. Her symptoms could be psychosomatic.

1. What should be included in the physical examination at this visit?

• Included items to address are skin for dryness, hair for thinning or irregular growth pattern, eyes for exopthalmus, neck/throat and thyroid for possible goiter, cardiac sounds for bradyarrhythmias, and also for peripheral manifestations like delayed relaxation of deep tendon reflexes (Chaker, et al., 2017).

1. What are the possible differential diagnoses at this time?

• Hypothyroidism
• Depression
• Anemia
• What tests should you order and why?
• TSH and free T3 and T4
• EKG
• CMP
• CBC
• Lipid Panel
• A depression screen can be done in office

Hypothyroidism can increase lipids and alter cardiac function (Chaker, et al., 2017). EKG may reveal cardiac abnormalities. CBC can reveal anemia. The metabolic panel can reveal diabetes or problems with hepatic or renal function. Hypothyroidism continues to be researched as far as the specific link to renal and hepatic dysfunction (Chaker, et al., 2017). The depression screen serves, like the other lab orders, to exclude causes of her symptoms. The most obvious test is a thyroid panel. To assess the circulating amount of hormone in the body is to judge her thyroid function.

1. How should this patient be managed?

• Pending the diagnosis, the patient should be encouraged to complete all lab work in a timely fashion. Since these labs can be resulted within 24hrs, if not same day, that would be my biggest priority for completion. For hypothyroidism, pending the thyroid results, the patient should start on hormone replacement with a drug like levothyroxine. Often, levothyroxine 50-100mcg is a starting dose (Dunphy, Winland-Brown, Porter, & Thomas, 2015), it should be taken daily, on an empty stomach, in the morning. She should return in about 1 mo to reassess symptoms and lab value. If the patient is difficult to manage, due to comorbid conditions or lack of therapeutic response, endocrine may be consulted.

References

Baisier, W. V., Hertoghe, J., & Eeckhaut, W. (2000). Thyroid insufficiency. is TSH measurement the only diagnostic tool? Journal of Nutritional & Environmental Medicine, 10(2), 105-113. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/215623935?accountid=167104

Bathla, M., & Singh, M. (2016). Reply to “how prevalent are depression and anxiety symptoms in hypothyroidism?”. Indian Journal of Endocrinology and Metabolism, 20(6) doi:http://dx.doi.org/10.4103/2230-8210.192913

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. doi:http://dx.doi.org/10.1016/S0140-6736(17)30703-1

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing, (4th ed.). [VitalSource Bookshelf version].  Retrieved from https://bookshelf.vitalsource.com/books/9780803655621

Reply to Hollie

Question 1—Postpartum Depression

Postpartum depression (PPD) is a major depressive disorder that occurs up to one year after birth (Hackley & Kriebs, 2017). Common symptoms of postpartum depression include: anhedonia; sleep disturbance; feelings of loneliness, isolation, or guilt; poor concentration; anxiety; and somatic complaints (Hackley & Kriebs, 2017). Mothers with postpartum depression are also less responsive to their infants and often need help caring for their infant (Hackley & Kriebs, 2017). Studies have shown that postpartum depression can impact child development, behaviors in childhood, and children’s cognitive function (Hackley & Kriebs, 2017).

The Edinburgh Postnatal Depression Scale (EPDS) is the screening tool used at my preceptor’s clinic to assess for postpartum depression. Hackley and Kriebs (2017) state that because postpartum depression has bimodal peaks at 2 and 6 months, the optimal time to screen for postpartum depression is between 2 weeks and 6 months postpartum. The American College of Obstetricians and Gynecologists (ACOG) recommends screening at the patient’s 6-week comprehensive postpartum visit (ACOG, 2018). However, because postpartum depression can occur at any time, studies and the American Academy of Pediatrics (AAP) are now supporting the use of EPDS screenings for mothers at the 2 month, 4 month, and 6 month well child visits (Emerson, Mathews, & Struwe, 2018).

The cutoff score for depression on the EPDS ranges from 9 to 13. The AAP (n.d.) recommends women with a score of 9 or more be further evaluated for depression. A score of more than 12 is considered likely for postpartum depression (Hackley and Kriebs, 2017). Women with these scores should be clinically evaluated, started on treatment, or referred to a a mental health clinician (Hackley and Kriebs, 2017). A score of less than 9 should not rule out depression if clinical suspicion of PPD is present. Any woman indicating suicidal thoughts on the EPDS or during the comprehensive clinical exam should be immediately assessed to determine if hospitalization is needed (Hackely & Kriebs, 2017). For those at high risk, the patient should be taken to the emergency room (Hackley & Kriebs, 2017).

References

AAP. (n.d.). Edinburgh postnatal depression scale. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/practicing-safety/Documents/Postnatal%20Depression%20Scale.pdf

ACOG. (2018). Screening for perinatal depression. American College of Obstetricians and Gynecologists, 132(5), 208-212. Retrieved from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co757.pdf?dmc=1&ts=20190310T2001493232

Emerson, M., Mathews, T., & Struwe, L. (2018). Postpartum depression screening for new mothers at well child visits. American Journal of Maternal/Child Nursing, 43(3), 139-145. doi: 10.1097/NMC.0000000000000426

Hackley, B. K., & Kriebs, J. M. (2017). Primary care of women(2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Reply Angela

uestion 2: 6-Week Postpartum Visit

At the 6-week postpartum visit a full physical assessment is done including gynecological exam. Assessment for postpartum depression continues as well as infant bonding and parenthood and transitioning to regular gynecological care (ACOG. Org, 2018). If there were issues with preeclampsia and eclampsia or gestational diabetes these areas are addressed as well. Providing the patient’s primary care provider with the prenatal and post-natal history is recommended as well to help the patient receive care that is complete and collaborative. ACOG (2018) recommends an initial postpartum visit in three weeks which may just include a phone conversation but is not a complete physical exam and then a six week to twelve weeks visit that will include a comprehensive exam. It is recommended that the postpartum visit be no later than 12 weeks postpartum.

ICD-10 codes that are used for these visits are Z39.0 encounter for care and examination of mother immediately after delivery, Z39.1 encounter for care and examination of lactating mother, Z39.2 encounter for routine postpartum follow-up. There are other codes for postpartum encounters but are more disease related. The code that is used most generally is the Z9.2 code (ICD.codes, 2019). CPT codes can be used in the numerical range of 99211 through 99215 to reflect that a postpartum patient is an established patient and is in clinic for a routine exam. The higher the number use the more intensive the visit, or the more information and procedures were provided (supercoder.com, 2018).

References

ACOG. Com. (2018). Optimizing postpartum care. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care (Links to an external site.)Links to an external site.

ICD10.codes. (2019). Code. Retrieved from https://icd.codes/icd10cm/Z712 (Links to an external site.)Links to an external site.

Supercoder.com. (2018). CPT code. Retrieved from https://www.supercoder.com/cpt-codes/99215 (Links to an external site.)Links to an external site.