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Addressing healthcare problems that have a large impact on individuals in our society, have been at the forefront of quality improvement initiatives. Identifying these areas of concern can be helpful for DNP prepared nurses to stimulate and create effective change that may be needed. One of the areas of concern identified is Opioid. Opioid use disorder is a national problem in the United States of America.  According to the US Burden of Disease Collaborators (2018), opioid use disorder (OUD) is the number 7 leading cause of morbidity and mortality in the US. As a mental health practitioner, OUD and other substance abuse are common problems I see in my patient population. This national burden is directly related to my daily practice because most of the patient population seen in the clinic are also being prescribed opioids for chronic pain for various reason from other providers.  In rural Tennessee where I practice, the small town is well known for drug abuse and drug overdose.  I have learned from my previous collaborator, to be very careful when prescribing antianxiety medications or any type of control substance, since at the time I was the new provider in the area.

OUD impacts nurses as it requires a multifaceted approach involving various interdisciplinary members where a nurse may take a leadership position in the patient’s care (Eckart et al., 2020). As a profession, nursing science advances knowledge to recognize, prevent, and treat OUD (Eckart et al., 2020). Health care organizations serve as the umbrella to support multidisciplinary teams in treating OUD. Last but not least, quality of care could be affected by prescriber practices, social stigma, and lack of resources that correlate to OUD (Eckart et al., 2020).

A couple of crucial national stakeholders come to mind with OUD: the Centers for Disease Control and Prevention (CDC) and Drug Enforcement Agency (DEA). The CDC plays a significant role in providing OUD guidance for the public, including clinicians and patients. The DEA plays another vital role in monitoring and regulating prescribers plus controlled substance prescriptions. Micro level stakeholders impacted by the resolution of this issue include patients, as well as community members who have day to day interactions with the patients.

At this time, there is a clinical practice guideline (CPG) issued by the CDC.  Clinicians in primary care have found that managing chronic pain can be a daunting task; therefore, the CDC has issued a CPG on prescribing treatment for chronic pain (Dowell, Haegerich, & Chou, 2016). Using a systematic review to assess benefits, risks, values, preferences, and costs, the CDC has issued 12 recommendations to clinicians when prescribing opioids (Dowell et al., 2016). The recommendations advise that clinicians avoid prescribing opioids if possible, take a stepwise dose approach if prescribing opioids is unavoidable, establish goals of treatment with patients before prescribing, and closely monitor patients for response to treatment; the recommendations also include avoiding concurrent use of other opioids or benzodiazepines, in addition to providing medication assisted treatment for OUD (Dowell et a., 2016).

The CPG provided the CDC has been a mainstay to patient education in my practice. My collaborating physician and I rarely issue opioid prescriptions. We often encounter frustrated patients when they are refused opioid prescriptions after having been given opioids from the emergent care setting; this is a time-consuming issue faced frequently in may primary care clinics (Tong et al., 2019). To improve patient safety and satisfaction, counseling is important to de-escalate patient frustrations and help them perceive the potential harms to opioid use.

I need a comment for this post at least 2 paragraphs and 2 sources no later than 5 years. 

Respond  to  your  colleagues by recommending at least one additional way you  would treat a  child or adolescent client differently than you would an  adult and at  least one additional way you would address the legal and  ethical issues  involved.  

(NOTE: Positive Comment)

                                                        Main Discussion

Psychiatric  emergencies are severe behavioral changes that may  result from  worsening mental illness. Psychiatric emergency is any  disturbance in  thoughts, feelings, or actions that require immediate  therapeutic  intervention (Stahl, S. M., 2014). The providers approach,  attitudes and  work environment may escalate the situation and interfere  with the  quality of care. Certain therapeutic measures can reduce the  intensity  of the situation and provide a more dignified way for  patients to  recover from the crisis. It is thus important that the  PMHNP understand  how to assess patient’s emergency status and address  their unique needs  while maintaining safety.

  Case selected.

Patient  is a 25-year-old AA male who presents to the emergency  department with  psychotic behavior in believing he should kill his  mother which led to  his attempt to stab his mother. Patient is admitted  for inpatient  psychiatric stabilization. Patient has a history of  schizoaffective  disorder and major depression that was managed with use  of clozapine  150mg twice a day and Zoloft 100mg daily. Family reported  that patient  has a history of medication non-compliant and had been on  different  psychiatric medications in the past but were not working for  him.  Additional reports by his parents shows that patient had missed  several  doses of his medication, decompensated and they had notices  some changes   recently including increase agitation, delusional  believes that he is  the savior in the family and God had directed him  to cast the demon in  his mother. Reports also that he had drawn a  picture of himself with  knives cutting a woman he portrayed as a demon  with blood flowing with a  man standing to the side, laughing. Patient  currently stated that he  participates in a meeting with angels from  which he gets directives on  how to attack his mother which led to his  attempt to stab his mother.  Because of this, patient was considered  dangerous to his mother per  admitting physician. Patients symptoms  include psychosis, extreme  agitation, paranoia, verbal outburst,  combative and very difficult to  redirect. Patient has no known drug  allergies per parents.  Verbal  restraint was used including letting  patient know what will happen if  he does not comply, respecting his  autonomy, empathetic listening,  decrease environmental stimulation,  reassure patient that they will be  safe, and maintain a safe  environment. The patient was given emergency  medications including  haloperidol lactate 5mg, lorazepam 2mg, and  diphenhydramine 50mg all IM  for severe agitation and danger to others.  To prevent  re-hospitalization within 12-24 hours of discharge, the  physician  ordered outpatient therapy and continued use of clozapine and  Zoloft  along with necessary lab work.

 How I would treat the client differently if he or she were a child or adolescent

Children and adolescent are usually brought for treatment when  their  behavior or thoughts come to the attention of parents, teachers,   social workers, or school.  For pediatric patients in a mental health   crisis, the typical chaotic nature of the situation may easily further   exacerbate an already traumatized state of the patient. Just like in   adults, as a PMHNP I would perform an evaluation to determine the type   of emergency and contributing factors in child and adolescent emergency   by assessing not just the child but also the entire family.   Additionally, safety and protection are essential mandate in  psychiatric  emergency evaluation especially when the patient pose  imminent threat  to self or others. What I will do different when  interviewing children  especially younger children is to assess the  underlying cause of the  violent behavior and delusional symptoms within  a developmental context. Specifically,  I would clarify that “bizarre  thinking ” or accounts of seeing or  hearing things that others do not  see or hear are different from  developmentally appropriate fantasy or  difficulty while distinguishing  inner voices from distressing  hallucinations. On like in adults where  they can provide information  during the interview, when it comes to  younger children, I would need  to obtain information from parents or  guardian. For adolescents,  I  would obtain information from the patient first then talk to their   parent or guardian if the adolescent is able to tell most of their own   story. This may also help to give a sense of autonomy and control to  the  adolescent which promote cooperation with the interview process.    However, information from family is very crucial particularly for a   child who is psychotic, frightened, unable, or unwilling to corporate   with the provider to help understand how the situation occurred and the   severity of the behavior. 

Same  interviewing strategies used in adult may be used including  speaking in  a soft voice respecting patients’ autonomy, assuring  safety, validating  feelings, offering distractions (like video games)  especially with very  young children, and clear limit-setting can be  helpful. However,  children should be evaluated in a carefully planned  setting with doors  closed for limiting access, and be sure appropriate  backup is available  (Margret, C. P., & Hilt, R., 2018).  

In  violent situations children may require a different approach in   deescalating the situation than adults. Safety is the essential mandate   in an aggression evaluation, with the interviewer specifically looking   for imminent threats, plans, targeted people, and access to means of   harm (Margret, C. P., & Hilt, R., 2018). Because adults are much   stronger, they may require physical restrain specially to administer   medication to calm the patient. Verbal restrain such as providing  verbal  directions in a nonthreatening manner, setting limits, and  assuring the  child that treatment may help them calm may be used for  children first.  However, if the child is dangerously out of control and  aggressive,  they may need medication to keep them calm and safe.

Legal or ethical issues I would consider when working with a child or adolescent emergency case

The  ethical issue I will consider when working with children and  adolescent  is respect for their autonomy, privacy, and confidentiality.  For very  young children parents must consent to treatment and the  health care  provider treating the child should make every reasonable  effort to  obtain and document informed consent. (American Academy of  Pediatrics,  2015). Just like adults, maintaining a patient’s  confidentiality is an  important ethical consideration when providing  care to children and  adolescents. However, when  a PMHNP is concerned  that the patient may be at imminent risk for harm  to self or others,  confidentiality requirements no longer apply (Chun,  T. H., Katz, E. R.,  & Duffy, S. J., 2013). This means that the PMHNP  in this situation  may disclose information collected  from patient to  caregivers or  others as needed and may obtain information from others  such as  friends, family members, school personnel, employers and other  without  obtaining consent from the patient or guardians (Chun, T. H.,  Katz, E.  R., & Duffy, S. J., 2013. Patient  autonomy is a major principle in  making decisions about an individual’s  health, and as a PMHNP we are  obligated to respect this right and allow  patients to practice their  autonomy in the course of their treatment  (Parsapoor, A., Parsapoor, M.  B., Rezaei, N., & Asghari, F., 2014).  However, a psychiatric  emergency and age may limit a child’s ability to  make such decisions.  Regardless, it is always important to involve the  child in informed  decision making even if the consent is signed by the  parents or  guardian.

References

Chun, T. H., Katz, E. R., & Duffy, S. J. (2013). Pediatric mental health emergencies and special 

health care needs. Pediatric clinics of North America, 60(5), 1185–1201. Retrieved from,

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792398/

Da Silva, A. G., Baldaçara, L., Cavalcante, D. A., Fasanella, N. A., & Palha, A. P. (2020). The 

Impact of Mental Illness Stigma on Psychiatric Emergencies. Frontiers in psychiatry, 11, 

573. https://doi.org/10.3389/fpsyt.2020.00573

Margret, C. P., & Hilt, R. (2018). Evaluation and Management of Psychiatric Emergencies in 

Children. Pediatric Annals, 47(8), e328–e333. https://doi-

org.ezp.waldenulibrary.org/10.3928/19382359-20180709-01

Parsapoor, A., Parsapoor, M. B., Rezaei, N., & Asghari, F. (2014). Autonomy of children and 

adolescents in consent to treatment: ethical, jurisprudential and legal considerations. 

Iranian journal of pediatrics, 24(3), 241–248. Retrieved from, 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4276576/

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New 

York, NY: Cambridge University Press.

REPLY1

For a long time health care was all about health care professionals taking control of a patients care, lacking involvement of the patient, which only enabled the patient once they were discharged from care. The last decade or so patients have been hearing the continuous message from health care professionals about getting involved in their care (Vahdat et al., 2014). Patients with chronic conditions should especially be taking control of their own health care, which includes taking medications properly and being on top of scheduling and attending appointments. I think what has changed mostly in patients having control of their own health care, is that health care professionals provide education and information to patients that uses involvement of health care professional and patient. This empowers patients to take control and see positive outcomes with their health. Doctors are known to be the point of contact of all the information, which is why I think for many years patients just had the health care professional take full control of their care because they had full trust in their knowledge and experience. Patients having control of their own health care is important when it comes to decision making about their health care. If the patient has always relies on health care professionals, they won’t have the knowledge of what decisions must be made to better their care (Flavo, 2011).

The biggest change I have seen with patients being able to have more control over their health care is patients now have full access to their own medical records which includes doctors notes, labs, and other results (Vahdat et al., 2014). Another reason why this change of patients having control of their health care has made an impact on medical costs according to a study in 2013. Patients who were encouraged to take control of their own health care were seen to have an overall of 5.3% lower medical costs, 12.5% fewer hospital admission and fewer elective surgeries (Vahdat et al., 2014). Of course, patient involvement is not new but it is becoming more of a necessity in the health care system. Overall, the best part about this change, is that empowers patients to stay healthy and have an easier access to their results and communication with their providers.

References

Falvo, D. (2011) Effective Patient Education: A guide to Increased Adherence. Retrieved from

REPLY2

The 21st Century Healthcare System has seen a shift from a paternalistic focus to a more collaborative approach with the health professional and the patient working together to plan the patient’s care. In the traditional health provider-patient relationship the physician is regarded as the authority figure with the knowledge and expertise having the sole responsibility for developing a treatment plan that was rarely challenged by the recipients. However, the healthcare system has evolved to give patients more autonomy to manage chronic conditions proactively and make informed decisions about treatment options. Research indicates that shared decision-making leads to better treatment outcomes, fewer elective surgeries, hospital admissions, and lower health costs. According to Falvo, (2011), the concept of patient-centered care has expanded to all areas of healthcare and is linked to increased patient satisfaction and increased quality of care as well as patient adherence to treatment. Patient-centered care is fostered by a partnership between the health professional and the patient that is built on mutual respect and incorporates the patient’s wishes and active participation.

Research done by the Agency for Healthcare Research and Quality indicates that when patients are engaged in their care it can lead to measurable improvements in safety and quality and has developed an evidence-based resource guide known as ‘A Guide to Patient and Family Engagement in Hospital Quality & Safety,’ that can be used to help nurses work in partnership with patients and their families. (Sherman, 2014). Health institutions stand to benefit from productive relationships with patients and families because the Centers for Medicare and Medicaid Services has also shifted its reimbursement system to a value-based program linked to patient outcomes and patient satisfaction. The ability of patients and their families to effectively engage in their healthcare is contingent on factors such as their knowledge, attitudes, and health literacy. Many patients are hesitant about taking the responsibility of participating in health decision making because they feel overwhelmed by the prospect. There are some health professionals who are also resisting the change to the new model of patient-provider partnership. The nurse is in a unique position to create an environment conducive to this model of patient partnership. 

The old model of health teaching limited to brief instructions and a few handouts at discharge is inadequate and many patients have begun to demand answers and express their dissatisfaction. Since patients are now expected to assume more personal responsibility for their health decisions, effective patient teaching requires that the health professional thinks beyond merely providing information but focus on customizing recommendations to meet the patient’s specific needs.(Falvo,2011). When patients are given adequate knowledge and the rationale for treatment, they develop the confidence and sense of control that empowers them to make health decisions that result in improved treatment outcomes. Computer technology has greatly enhanced patients’ knowledge and ability to take charge of their health and become familiar with a vast array of therapeutic options, disease prevention, and disease management methods. As nurses, we must embrace health care reform that facilitates patient engagement and assist patients in their healthcare journey throughout the continuum of care.

References

Falvo, D. (2011). Effective patient education. A guide to increased adherence. https://viewer.gcu.edu/RQBKXW

Sherman, R. (2014). The patient engagement imperative. American Nurse Today. https://reasearchgate.net/publication/200036096_The_patient_engagement_imperative/link

https://viewer.gcu.edu/RQBKXW

Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient involvement in health care decision making: a review. Iranian Red Crescent medical journal, 16(1), e12454. https://doi.org/10.5812/ircmj.12454

Find a media message (print, commercial, tweet, post, etc.) that is communicating a false message, spreading misinformation. Sometimes, people misinterpret information and make assumptions about events. One way to double-check information is Snopes, visit Snopes and type the issue or story and verify it! 

Introduce the misinformed message you found, what Snopes had to say about it, and what we could do to dispel messages like that. Why is it dangerous to allow misinformation to spread? How does misinformation affect public health? 

Hi,

Please see the requirements for the PowerPoint Presentation.

Must be between 10-12 slides

I included the powerpoint layout with the first 2 slides on it. Please use that one and add the required information.

Thanks

PLEASE USE THE LINK PROVIDED BELOW WHICH IS THE PDF VERSION OF THE TEXTBOOK TO VIEW THE DISCUSSION QUESTIONS AT THE END OF CHAPTER 5 TO ASSIST IN ANSWERING THE QUESTIONS: 

https://drive.google.com/file/d/1Lho7gBgscbBQ1CFC16v6zMPSPHm2iDDV/view

NO HEADER OR FOOTER

FONT: ARIEL 12 POINT FONT, DOUBLE SPACED

** HIGHLIGHT THE NUMBER OF WORDS AFTER EACH PARAGRAPH**

** 20 PARAGRAPHS TOTAL**

ON Page 1: 

Discussion Question 1—Please write 4 paragraphs with each paragraph containing 50-60 words.

ON Page 2: 

Discussion Question 3—Please write 4 paragraphs with each paragraph containing 50-60 words.

ON Page 3: 

Discussion Question 4—Please write 4 paragraphs with each paragraph containing 50-60 words.

ON Page 4: 

Discussion Question 5—Please write 4 paragraphs with each paragraph containing 50-60 words.

ON Page 5: 

Experiential Exercise 2—Please write 4 paragraphs (one answering each question) with each paragraph containing 50-60 words.

Describe two external stressors that are unique to adolescents. 

Discuss what risk-taking behaviors may result from the external stressors and what support or coping mechanism can be introduced.

What’s good or bad about bacteria

Module 4 Discussion

Nicole Bachich

St. Thomas University

This patient is a 75-year-old woman who presents with complaints of chest pain. Chest pain is a common presenting symptom with various causes (Ayerbe, González, Gallo, Coleman, Wragg, & Robertson, 2016). This patient’s chest pain began when she was walking up the steps and at that time, she rated it an 8 out of 10. In order to collect more subjective data, I would ask this patient to describe her pain in more detail. First, I would ask her to describe the pain. This patient described her pain as burning or aching. I would want to know if the burning, aching pain was constant or if it would come and go. The patient denied that the pain radiated to her arm, but I would ask if it radiated to the upper chest. I would ask her if she was diaphoretic when the pain occurred. I would also ask the patient if laying down caused more pain. Other questions to ask this patient would be if she took anything to try and relieve the pain and I would ask her about any drug or alcohol use in her present or past. Cocaine use can cause coronary spasms (Rhoads & Wiggins Petersen, 2021). I would also ask the patient if she has a history of anxiety.

When conducting the physical assessment on this patient I would gather more objective data. I would assess the patient’s skin color, mucous membranes, and lips to assess for cyanosis or anemia. I would assess her skin temperature as well and check to see if she was diaphoretic. I would also assess the patient’s eyes and check for Xanthelasmas and any skin or nail changes, which may be present in a patient with angina (Zitkus, 2010). Changes in skin texture and hair distribution may also be present in peripheral vascular disease.

The diagnostic tests that I would order would be an electrocardiogram (ECG), a troponin I level, an X-Ray of the digestive system and chest, and an endoscopy. The ECG and troponin lab would be done to rule out any cardiac abnormalities or if the patient may have had a myocardial infarction, and this patient does not appear to be in acute cardiac distress. The other tests would be done to assess for a possible gastrointestinal cause for her chest pain. Non-cardiac chest pain can cause angina like pain in patients without heart disease.

Three differential diagnoses that I would give for this patient are Gastroesophageal reflux (GERD), esophageal motility disorders, and gastric ulcer. I believe that this chest pain is related to a gastrointestinal cause because gastrointestinal pain can be described as a burning sensation in the middle of the chest (Rhoads & Wiggins Petersen, 2021). However, thee diagnoses can only truly be made after ruling out any cardiac related chest pain, as cardiac related chest pain caused by a myocardial infarction may have similar symptoms (Frieling, 2018). GERD is a common cause of non-cardiac related chest pain, and it is attributed to up to 60% of non-cardiac chest pain diagnoses (Frieling, 2018).

References

Ayerbe, L., González, E., Gallo, V., Coleman, C. L., Wragg, A., & Robson, J. (2016). Clinical assessment of patients with chest pain; a systematic review of predictive tools. BMC cardiovascular disorders, 16, 18. https://doi.org/10.1186/s12872-016-0196-4

Frieling, T. (2018). Non-Cardiac Chest Pain. Visceral Medicine, 34, 92-96. doi: 10.1159/000486440

Rhoads, J., & Wiggins Petersen, S. (2021). Advanced Health Assessment and Diagnostic Reasoning. Burlington, MA: Jones and Bartlett Learning.

Zitkus, B. (2010). Assessing chest pain accurately. Nursing2010, 40, 1-6 doi: 10.1097/01.NURSE.0000389904.40627.35

Introduction and Alignment

This workshop provides additional instruction on integrated mental healthcare and is intended to expand the student’s comprehension of roles and responsibilities of the PMHNP while functioning as part of the larger interprofessional team. 

Upon completion of this assignment, you should be able to:

• Summarize duties and responsibilities of the PMHNP associated with the role of Consult-Liaison.
• Compose a brief case study or client scenario which incorporates the services of the PMHNP functioning as a Consult-Liaison.
• Compare specific tasks, duties, and responsibilities associated with the Consult-Liaison role as it pertains to inpatient and outpatient mental healthcare settings.

Resources

• Textbook: American Nurses Association (2014). Psychiatric Mental Health Nursing: Scope and Standards of Practice – pages 12-16; pages 36-37.
• Article: Sharrock, J. and Happell, B. (2002), The psychiatric consultation-liaison nurse: Thriving in a general hospital setting. International Journal of Mental Health Nursing, 11(1), 24–33. https://doi.org/10.1046/j.1440-0979.2002.00205.x

Instructions

1. Use the included resources and/or other articles you find in the Assignment 5.4 literature review.
2. Navigate to the threaded discussion and respond to the following:
   1. In 3-4 paragraphs, summarize the role of the PMHNP as a consult-liaison. Look at the role from both the inpatient and outpatient setting. How do the tasks, duties and responsibilities differ?
   2. Develop a case study or client scenario in which the PMHNP serves in the role of a consult-liaison.
3. Your initial post is due by the end of the fifth day of the workshop.
4. Read and respond to at least two of your classmates’ postings by the end of the workshop.

Select here to access the discussion topic.

Assessment Criteria

Criteria

Points

Question answered comprehensively

• Summarizes consult-liaison role for the PMHNP (20)
• Case study/client scenario fully shows PMHNP acting in a consult-liaison role (20) 

40

Student’s post adheres to APA guidelines, including references and citations, and proper style/grammar/punctuation/spelling

5

Responds to at least two peers’ posts by end of workshop

5

Total Points

50