STU Nursing Health Promotion and Plan of Care Discussion Responses – Description
respond to at least two peers by extending, refuting/correcting, or adding additional nuance to their post:
Peer 1 jennifer
Clinical Week
Overall, I am satisfied with the way my second week of clinicals turned out. I feel like I have learned so much already in the primary care setting. I am becoming more comfortable with my assessments of the patients and work well with my preceptor. I continue to see the importance of health promotion and disease prevention in every patient encounter.
Challenges and Successes
One of the challenges of a nurse practitioner that I experienced this week was dealing with patients who are noncompliant with medical treatment plans. Up to 50% of patients who are prescribed medications for the management of chronic disorders like diabetes or hypertension have medication nonadherence, which is highly frequent for patients with chronic diseases (Kleinsinger, 2018). Barriers to medication adherence include patient-related barriers and treatment-related barriers. Examples of patient-related barriers include lack of motivation, denial, cognitive impairment, cultural issues, low educational level and alternative belief systems, while treatment-related issues can include complexity in the treatment prescribed, side effects, cost and inconvenience of the treatment (Kleinsinger, 2018). In the office this week, there was a morbidly obese patient with a history of hypertension and hyperlipidemia who came into the office and his blood pressure was 180/110. He stated that he hasn’t taken his blood pressure medication in two weeks. When explaining to him the importance of taking his blood pressure medication, he made a comment stating, “I feel like you guys are being dramatic. Nothing is going to happen to me.” At least 100,000 avoidable deaths and $100 billion in avoidable medical costs are believed to result each year from nonadherence to recommended therapy (Kleinsinger, 2018).
As far as successes, I have been receiving good feedback from my preceptor on my ability to perform adequate health histories and physical assessments on the patients. My preceptor allowed me to come a Medicare “Annual Wellness Visit” on a patient primarily on my own. Specifically created to promote health and wellbeing for Medicare recipients, the Medicare Annual Wellness Visit (AWV) is a preventive program offered by Medicare (Ganguli et al., 2019).
Patient Encounter, Health Promotion and Plan of Care
One patient encounter experienced this week was a 50-year-old female patient coming into the clinic for complaints of fatigue, urinary frequency, dysuria, flank pain, and intermittent fever. Patients vital signs were within normal limits with no evidence of fever at this time and physical assessment showed costovertebral angle tenderness to the right flank area. A urinalysis completed showed a urinary tract infection and the patient was prescribed Bactrim DS 800 mg by mouth daily for 7 days and was instructed that she should have an adequate response to the antibiotic within 48 hours. Research has shown that treatment with trimethoprim/sulfamethoxazole (Bactrim) for 7 days was noninferior to 14 days of treatment with regard to resolution of UTI symptoms (Drekonja et al., 2021). The patient was instructed to increase her water intake, educated on proper wiping technique of front to back, and instructed to finish the antibiotics completely even if she beings to feel better. Three differential diagnoses for urinary tract infections include pyelonephritis, interstitial cystitis, and a sexually transmitted disease. Pyelonephritis can be considered due to the patient’s fever and flank pain, interstitial cystitis is possible due to its similar symptoms of UTI including frequency of urination and dysuria, and sexually transmitted disease such as chlamydia or gonorrhea can present with frequency and dysuria as well.
One thing my preceptor exposed me to was the numerous guidelines and sources that exist in deciding the best treatments for patients based on research and evidence-based practice. I feel that with time and increased exposure to the clinical setting, I will be able to gain more experience in the treatment plans of patients with chronic diseases.
Peer 2 Jane
Hello everyone I hope all of you had a productive week. I felt better about seeing patients every hour during this week’s rotation. It can be stressful at times because we have back-to-back patients. This field has shown me so far that you learn more about diseases and dig into more depth of the disease process. One of my exciting cases was a 50-year-old female who returned to review her blood work with the Nurse Practitioner. She came in 2 weeks ago because she was feeling bad; her symptoms were tiredness, hair loss, shortness of breath, weight gain, muscle cramps, and sensitivity to colds. The Nurse Practitioner ordered labs because the patient was there a year ago, and she did not look the way she did today a year ago. The Nurse Practitioner reviewed her labs and told the patient that her thyroid TSH is at 10.0 mU/L, which is elevated; also, her LDL, her cholesterol is at 400, and her total cholesterol is at 500. After reviewing her labs, she diagnosed her with Hypothyroidism.
When the TSH is high, it causes thyroid dysfunction, which is clinically called Hypothyroidism (Chaker, 2022). If left untreated, this condition can lead to many serious health problems that affect multiple organ systems, especially the cardiovascular system (Chaker, 2022). What it does to the heart is that it decreases cardiac out, which leads to bradycardia, a decrease in left ventricular function, pericardial effusion, myocardial injury, hypertension, an increase in waist circumference, and dyslipidemia (Chaker, 2022). In fact, the patient has high cholesterol levels. A severe iodine deficiency causes Hypothyroidism caused by chronic autoimmune thyroiditis in iodine-replete areas (Heppel, 2021). When symptoms begin is usually late in the disease. The nurse practitioner prescribed Levothyroxine 50 mcg one tablet daily by mouth 30 minutes before breakfast (Heppel, 2021). She explained the side effects of the medication, which can be a thyrotoxic crisis that requires immediate medical attention (Heppel, 2021). The patient was also suggested to return in 2 weeks to repeat labs. The patient was given a referral to see an endocrinologist where she can be monitored more closely for Hypothyroidism and myxoedema.
The nurse practitioner explained that her labs must be drawn every six weeks to check her TSH levels; once her TSH levels are under control, labs are drawn every 6 to 12 months. She also explained the seriousness of the disease that, if untreated, can lead to Myxoedema coma, which is a severe form of Hypothyroidism; it is characterized by reduced consciousness, periorbital edema, coarse hair, and hypothermia; this is fatal, and the mortality rate is about 60% (Heppel, 2021). Treatment for myxoedema is IV levothyroxine and liothyronine. She also explained that levothyroxine therapy is a lifelong medication that cannot be taken with calcium supplements and ferrous sulfate because it will decrease the absorption of the drug. The nurse practitioner explained that the liver metabolizes this drug to activate T3 (Heppel, 2021). The patient left the clinic in disbelief and sadness. I hope she follows the endocrinologist doctor’s orders for her not to end up in the hospital with complications.
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