DISCUSSION REPLIES UNIT 2
10592Peer Response: Unit 2, Due Sunday by 11:59 pm CT
Instructions:
Read the SOAP notes constructed by your course colleagues.
Review the ‘P’s posted by your peers from your advanced practice nursing role perspective – educator, leader or practitioner. From your advanced practice mindset reflect on a discussion you would like to have with two of your course colleagues about their ‘P’.
Post a response individually to each of them that expresses your advanced practice nursing role perspective of their ‘P’.
Use scholarly resources relevant to your advanced practice nursing role to support the key elements of the peer discussions you construct. [For example – if you are a nurse educator (clinical or academic) what are your thoughts about the patient education provided in the ‘P’, or do you want to comment on the fact that a peer put N/A for educational, etc.?’; if you a nurse leader what are your thoughts about the risk profile or cost-effectiveness of the ‘P’, or adherence to the Patient Bill of Rights, etc.?; if you are a nurse practitioner did your peer develop a ‘P’ that aligns with Evidence-Based Practice (EPB)/Clinical Practice Guidelines (CPG) and/or the basic sciences, etc.?
RESPONSE 1:
LeAnn Kolovitz
TuesdaySep 13 at 10:47am
Subjective:
57-year-old mixed-race male (black and Asian) complaining of neck pain. He has a history of neck pain and was diagnosed six years ago with spinal stenosis at the C5-C6 level. He is visiting the office for a study participation screening. The study will evaluate the effectiveness of home cervical traction device on neck pain and intervertebral disc space.
Objective:
Blood pressure 217/109
Assessment:
Patient does not meet the qualifications for participation in study. The assessment should contain a medical history and physical examination. A focused assessment to rule out end-organ damage which would differentiate between hypertensive urgency or emergency. Blood pressure should be checked in both arms, standing and lying, pulse check in all extremities and focused neurological and eye exam ((Sharma et al., 2009).
Plan:
Therapeutic:
There is no evidence that the treatment of patients without acute organ damage should differ from that of patients with asymptomatic uncontrolled arterial hypertension (Rossi et al., 2021). Research points to the use of BARKH -based algorithm (B-brain, A-arteries, R-retina, K-kidneys, H-heart) for quick identification of hypertensive emergencies (Rossi et al., 2021).
Figure 1
Grade III High Blood pressure
(Rossi et al., 2021)
Full-article-Management-of-hypertensive-emergencies-a-practical-approach.png
Therapy in an office/urgent care setting could be limited as there may not access to properly diagnose end-organ damage. Additionally, treatment outside a managed setting could be difficult as to patient monitoring and rate at which blood pressure is decreased. In light of these circumstances referral to the emergency department would be recommended.
In our particular patient, 57 yr old Black/Asian male, a medication regimen can not be determined as we do not have access to data that would outline the best medication regimen. However, based on the 2017 AHA guidelines our patient is currently Stage 2 HTN and first line therapies would include two drugs from different classes: thiazide diuretics, calcium channel blockers, ACEI or ARB’s. We should also consider our patient’s ethnicity when prescribing and those recommendations are thiazide diuretics or CCB in combination with another agent (Arcangelo et al., 2021).
Educational:
Education would include specific medication regimen and side effects of medications. Explantation of minor side effects and adverse reactions with new medications and the potential outcomes of medication nonadherence or risks of uncontrolled hypertension. Education would also include at home monitoring of blood pressure before and after medications. Highlighting the importance of lifestyle modification to ensure the best potential outcomes. The visit would also include discussion regarding the importance of patience when investigating which medications will work effectively and scheduling follow-up appointments (Arcangelo et al., 2021).
Consultation/Collaboration:
Collaboration could include referrals to specialties: Cardiac, Nephrology, and Certified Nutritionist. In addition, recommendations for nursing follow up to review medications and treatment could be part of outpatient management. This particular patient could prove to be difficult and may take a very straight forward approach because he himself is in the healthcare profession at the provider level.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2021). Pharmacotherapeutics for advanced practice: A practical approach (Fifth, North American ed.). LWW.
Rossi, G., Rossitto, G., Maifredini, C., Barchitta, A., Bettella, A., Latella, R., Ruzza, L., Sabini, B., & Seccia, T. M. (2021). Management of hypertensive emergencies: A practical approach. Blood Pressure, 30(4), 208–219. https://doi.org/10.1080/08037051.2021.1917983Links to an external site.
Sharma, S., MD, Anderson, C., PharmD, Sharma, P., MD, & Frey, D., MD. (2009, April 1). Management of hypertensive urgency in an urgent care setting. Journal of Urgent Care Medicine. https://www.jucm.com/management-of-hypertensive-urgency-in-an-urgent-care-settingLinks to an external site.
RESPONSE 2:
Nicole Totten
YesterdaySep 14 at 10:43am
Subjective(S):
Chief complaint- Neck pain, seeking inclusion in study
PMH- undiagnosed hypertension, spinal stenosis at c5-c6
Allergies- unknown
Medications- unknown
Family/Social history- unknown
Objective(O):
Patient seems alert and oriented x4, not in acute distress. Normal physical exam.
VS- elevated bp 217/109
Assessment (A)
Diagnosis
1. Spinal Stenosis, Neck Pain
2. Hypertension
Plan (P)
Therapeutics- With this patient stating he has sustained this blood pressure for 10 years is concerning. To confirm this as hypertension, I would confirm this reading with a subsequent reading 1 week apart. In any case, however, I would diagnose this patient as currently in a hypertensive urgency. Since the diastolic is around 110 and systolic is greater than 180 and this patient is not experiencing any symptoms that would lead me to believe he has organ damage occurring (Sharma et.al., 2021). In the acute clinical situation, I would speak with the patient about controlling the blood pressure with medications. Usually in acute emergent situations, IV medications, such as direct vasodialators, like Hydralazine could be considered. In this patient, who is asymptomatic, and hypertension is chronic, I would consider the use of a Calcium Channel Blocker such as Amlodopine to control this patient long term. In this patient specifically, I would be inclined to know more medical history, medication history before discussing possible options. To add, this patient’s ethnicity puts him at an increased risk for complications associated with hypertension. In addition to coming up with both an acute and long term, I would discuss with the patient about non pharmacological ways to help control his pressure like stress reduction and diet change.
Educational- I would outline the seriousness of prolonged uncontrolled hypertension. Stroke, MI, Heart Failure, and Renal disease are important complications related to hypertension. In this patient specifically, since he is a medical care provider, I would stress the importance of taking care of himself. This is an important message to all healthcare providers. We cannot care for others if we do not care for ourselves.
Consultation- After controlling the blood pressure in the acute phase, and prescribing some medication for the patient to start at home, I would refer him to a cardiologist for cardiac testing and adjustment of medication therapy. I would also address this patient mental health care and encourage therapeutic measures to control stress, help his neck pain, and aid in putting his health first before others.
Sharma, S., MD., Anderson, C. PharmD., Sharma, P., MD., Frey, D., MD. (2021). Management of hypertensive urgency in an urgent care setting (Links to an external site.). The Journal of Urgent Care Medicine. https://www.jucm.com/management-of-hypertensive-urgency-in-an-urgent-care-setting/
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