NR 566 CLASS DISCUSSION WEEK 1 2021 (A GRADED)

This is a graded discussion: 100 points possible due Jan 10 Week 1: Clinical Case Study (Original response due by Wednesday, responses due by Sunday) No unread replies.9999 replies. Purpose Problem-based learning is ...

This is a graded discussion: 100 points possible due Jan 10 Week 1: Clinical Case Study (Original response due by Wednesday, responses due by Sunday) No unread replies.9999 replies. Purpose Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice. The purpose of this activity is to develop students’ clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group. Activity Learning Outcomes Through this discussion, the student will demonstrate the ability to: Synthesize clinical knowledge, didactic learning and research findings to provide appropriate pharmacological care to primary care patients. (CO 1, 2, 3, 4, & 6) Due Date: The student must provide an initial response to the discussion topic by Wednesday, 11:59pm MT. Subsequent posts, including substantive responses to peer(s) and faculty questions must occur by Sunday, 11:59pm MT. A total of 3 substantive posts are required on 3 different days. A 10% late penalty will be imposed for initial discussions posted after the deadline on Wednesday 11:59pm MT, regardless of the number of days late. NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0). Week 8 discussion closes on Saturday at 11:59pm MT. A 10% penalty will be imposed for not entering the minimum number of interactive dialogue posts (3) OR not posting on the minimum required number of days (3). NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0) Total Points Possible: 100 Case Study & Discussion Questions John is a 46-year-old male who presents for his yearly physical examination. He has no complaints. Previous medical history is notable for obesity and hyperlipidemia. He reports a very sedentary lifestyle. He sits at a desk for 8 to 10 hours per day and when he comes home he “just wants to relax in front of the television.” He doesn’t feel motivated enough to exercise on a regular basis, although he knows he should. John is allergic to penicillin (hives). Medications include atorvastatin 10mg daily and a multivitamin. He occasionally takes acetaminophen for a headache. Family history is significant for diabetes (mother, maternal grandmother, paternal grandfather) and hypertension (father and brother). He is a nonsmoker and reports drinking “a few beers on the weekend during football season”. His diet largely consists of fast food meals. He drinks sweet tea with every meal and an additional 3-4 cups of coffee per day. Previous labs and exam last year are unremarkable. Vitals today: BP 130/70 mm Hg, pulse 82 and regular, temperature 98.7, respirations 18, height 6’1”, weight 235 pounds (up 3 lbs. since his visit 1 year ago). He completed fasting labs prior to this appointment as he was instructed which reveal the following: Fasting plasma glucose=209 mg/dl, HgbA1C=9.1%, TSH=4.0mU/L and Free T4=1.1 ng/dl. Fasting lipid panel includes the following: total cholesterol=190 mg/dL, HDL=35 mg/dL, LDL=120 mg/dL and triglycerides=260 mg/dL. Physical exam is remarkable for obesity but is otherwise normal. What are your treatment goals for John? What is your pharmacologic plan and rationale? (cite with appropriate clinical practice guidelines or scholarly, peer-reviewed journals) What is the mechanism of action for each drug? Please give five medication teaching points for each drug prescribed. How would you change the plan if his initial HbgA1C was 14.0 mg/dL and his fasting blood glucose was 350mg/dL along with a urine dipstick that revealed 3+ glucose and + ketones? Provide a detailed alternative plan with the rationale. 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 levelappropriate 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. Direct Quotes Good writing calls for the limited use of direct quotes. Direct quotes in discussions are to be limited to one short quotation (not to exceed 15 words). The quote must add substantively to the discussion. Points will be deducted under the grammar, syntax, APA category. **To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric.  DISCUSSION CONTENT Category Points % Description Application of Course Knowledge 35 35% Decisions are well supported with evidence based medicine (EBM) arguments that are in-line with the scenario; AND Proper rationale and reasoning skills are demonstrated; AND Information is taken from source(s) with appropriate interpretation/evaluation to develop a comprehensive analysis or synthesis of the topic at hand; AND Applies concepts to personal experience in the professional setting and/or information has relevant application to real life; AND All of the post makes direct reference to concepts discussed in the lesson; AND Posts are on topic and answer all presented questions which demonstrates a solid understanding of the topic. (6 critical elements) Support from Evidence-Based Practice (EBP) 35 35% Discussion post is supported with appropriate, scholarly sources; uses valid, relevant, and reliable outside sources to contribute to the threaded discussion; AND Sources are published within the last 5 years (unless it is the most current CPG); AND Reference list is provided and in-text citations match; AND Provides relevant evidence of scholarly inquiry clearly stating how the evidence informed or changed professional or academic decisions (4 critical elements) Interactive Dialogue 15 15% Student provides a substantive* response to at least one topic-related post of a peer; AND Evidence from appropriate scholarly sources are included; AND Reference list is provided and in-text citations match; AND Student responds to all direct faculty questions OR if student was not asked a direct question student responds to either a 2nd peer post or a faculty question directed towards another student (*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response (4 critical elements) Total CONTENT Points= 85 pts DISCUSSION FORMAT Category Points % Description Grammar, Syntax, Spelling & Punctuation 15 15% Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors* (*) APA style references and in text citations are required; however, there are no deductions for errors in indentation or spacing of references. All elements of the reference otherwise must be included. Total FORMAT Points= 15 pts DISCUSSION TOTAL= 100 pts This topic is closed for comments. Search entries or author Search entries or author Filter replies by unread Collapse SubdiscussionXinyun Wu Xinyun Wu Jan 5, 2021Jan 5 at 10:57am Good morning Class: What are your treatment goals for John?  The treatment goals for John is to motivate him to do some life modifications such as daily exercises and healthy eating habits. Secondly, instruct him to take metformin 500 mg po BID as the first line treatment for type II diabetic which should help him lower his Hgb A1C level and make him lose weight due to the drug effect. Last but most important is to ensure he will be medication compliance with the treatment. What is your pharmacologic plan and rationale?  Biguanides (Metformin) is the only drug in antihyperglycemic class used clinically for type 2 diabetes mellitus. It is the first-line therapy for children above 10 years old and adults (Woo & Robinson 2016). Metformin can be used as monotherapy. In this case, since we just initiated metformin therapy for him, so 500 mg BID po with the morning and evening meals, or 850 mg daily in the morning under fasting condition. Then the dosage can be titrated from 500 mg bid to 850 mg bid after 2 weeks. What is the mechanism of action for each drug?  50% - 60 % of metformin is absorbed after oral administration. Metformin decreasing hepatic glucose production by suppression of gluconeogenesis and enhancing insulin suppression of endogenous glucose production then reducing intestinal glucose absorption and possibly improving glucose uptake and utilization. It increases peripheral glucose uptake and decrease hepatic glucose production and further decrease intestinal absorption of glucose. Metformin effects AMP-activated protein kinase (AMPK)- dependent and AMPK-independent mechanisms. It inhibits mitochondrial respiration and glycerophosphate dehydrogenase which is a mechanism involving the lysosome (Foretz., ect, 2014.) Please give five medication teaching points for each drug prescribed.  Monitor GI adverse reactions. If GI upset is a medication regiment issues, then notify health care provider. The medication can be given twice a day instead of daily. Take metformin at the same time each day exactly as prescribed. He should take the whole pill no cut, crush, or chew. Watching out for lactic acidosis such as chills, dizziness, low blood pressure, muscle pain, sleepiness, trouble breathing, slow heart rate and weakness. He should report to his provider if he experiences these symptoms. Hydration is necessarily to prevent lactic acidosis and improve renal function. Low blood sugar can happen. Signs may be dizziness, headache, feeling sleepy or weak, shaking, fast heartbeat, confusion, hunger, or sweating. Hold metformin temporarily for 48 hours prior to radiological studies which involve iodine-based contrast. Due to iodine contrast may cause renal function alternation (Woo & Robinson 2016). How would you change the plan if his initial HbgA1C was 14.0 mg/dL and his fasting blood glucose was 350mg/dL along with a urine dipstick that revealed 3+ glucose and + ketones? In this case, his care plan will definitely be changed because he is experiencing diabetic ketoacidosis which is a serious complication of diabetes. Diabetic ketoacidosis includes fasting blood glucose greater than 250 mg/dL and have ketones and glucose in urinalysis. Since diabetic ketoacidosis is an emergency condition, he needs to seeking care in the emergency room for further treatment and medical evaluation immediately. First of all, the possible triggers of diabetic ketoacidosis may due to binge drinking beers or he may have unknow infections which case body to produce higher level of certain hormones which counter the effects of insulin and triggering this episode of diabetic ketoacidosis. Furthermore, this diabetic ketoacidosis may be due to prolong poor eating habits, sedentary lifestyle and uncontrolled blood sugar level. Fluid and electrolyte replacement by offering him oral hydration or IV fluids and replacement electrolyte are essential. IV hydration such as 0.9% normal saline or 0.45 % NS with Dextrose 5% at 250 ml/hour. Oral or IV hydration helps to flush ketones out off system and balance acid-base level. Monitor potassium level because potassium level may drop quickly as fluid and insulin take effect. Insulin facilitate the uptake of glucose into muscle cells which brings potassium into cell and lowering serum potassium level. Furthermore, low-dose regular insulin by SQ or IV are needed (Woo & Robinson 2016). Based on the diabetic ketoacidosis protocol check serum glucose level every 2 hours. When serum glucose is 200 mg/dL, gave regular insulin infusion 0.02-0.05 U/KG/hr IV, or gave rapid acting insulin at 0.2 U/Kg SQ. Keep serum glucose between 150 mg/dL. When serum glucose reaches 200 mg/dL, change to D5W at 150 – 250 ml/hour (Xafis, 2010.) Check urine dipstic ketone level every 6 hours. DKA is considered resolve when HGT is less than 11.1 mmol/L, serum bicarbonate great than 18 mmol/L, and clearance of serum or urine ketones. Once patient stabilized from ketoacidosis then patient education about monitor blood sugar levels by using glucometer 3 times a day before each meal and before sleep. Manage for sick days, if patient feels under the weather, then he needs to check his blood glucose level more often. Adequate hydration is needed in daily bases. For medication management, metformin with sulfonylurea meds such as Glipizide. 2.5 mg /250 mg glipizide /metformin daily with food. Since he cannot achieve adequate blood glucose level on healthy eating, exercise and weight loose, then multidrug therapy may be more effective than use metformin along. If the patient still has not met BG and HgA1C target level after 3-month therapy, then adding a third drug to regiment may needed. Furthermore, the patient may be benefits to see an endocrinologist for further medical management (Woo & Robinson 2016). . Reference: Foretz, M., Guigas, B., Bertrand, L., Pillak, M., & Viollet, B. (2014). Metformin: From Mechanisms of Action to Therapies. Cell Metabolism, 20(6), 953– 966. https://doi.org/https://www.sciencedirect.com/science/article/pii/S1550413114004410?via %3Dihub#cebib0010 (Links to an external site.)