NUR 503 Pathophysiology-Infectious Disease

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NUR 503 Pathophysiology-Infectious Disease.

Based on the rigorous and comprehensive nursing knowledge that I have obtained as an MSN-prepared nurse, this paper provides a compiled reflection of the entire journey. It describes the program outcomes, MSN Essentials, and core competencies of the NONPF. It also includes ten exemplars as evidence of all the aforementioned requirements covered.NUR 503 Pathophysiology-Infectious Disease.

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Exemplar # 1 NUR 503 Pathophysiology-Infectious Disease

Introduction

        Lyme disease is the name given to the condition brought on by infection of the human body by the bacterium Borrelia Burgdorferi.  This bacterium is transmitted through the bite of a tick, most commonly known as deer ticks, in their nymphal stage when they are more likely to go undetected for a longer period.  The Centers for Disease Control and Prevention (CDC, 2017) stated that the risk of infection can be greatly reduced if infected ticks are removed within 24 hours since in most cases it takes at least that long for the bacterium to be transmitted.

The initial symptoms that are typically noticed after being infected with Lyme Disease for as few as three or as many as thirty days are headache, fever, fatigue, chills, muscle and joint pain, swollen lymph nodes, and the tell-tale bullseye rash that occurs in 70-80% of cases. Even after successful treatment with a 3-4 week round of antibiotics, there are an array of long-term complications of Lyme disease, known as post-Lyme Disease Syndrome (PLDS), it can include a range of symptoms such as severe headaches and neck stiffness, joint and muscle pain, facial palsy, joint swelling, irregular heartbeat, vertigo, nerve pain, memory loss, and meningitis. NUR 503 Pathophysiology-Infectious Disease.

Determinants of Health

The determinants of health play a leading role in the progression of illness and disease throughout our communities. Personal, social, economic, and environmental factors make up the determinants of health and can either help or hinder a person’s health. A person’s environment, for example, could increase the likelihood of exposure to ticks that can could carry the disease if conditions aren’t sanitary. NUR 503 Pathophysiology-Infectious Disease. Similarly, if access to a provider is not readily available, patients may be unaware of preventative measures or may go longer without treatment. There is also a trend of increasing incidences of Lyme Disease in urban areas due to increasingly dense populations and often subpar sanitary conditions (van der Heijden, Mulder, Poortvliet, & van Vliet, 2017).

Host Factors

The epidemiological triad of disease is a model that helps to show how disease transmission. In Lyme disease, it consists of the agent, environment, vector, and host. The agent is the Borrelia Burgdorferi bacterium that resides in small mammals and dear, the tick acts as a vector carrying the bacterium from an animal to a susceptible human host. The environment is that in which the agent, vector, and host are able to interact.

Role of FNP

The role of the FNP is to not only treat illness and disease but to try and prevent it from occurring. The American Association of Nurse Practitioners (2019) states that “NPs diagnose and manage acute and chronic conditions and emphasize health promotion and disease prevention.” In the management of conditions such as Lyme disease, surveillance and primary prevention such as educating patients is key. Secondary and tertiary interventions such as quick assessment and correct diagnosis, and treatment of both early and late symptoms of the disease. The Chronic Care Model can assist the FNP’s practice by directing holistic care toward health promotion, which would undoubtedly work to educate patients about Lyme disease.NUR 503 Pathophysiology-Infectious Disease.

Identify and Explain
The MSN Essential and NONP competencies that the author attained in exemplar #1 are:

PO # 4: Integrate professional values through scholarship and service in health care (Professional Identity)

The author attained this outcome by applying the following nursing professional values: integrity, human dignity, justice, and altruism, to promote health, advocate and prevent disease among populations. Besides, the author obtained outcomes through the development of in-depth knowledge related to the integration of the most recent scientific findings to nursing practice.NUR 503 Pathophysiology-Infectious Disease.

MSN Essential: Essential IV: Translating and Integrating Scholarship into Practice

The author attained this MSN Essential by identifying, analyzing, and integrating the most recent evidence to solve healthcare issues such as poor health outcomes among people living in urban settings. Through the identification of health issues encountered by urban dwellers in congested and densely populated settings, the author was able to develop evidence-based solutions and share with relevant stakeholders to influence positive outcomes.

NONPF #4: Practice Inquiry Competencies.

The author developed research questions that guided evidence-based research on different population health concerns and their most relevant evidence-based solutions as a way to advance outcomes and health systems.NUR 503 Pathophysiology-Infectious Disease.

Connect
Concepts related to exemplar#10 include evidence-based practice and evidence-based care

Evidence-Based Practice

EBP refers to incorporating the most recent findings from scientific research, patient’s values and clinical expertise when making decisions regarding care.

Evidence-Based Care

It involves providing safe, optimal and quality care to patients as guided by current scientific research while incorporating clinical expertise and patient’s values.NUR 503 Pathophysiology-Infectious Disease.

Reflection
In this course, I improved my skills and knowledge in nursing in regards to methods for conducting advanced research. I will use these skills in my current and future practice to search for the most appropriate interventions for specific heath issues with the aim of improving patient health outcomes, healthcare systems, nursing practice, and nursing as a profession.NUR 503 Pathophysiology-Infectious Disease.

Exemplar # 2 NUR603 Sick Child Case Presentation

Initials: E, C

Age: 17

Gender: Female

Height: 5’6”

Weight: 126lbs

BMI: 20.3

Growth Chart Perc: 59%

Tanner Staging: Stage 5

BP: 101/53

HR: 77

RR: 16

Temp: 98.7

SPO2: 99%

Pain: None

Allergies: None

Current Medications: Tylenol 650mg q4-6hrs PRN pain, Ibuprofen 600mg q6hrs PRN pain

SUBJECTIVE:

Chief Complaint:

E, C is a 17-year-old female who presents for evaluation of an abnormal vaginal discharge. Symptoms have been present for 2 weeks. Complains of brownish-gray vaginal discharge with odor and vaginal itching. She denies abnormal bleeding, blisters, bumps, dyspareunia, lesions, post coital bleeding, tears, or warts. Menstrual flow: regular every 28-30 days.

Past medical history:

Asthma

Intermittent lower back pain, present since MVA 4 years ago

STI-chlamydia, treated last year

Immunizations are up to date, has had 2 out of 3 Gardasil vaccines with final shot due in 3 months

Social history:

Patient is a student at the local high school but attends early college courses at the local community college. Plays tennis weekly. Works as a waitress some evenings and weekends. Currently lives with her parents but plans to move to Wilmington after graduation to attend college there. She has been sexually active for 2 years and has had multiple sexual partners in the last year. Reports having unprotected sex at times, has IUD and otherwise uses condoms for contraception/STI prevention.NUR 503 Pathophysiology-Infectious Disease.

Family history:

Mother: type II diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity

Father: smoker, HTN, hypercholesterolemia, asthma in childhood

Maternal grandmother: type II diabetes, HTN

Maternal grandfather: smoker, eczema

Paternal grandmother: died at age 59 d/t MVA

Paternal grandfather: no known history

Review of systems:

Constitutional: Negative, no acute distress

Respiratory: Negative, denies cough, dyspnea, or pain on inspiration

Cardiovascular: Negative, denies palpitations, shortness of breath, or chest pain

Gastrointestinal: Denies abdominal pain, N/V, constipation, or diarrhea

Genitourinary: Reports dysuria (burning) with urination, denies hematuria

Gynecological: Reports brownish vaginal discharge, foul odor, vaginal itching, denies dysmenorrhea or amenorrhea

OBJECTIVE:

Physical assessment:

General: Alert and cooperative, appears stated age. Patient is a very pleasant 17-year-old female who is gravida 0.

Head: Normocephalic, without obvious abnormality, atraumatic

Abdomen: Soft, non-tender, no palpable organomegaly

Pelvic: External Genitalia: Area of redness noted to left labia, acutely tender to touch

Urethra: Normal anatomy without lesions or prolapse

Vaginal: Normal rugae, grayish mucoid discharge noted, no lesions

Cervix: Nulliparous, IUD strings noted, no lesions, nontender to manipulation

Uterus: Midline, nontender

Adnexa: No masses or tenderness

Skin: warm, dry, normal color, no rashes

Lymph nodes: Cervical, supraclavicular, and axillary nodes normal

Neurologic: Grossly normal

Labs:

Wet prep w/KOH 

Clue cells Moderate

Yeast None

Hyphae Moderate

Trichomonas None

WBC Moderate

RBC None

Identify and Explain
Program Outcome #1 Practice safe, high-quality advanced nursing care based on concepts and knowledge from nursing and related disciplines.

The author met this outcome by using contemporary EBP to develop an SOAP note, determine potential differential diagnoses and to develop a care plan to ensure that the patient received high-quality and safe care.

MSN Essential I: Background for Practice from Sciences and Humanities

I achieved this essential by utilizing the most recent EBP to develop an SOAP note, determine the most appropriate differential diagnoses and to develop a care plan. Since I also participated actively in classroom discussions and responded to peers, I advanced my EBP knowledge on how to analyze nursing interventions and outcomes, and how to initiate new changes.NUR 503 Pathophysiology-Infectious Disease.

NONPF#9 Independent Practice Competencies

The author met these competencies by combining knowledge on how to write an SOAP note for patients with different ages and clinical presentations, and how to develop the appropriate care plans and conduct follow-up.NUR 503 Pathophysiology-Infectious Disease.

Connect
Concepts in exemplar #2 were quality care and patient safety.

Quality care

Quality care refers to the extent that healthcare services for populations and individuals increase the chances of expected health outcomes and are highly consistent with the most recent professional knowledge and skills.NUR 503 Pathophysiology-Infectious Disease.

Patient Safety

Patient safety is the process of preventing, reducing, reporting, analyzing, and evaluating adverse events such as medical errors related with healthcare processes.

Reflection
The author obtained more knowledge and skills on how to write SOAP notes, to formulate differential diagnoses, and make patient care plans. The author will apply this knowledge in present and future practice with the purpose of increasing patient satisfaction, improving the quality of life, and patient health outcomes.

Exemplar # 3 NR511: Case Study

The patient is a 62yo Caucasian male in no acute distress. He presents today complaining of persistent cough with recent onset of shortness of breath, which has him unable to walk more than 20ft without stopping to catch his breath. His cough started 6 months ago. It has been intermittent but frequent and is worse in the morning. The cough produces a white-yellowish phlegm. His condition is aggravated by activity and relieved by rest. He has tried to treat his cough with Robitussin DM, which provided no relief. ROS is unremarkable with the exception of the aforementioned cough w/phlegm and SOB w/activity. Physical assessment is significant for hypertension (BP 156/94), morbid obesity with a BMI of 40.4; lungs are clear with faint forced expiratory wheezes in bilateral bases. No fever, JVD, abnormal heart sounds, or lower extremity edema. History is significant for hypertension and former smoker (20 pack-year).NUR 503 Pathophysiology-Infectious Disease.

Diagnosis #1 Chronic Obstructive Pulmonary Disease (COPD)

Diagnosis #2 Heart Failure (HF)

Diagnosis #3 Asthma

                                             Patient Findings and Differential

FINDINGS COPD Asthma Heart Failure
Persistent cough + + +
Shortness of breath + + +
White-yellowish phlegm + – +
Wheezing + + +

Diagnosis #1 COPD

The patient’s pertinent positives that point towards COPD are his persistent cough that started 6 months ago, recent onset of SOB w/exertion, white-yellowish phlegm, and wheezes on forced expiration. His 20 year-pack history also lends itself to the diagnosis of COPD, which is the most significant risk factor for developing this condition (CDC, 2019).

Diagnosis #2 Heart Failure

Each of the pertinent positives (persistent cough, SOB, phlegm production, wheezing) could also be symptoms associated with heart failure. The patient also has risk factors that are significant for heart failure such as uncontrolled hypertension, morbid obesity, and his 20 pack-year tobacco use history (Guirguis-Blake et al., 2016). Pertinent negatives are no progressive edema, nocturnal dyspnea, or weakness. The patient also has no JVD, rapid heart rate, or chest pain.NUR 503 Pathophysiology-Infectious Disease.

Diagnosis #3 Asthma

Several of the pertinent positives were in patients suffering from asthma. Persistent cough, shortness of breath, and expiratory wheezing are all common signs of the disease (Guirguis-Blake et al., 2016). Obesity coexists with asthma in most patients. Pertinent negatives are his productive cough, childhood diagnosis.

Additional testing needed:

*Spirometry

*A CXR

*A CBC w/diff

*An EKG

Identify and Explain
Program Outcome #1 Practice safe, high-quality advanced nursing care based on concepts and knowledge from nursing and related disciplines.

The author met this outcome by using contemporary EBP to develop an SOAP note, determine potential differential diagnoses and to develop a care plan to ensure that the patient received high-quality and safe care.NUR 503 Pathophysiology-Infectious Disease.

MSN Essential I: Background for Practice from Sciences and Humanities

I achieved this essential by utilizing the most recent EBP to develop an SOAP note, determine the most appropriate differential diagnoses and to develop a care plan. Since I also participated actively in classroom discussions and responded to peers, I advanced my EBP knowledge on how to analyze nursing interventions and outcomes, and how to initiate new changes.NUR 503 Pathophysiology-Infectious Disease.

NONPF#9 Independent Practice Competencies

The author met these competencies by combining knowledge on how to write an SOAP note for patients with different ages and clinical presentations, and how to develop the appropriate care plans and conduct follow-up.

Connect
Concepts in exemplar #2 were quality care and patient safety.

Quality care

Quality care refers to the extent that healthcare services for populations and individuals increase the chances of expected health outcomes and are highly consistent with the most recent professional knowledge and skills.

Patient Safety

Patient safety is the process of preventing, reducing, reporting, analyzing, and evaluating adverse events such as medical errors related with healthcare processes.NUR 503 Pathophysiology-Infectious Disease.

Reflection
The author obtained more knowledge and skills on how to write SOAP notes, to formulate differential diagnoses, and make patient care plans. The author will apply this knowledge in present and future practice with the purpose of increasing patient satisfaction, improving the quality of life, and patient health outcomes.

Exemplar # 4 NR 503 Women’s Health Final SOAP Analysis – Part 2
The primary diagnosis for this patient is COPD. Pertinent positives are post bronchodilator spirometry readings showing his FEV1/FV=.52 and his FEV1=.47 which showed little to no improvement from his pre-bronchodilator results and would deem his condition as severe COPD (GOLD, 2019). Other pertinent positives are his persistent, productive cough producing white-yellowish phlegm, a gradual onset 6 months ago, forced expirations with wheezes heard in the bilateral bases, dyspnea that is improved at rest, decreased activity tolerance, cough that is worse in the morning, history of smoking (20 pack-year history), and onset of the condition in his 60’s. Pertinent negatives are lack of chest tightness, cyanosis, weight loss, and extremity edema that can often be seen in COPD patients. NUR 503 Pathophysiology-Infectious Disease.

The IDC-10 code that corresponds with this diagnosis is J44.1 (Chronic obstructive pulmonary disease with acute exacerbation) (MyEvaluations.com, 2019).

Treatment Plan:

This patient is presenting with severe COPD and a treatment plan could include initiation of a short acting bronchodilator as needed, a long acting bronchodilator (LABA) and long acting muscarinic antagonist (GOLD, 2019). An inhaled corticosteroid (ICS) could be added if he has repeated exacerbations after reaching a level of stability with his condition or if his blood eosinophil count is greater than 300 (GOLD, 2019). Combination therapy with a LABA and LAMA for patients with a FEV1 less than 60% predicted is also recommended by the American College of Physicians (Gentry, S. & Gentry, B., 2017).

Prescription Medications:

Proair HFA Inhaler 90mcg/actuation

Disp# 1

Sig: 1-2 inhalations q 4-6hrs prn for shortness of breath

Refill: 1


Tiotropium/olodaterol 2.5mcg/2.5mcg per actuation

Disp# 1

Sig: 2 inhalations once daily at the same time of day

Refill: 1


Additional Testing:

COPD Assessment Test (CAT)

Cardiac Panel

A CBC with differentials

Patient Education

Referral

Follow-up

Identify and Explain
Program Outcome #1 Practice safe, high-quality advanced nursing care based on concepts and knowledge from nursing and related disciplines.

The author met this outcome by using contemporary EBP to develop an SOAP note, determine potential differential diagnoses and to develop a care plan to ensure that the patient received high-quality and safe care.

MSN Essential I: Background for Practice from Sciences and Humanities

I achieved this essential by utilizing the most recent EBP to develop an SOAP note, determine the most appropriate differential diagnoses and to develop a care plan. Since I also participated actively in classroom discussions and responded to peers, I advanced my EBP knowledge on how to analyze nursing interventions and outcomes, and how to initiate new changes.NUR 503 Pathophysiology-Infectious Disease.

NONPF#9 Independent Practice Competencies

The author met these competencies by combining knowledge on how to write an SOAP note for patients with different ages and clinical presentations, and how to develop the appropriate care plans and conduct follow-up.NUR 503 Pathophysiology-Infectious Disease.

Connect
Concepts in exemplar #2 were quality care and patient safety.

Quality care

Quality care refers to the extent that healthcare services for populations and individuals increase the chances of expected health outcomes and are highly consistent with the most recent professional knowledge and skills.

Patient Safety

Patient safety is the process of preventing, reducing, reporting, analyzing, and evaluating adverse events such as medical errors related with healthcare processes.

Reflection
The author obtained more knowledge and skills on how to write SOAP notes, to formulate differential diagnoses, and make patient care plans. The author will apply this knowledge in present and future practice with the purpose of increasing patient satisfaction, improving the quality of life, and patient health outcomes.NUR 503 Pathophysiology-Infectious Disease.

Exemplar # 5- NR601-Diabetes Case Study

Assessment

Primary Diagnosis: Type II Diabetes Mellitus without complications (ICD 10 code: E11.9)

Pertinent positive findings: Mr. Jones presents with complaints of fatigue, increased hunger, increased thirst, inability to lose weight, and nocturia. He is also obese with a BMI of 31, has a fasting glucose of 135, a HgbA1c of 6.9%, and is spilling glucose into his urine with a 1+ glucose (ADA, 2020a). NUR 503 Pathophysiology-Infectious Disease.

Pertinent negative findings: Although Mr. Jones presents with several symptoms

indicative of type 2 diabetes, he doesn’t complain of any pruritus, numbness and tingling, poor wound healing, or blurred vision that is also often seen with these patients (ADA, 2020a).

Secondary Diagnosis: Morbid obesity due to excess calories (ICD 10 code: E66.01)

Pertinent positive findings: Mr. Jones’ history includes previously talking with him about how to lose weight so this is not a new development. He is complaining of fatigue, has osteoarthritis, and his current body mass index (BMI) at today’s visit is 31. According to Dunphy et al. (2019), a clinician can diagnose obesity for a patient with a BMI greater or equal to 30.NUR 503 Pathophysiology-Infectious Disease.

Pertinent negative findings: Mr. Jones is not complaining of many of the classic subjective symptoms of obesity such as depression, shortness of breath, decreased energy, or daytime sleepiness ADA, 2020a).

Plan

Diagnostics

Lab test (#1) HgbA1c rechecked during follow up in 3 months

Lab test (#2) Lipid panel at 3 month follow up

Medications

Medication (#1)

Metformin ER 500mg

Disp# 30

Sig: 1 tablet PO daily

Refill: 0

Rationale: The American Diabetes Association (2020f) stated that the first line pharmacological treatment for type 2 diabetes is Metformin and as long as it is well tolerated.

Medication (#2)

OTC Vitamin B Complex daily tablet

Education

Diagnoses

Medications

Diet

Exercise

Warning Signs for diagnoses and medications.

Mr. Jones will be educated about type 2 diabetes and the warning signs of excessively high blood sugar (increased thirst, frequent urination, fatigue, shortness of breath, nausea and vomiting, rapid heartbeat, and fruity breath), and excessively low blood sugar (anxiety, fatigue, shakiness, sweating, nausea, extreme hunger, lightheadedness, slurred speech, confusion, or seizure) (ADA, 2019). Education about metformin would include warning against taking more than is prescribed due to the risk of lactic acidosis (ADA, 2020f). Signs of lactic acidosis may include decreased appetite, abdominal pain, diarrhea, shallow breathing, muscle cramping/pain, abnormal sleepiness, and weakness.NUR 503 Pathophysiology-Infectious Disease.

Referral (#1) Specialty practice or service registered dietician (RD)/registered dietician nutritionist (RDN)

Follow up in 4 weeks

Identify and Explain
Program Outcome #1 Practice safe, high-quality advanced nursing care based on concepts and knowledge from nursing and related disciplines.

The author met this outcome by using contemporary EBP to develop an SOAP note, determine potential differential diagnoses and to develop a care plan to ensure that the patient received high-quality and safe care.

MSN Essential I: Background for Practice from Sciences and Humanities

I achieved this essential by utilizing the most recent EBP to assess patient findings and determining the most appropriate differential diagnoses and developing care plans. Since I also participated actively in classroom discussions and responded to peers, I advanced my EBP knowledge on how to analyze nursing interventions and outcomes, and how to initiate new changes.NUR 503 Pathophysiology-Infectious Disease.

NONPF#9 Independent Practice Competencies

The author met these competencies by combining knowledge on how to assess patients with different ages and their clinical presentations, and how to develop the appropriate care plans and conduct follow-up.

Connect
Concepts in exemplar #2 were quality care and patient safety.

Quality care

Quality care refers to the extent that healthcare services for populations and individuals increase the chances of expected health outcomes and are highly consistent with the most recent professional knowledge and skills.

Patient Safety

Patient safety is the process of preventing, reducing, reporting, analyzing, and evaluating adverse events such as medical errors related with healthcare processes.

Reflection
The author obtained more knowledge and skills on how to write SOAP notes, to formulate differential diagnoses, and make patient care plans. The author will apply this knowledge in present and future practice with the purpose of increasing patient satisfaction, improving the quality of life, and patient health outcomes.NUR 503 Pathophysiology-Infectious Disease.

Exemplar #6-NR510 Advanced Practice Nurse Personal Development Plan

Accreditation ensures that educational programs meet nationally established standards. In order to be accredited, one of four nursing accrediting bodies must verify a program. Certification is the process of testing an APN’s knowledge through taking an exam administered by one of the nursing organizations recognized in the state. Education refers to accredited programs that provide postgraduate masters and doctorate level education. Licensure, accreditation, certification, and education (LACE) considerations can differ greatly from state to state and even between advanced practice nurse (APN) roles.

California is a restricted practice state. This means that in order for an APN to provide patient care they must work under the supervision of a physician. This effectively restricts the ability of nurse practitioners to provide patient care within the state. Nurse practitioners and nurse midwives must also apply for prescriptive authority once certified for advanced practice by the California Board of Registered Nursing. In order to be eligible to apply for a furnishing number, they must first complete the required advanced pharmacology course as well as have proof of at least 520 hours of physician-supervised experience furnishing patients with drugs and medical devices. Continuing education requirements in the state are currently only 30 hours every 2 years to maintain your RN license and no additional continuing education for APN certification is required by the state according to the California Board of Registering Nurses (CBRN, 2018c, 2018d).NUR 503 Pathophysiology-Infectious Disease.

California is one of only three states, including Indiana and Kansas that will recognize nurse practitioners without national certification.

Nurse midwives can meet the requirements for licensure by

graduating from a Board approved nurse midwifery program within the state,
Obtaining national certification from an organization with equivalent standards as the California Board.
Graduating from program that meets the state’s standards but is not yet Board approved (in which case additional documentation including a Verification of the Content of the Nurse-Midwifery Academic Program Form must be submitted) (CBRN, 2018c).
Achieving Continuity

In North Carolina, the current scope of practice does not allow for independent practice. North Carolina is considered a restricted practice state and therefore full practice authority (FPA) is prohibited. Advanced practice nurses who wish to practice within the state must sign a collaboration agreement and practice under the supervision of a physician. Under these stipulations a nurse practitioner may work to promote and maintain health, prevent illness and disability, diagnose, treat, and manage acute and chronic illness, provide guidance and counseling for individuals and families, prescribe medications, order and interpret diagnostic tests, and evaluate outcomes (NCBON, 2018).NUR 503 Pathophysiology-Infectious Disease.

Identify and Explain
The author attained the following competencies on exemplar #6

PO #3: Engage in lifelong personal and professional growth through reflective practice and appreciation of cultural diversity (Cultural Humility)

The author attained this outcome by developing an individual career plan following the identification of the roles of NPs in California with areas of strengths and weaknesses. The plan guided my continuous professional growth and informed my understanding on potential practice limitations that prevent the growth of the nursing profession. NUR 503 Pathophysiology-Infectious Disease.

MSN Essential IV: Translating and Integrating Scholarship into Practice

The author achieved this MSN essential by developing a professional plan in line with specific evidence-based guidelines that promote integration and advancement of knowledge obtained in actual practice.

NONPF #2: Leadership Competencies.

The author attained leadership competencies after identifying and suggesting improvements to advance the nursing profession through role modeling, communication skills, teamwork, decision-making, coordination, and inspirational guidance skills.

NONPF #9 Independent Practice Competencies

The author attained this competency by developing an individual plan that facilitated transition from novice to expert level.

Connect
The concepts associated with exemplar #6 were health policy and healthcare systems.

Healthcare Systems

Refers to a network of institutions, resources, and individuals who deliver healthcare services with the aim of attaining the healthcare needs of specific patient populations.

Health policy

Policy is a set of rules and regulations that purpose to attain specific healthcare goals at societal level or in a given patient population.

Reflection

In the entire course, the author was able to identify practice limitations, individual practice strengths and limitations that influence my practice to date. I also learned to advocate nurses’ autonomy in practice in order to advance the nursing profession.

Exemplar # 7 NUR 511 Case Study

Patient is a 56yo Caucasian female in no acute distress. She presents today complaining of fatigue that started 2-3 months ago, moderate in severity. It has been constant and getting progressively worse since onset. Her fatigue is aggravated with exertion and she hasn’t identified any relieving factors. She has not tried anything to treat her fatigue up to this point. The ROS revealed constipation, cold intolerance, muscle weakness and intermittent cramping in her calves, and worsening depressive symptoms. Her physical exam is significant for elevated BP of 146/95, 5lb weight gain compared to her last visit 6 months ago, she is overweight with a BMI of 28, HEENT exam unremarkable, and skin is dry, hair is thick and coarse. DTRs slightly reduced in lower extremities 1+ at B/L knees and ankles compared to brisk 2+ at B/L biceps.

Patient Findings and Differential

Patient’s Symptoms Hashimoto’s Disease Hypovitaminosis D Myalgic Encephalomyelitis
fatigue + + +
lethargy + + +
weight gain + + +
dry skin +
coarse hair +
muscle aches/cramps + + +
depression + + +
cold intolerance +
slowed DTR’s +

Diagnosis #1 Hashimoto’s Disease

The patient’s pertinent positives (see above) point heavily toward Hashimoto’s disease which is the most common cause of primary hypothyroidism. Hashimoto’s disease is therefore the most likely diagnosis for this patient and is at the top of my differential. There are several pertinent negatives as well since Hashimoto’s disease will ultimately affect virtually every body system so there will be a wide range of possible symptoms (AACE, 2019). Some that may be seen but are absent in this patient are puffy face, hoarseness, muscle weakness, stiff/swollen joints, impaired memory, and goiter.

Diagnosis #2 Hypovitaminosis D

Several of the patient’s pertinent positives could also be an indication that the patient has Vitamin D deficiency, which is second on my differential. Symptoms such as fatigue, lethargy, weight gain, muscle aches, and depression are present in relation to this condition (McCance & Huether, 2019). Other symptoms the patient exhibits such as dry skin, coarse hair, cold intolerance and slowed DTR’s are absent with Hypovitaminosis D and may work to rule out this condition.NUR 503 Pathophysiology-Infectious Disease.

Diagnosis #3 Myalgic Encephalomyelitis

The patient presents with several indicators for this condition as well, but that is what makes Chronic Fatigue Syndrome (CFS) so difficult to diagnose. It carries many of the same symptoms as several other conditions without any definitive diagnostic testing to confirm the diagnosis. The patient presents with fatigue, lethargy, weight gain, muscle aches, and depression, which are often seen in patients suffering from CFS but her other symptoms of dry skin, coarse hair, cold intolerance and slowed DTR’s are not typical symptoms for this condition(Institute of Medicine of the National Acadamies, 2015). A patient with CFS may also have difficulty with temperature changes, sore throat, memory loss, and enlarged lymph nodes. Our patient is negative for these symptoms as well. A diagnosis of CFS also requires least 6 months reported symptoms (Institute of Medicine of the National Acadamies, 2015).NUR 503 Pathophysiology-Infectious Disease.

Additional testing needed:

Thyroid function test (TSH, Free T4) and Anti-TPO

A Lipid Panel

A CBC and CMP

Identify and Explain
The NONPF competencies and MSN Essential attained by exemplar #7 are

PO #1: Provide high quality, safe, patient-centered care grounded in holistic health principles (Holistic Health & Patient-Centered Care)

The authir utilized the current and most recent evidence to conduct patient assessments, make and diagnoses, and manage patients based on individual needs to guarantee patient safety and high quality care.

MSN Essential III: Quality Improvement and Safety

The author met this MSN Essential by using different methodologies, contemporary diagnostic tools, and decision support systems to assess patients, make diagnoses and determine management plans.NUR 503 Pathophysiology-Infectious Disease.

NONPF #4 Practice Inquiry Competencies

The author achieved this competency by utilizing EBP resources, general knowledge, preceptor’s knowledge, individual expertise, and decision-making skills to assess, diagnose and manage patients.NUR 503 Pathophysiology-Infectious Disease.

Connect
The concepts related to exemplar # 4 include patient-centered care and quality care.

Quality care

Quality care refers to the extent that healthcare services for populations and individuals increase the chances of expected health outcomes and are highly consistent with the most recent professional knowledge and skills.

Patient Safety

Patient safety is the process of preventing, reducing, reporting, analyzing, and evaluating adverse events such as medical errors related with healthcare processes.NUR 503 Pathophysiology-Infectious Disease.

Reflection
The author obtained more knowledge and skills on how to provide patient-centric care by integrating EBP and acknowledging a patients/family’s values, and perceptions. Similarly, the author improved her ability to use different methods, and tools to promote patient safety, and quality care hen making diagnoses.NUR 503 Pathophysiology-Infectious Disease.

Exemplar # 8 NUR 509: SOAP Note

This course provides a FNP student with the basic knowledge, experience and information to assess, diagnose, and manage a child within a family setup and provide essential primary care services for common presenting illnesses. The course particularly focused on helping childbearing families to not only maintain but also attain the highest functioning level of health and to focus more on health maintenance and promotion activities. This enabled me to attain MSN PO#5, MSN Essential IX and Core competency #1.

The course was specific to the primary care for children presenting with common respiratory infections. It is vital for an FNP since it applies pathophysiology, assessment, and management in a family setup. The provided case study provides an opportunity for an MSN-prepared FNP to incorporate the learned knowledge from previous courses to assess and diagnose a child. It provides a student FNP the much needed skills to assess, diagnose and manage a childbearing in mind the role played by culture in communication and management of patients.NUR 503 Pathophysiology-Infectious Disease.

The course comprehensively explains the process of assessing, diagnosing and managing children within the family setup in different ages, ethnicities, social circumstance and incorporates how to conduct advanced physical assessments and to assess for ant red flags in developmental milestones. Additionally it builds on child development and growth to emphasize on knowledge in conducing assessments and manage both acute and chronic conditions that FNPs commonly encounter in primary care and pediatric settings. The course analyzes common medical conditions in pediatric populations within a FNP framework. MSN- prepared FNPs care for families thus, will constantly meet children who require pediatric care. Having knowledge on how to assess, diagnose and manage common pediatric illnesses is vital as this will inform and promote the formation of a highly coordinated system and the understanding of when and when not to refer children for specialized and comprehensive care.NUR 503 Pathophysiology-Infectious Disease.

Identify and Explain
Program Outcome #1 Practice safe, high-quality advanced nursing care based on concepts and knowledge from nursing and related disciplines.

The author met this outcome by using contemporary EBP to develop an SOAP note, determine potential differential diagnoses and to develop a care plan to ensure that the patient received high-quality and safe care.

MSN Essential I: Background for Practice from Sciences and Humanities

I achieved this essential by utilizing the most recent EBP to develop an SOAP note, determine the most appropriate differential diagnoses and to develop a care plan. Since I also participated actively in classroom discussions and responded to peers, I advanced my EBP knowledge on how to analyze nursing interventions and outcomes, and how to initiate new changes.NUR 503 Pathophysiology-Infectious Disease.

NONPF#9 Independent Practice Competencies

The author met these competencies by combining knowledge on how to write an SOAP note for patients with different ages and clinical presentations, and how to develop the appropriate care plans and conduct follow-up.NUR 503 Pathophysiology-Infectious Disease.

Connect
Concepts in exemplar #2 were quality care and patient safety.

Quality care

Quality care refers to the extent that healthcare services for populations and individuals increase the chances of expected health outcomes and are highly consistent with the most recent professional knowledge and skills.NUR 503 Pathophysiology-Infectious Disease.

Patient Safety

Patient safety is the process of preventing, reducing, reporting, analyzing, and evaluating adverse events such as medical errors related with healthcare processes.NUR 503 Pathophysiology-Infectious Disease.

Reflection
The author obtained more knowledge and skills on how to write SOAP notes, to formulate differential diagnoses, and make patient care plans. The author will apply this knowledge in present and future practice with the purpose of increasing patient satisfaction, improving the quality of life, and patient health outcomes.NUR 503 Pathophysiology-Infectious Disease.

Exemplar # 9 NR 508: Prescribing

North Carolina is currently not one of the twenty-one states that allows full practice authority. We, along with the majority of southern states, are considered a restricted practice state. As a restricted practice state, nurse practitioners are required to maintain career-long supervision and/or collaboration with a physician. Nurse practitioners must hold at least a Master’s degree and complete a nationally accredited graduate level nurse practitioner program. Board certification is earned by completing a certification exam with one of the nationally certified agencies. State laws limit nurse practitioner’s ability to prescribe medications as well, requiring a collaborative practice agreement with a physician, an assigned DEA number, and the same schedule(s) of controlled substances must be on the supervising physician’s DEA registration (NCBON, 2018).NUR 503 Pathophysiology-Infectious Disease.NUR 503 Pathophysiology-Infectious Disease.

The state’s Medical Board and the Board of Nursing set required continuing education (CE) hours for nurse practitioners. A nurse practitioner must earn 50 continuing education contact hours each year beginning with the first renewal after granted initial practice approval (NCBON, 2019). Of the required 50, a national credentialing body such as the American Nurses Credentialing Center (ANCC) must approve at least 20. Nurse practitioners that prescribe controlled substances must earn at least one hour out of the required 50 continuing education hours in a CE that addresses the prescribing of controlled substances, substance abuse and misuse, or the management of chronic pain (NCBON, 2019). Additionally, documentation of completed CE must be retained for the previous 5 years for possible review by the state board.NUR 503 Pathophysiology-Infectious Disease.NUR 503 Pathophysiology-Infectious Disease.

Knowing and understanding the specific laws in North Carolina pertaining to nurse practitioners prescribing medications is very important to protect both the patient and the provider. Nurse practitioners should always be aware of the prescribing laws in the state that they practice since these laws change from state to state. In order to protect your nursing license, all nurses must follow all laws, rules, and regulations. Nurse practitioners must be aware of not only the medications being prescribed, but also any medications that have been prescribed for the patient by other providers. Ultimately, nurse practitioners should understand that not abiding by the laws for prescribing medications in their state will result in disciplinary action by the board of nursing and may include legal action and/or loss of licensure. Buppert (2018) stated that their board of nursing usually sanctions nurse practitioners that commit negligence that is seen as reckless but there are situations in which nurse practitioners can face jail time.NUR 503 Pathophysiology-Infectious Disease.

Identify and Explain
Identify and Explain
The author attained the following competencies on exemplar #6

PO #3: Engage in lifelong personal and professional growth through reflective practice and appreciation of cultural diversity (Cultural Humility)

The author attained this outcome by developing an individual career plan following the identification of the roles of NPs in California with areas of strengths and weaknesses. The plan guided my continuous professional growth and informed my understanding on potential practice limitations that prevent the growth of the nursing profession.

MSN Essential IV: Translating and Integrating Scholarship into Practice

The author achieved this MSN essential by developing a professional plan in line with specific evidence-based guidelines that promote integration and advancement of knowledge obtained in actual practice.

NONPF #2: Leadership Competencies.

The author attained leadership competencies after identifying and suggesting improvements to advance the nursing profession through role modeling, communication skills, teamwork, decision-making, coordination, and inspirational guidance skills.NUR 503 Pathophysiology-Infectious Disease.

NONPF #9 Independent Practice Competencies

The author attained this competency by developing an individual plan that facilitated transition from novice to expert level.

Connect
The concepts associated with exemplar #6 were health policy and healthcare systems.

Healthcare Systems

Refers to a network of institutions, resources, and individuals who deliver healthcare services with the aim of attaining the healthcare needs of specific patient populations.NUR 503 Pathophysiology-Infectious Disease.

Health policy

Policy is a set of rules and regulations that purpose to attain specific healthcare goals at societal level or in a given patient population.

Reflection

In the entire course, the author was able to identify practice limitations, individual practice strengths and limitations that influence my practice to date. I also learned to advocate nurses’ autonomy in practice in order to advance the nursing profession.NUR 503 Pathophysiology-Infectious Disease.

Exemplar # 10 NUR 503: Healthy People Impact

There is an epidemic in North Carolina on the horizon that coincides with an ever-increasing population of aging senior citizens. The impending epidemic is falls and the effects that they can have are detrimental. Falls among the elderly population are not only a risk for death but more often are the cause for disability and debilitation. Falls are the most common cause of hip fractures and traumatic brain injuries. NUR 503 Pathophysiology-Infectious Disease.

In Brunswick County, where the percentage of individuals 65 and older is over 27%, almost two times that of the state-wide percentage, the increased prevalence of falls plays a significant role in the health and well-being of the community (BCHHS, 2015). Incidences of falls in the state number in the hundreds each year. According to the North Carolina Department of Health and Human Services (2016) there are approximately 17 deaths related to falls each week throughout the state. Nationally, it is estimated that someone dies as the result of a fall every 20 minutes and death rates increased by over 29% in the last 10 years (CDC, 2019).

Epidemiological Analysis

In order to analyze the epidemiology of falls, one must first understand the at-risk population. The population most at risk for serious injury or death from falls is adults aged 65 and older. Of those aged 65 and older, women tend to be at a higher risk for falls than men of the same age (Johansson, Nordström, A., & Nordström, P., 2016). While this is true for the overall number of falls, men have a higher incidence of death due to falls.

Falls are instigated by factors that inhibit a person’s ability to maintain a proper balance and gait. There are many factors to consider which can affect the elderly such as chronic pain, vision/hearing loss, muscle weakness, urinary incontinence, and increased prescription drug use (CDC, 2018). There are also conditions to consider such as arthritis, diabetes, Parkinson’s, and dementia. Environmental conditions such as loose rugs, power cords, small pets, and uneven walkways must also be considered as they are often the cause of falls.

Healthy People 2020 Goal Synthesis

        Healthy People 2020 (2019) set a goal to “improve the health, function, and quality of life of older adults”.  This goal includes an overview on injury prevention, which is preventable through the reduction of fall risk factors.  Objectives focused on this goal aim to work toward increasing and/or maintaining physical or cognitive function.  Another objective aims to reduce functional limitations of older adults.  There is also an objective focused on reducing emergency room visits due to falls (HP, 2019).  The national snapshot provided by Healthy People 2020 illustrates multiple graphs to highlight the progress made by 2015 and how much more work there is to be done.  Emergency room visits attributed to falls in 2015, for instance, were still considerably higher than the goal that was set to be met by 2020.  Overall, there appears to be a good deal of ground to be made up in order to reach the goals set by Healthy People 2020.

Program Plan

        A plan must be put in place to facilitate the attainment of the Healthy People 2020 goal for fall reduction.  Resources and possible interventions are presented by Healthy People 2020 and should be utilized.  One of the interventions presented by Healthy People 2020 and recommended by the U.S. Preventative Services Task Force is an exercise program that focuses on strength and coordination (USPSTF, 2018).  Screening of high-risk patient’s home environment is another great way to possibly reduce falls.  Assessment of other risk factors such as medications effecting the central nervous system and visual/hearing impairment should be evaluated as well.

Overall, implementation of this program amounts to a thorough fall risk screening and introduction into a strength and coordination exercise regimen. In order to implement this program plan, primary care providers should evaluate patient’s medications and any possible interactions that could precipitate a fall. Upon assessing patients, providers should be sure to recognize the need for any visual/hearing aids and mobility devices that may help to prevent falls. In patients where a need exists, a home health aide should be available to travel to homes to ensure a safe, fall risk free environment.

Identify and Explain
The MSN Essential and NONP competencies that the author attained in exemplar #1 are:

PO # 4: Integrate professional values through scholarship and service in health care (Professional Identity)

The author attained this outcome by applying the following nursing professional values: integrity, human dignity, justice, and altruism, to promote health, advocate and prevent disease among populations. Besides, the author obtained outcomes through the development of in-depth knowledge related to the integration of the most recent scientific findings to nursing practice.NUR 503 Pathophysiology-Infectious Disease.

MSN Essential: Essential IV: Translating and Integrating Scholarship into Practice

The author attained this MSN Essential by identifying, analyzing, and integrating the most recent evidence to solve healthcare issues such as poor health outcomes among people living in urban settings. Through the identification of health issues encountered by urban dwellers in congested and densely populated settings, the author was able to develop evidence-based solutions and share with relevant stakeholders to influence positive outcomes.

NONPF #4: Practice Inquiry Competencies.

The author developed research questions that guided evidence-based research on different population health concerns and their most relevant evidence-based solutions as a way to advance outcomes and health systems.NUR 503 Pathophysiology-Infectious Disease.

Connect
Concepts related to exemplar#10 include evidence-based practice and evidence-based care

Evidence-Based Practice

EBP refers to incorporating the most recent findings from scientific research, patient’s values and clinical expertise when making decisions regarding care.

Evidence-Based Care

It involves providing safe, optimal and quality care to patients as guided by current scientific research while incorporating clinical expertise and patient’s values.

Reflection
In this course, I improved my skills and knowledge in nursing in regards to methods for conducting advanced research. I will use these skills in my current and future practice to search for the most appropriate interventions for specific heath issues with the aim of improving patient health outcomes, healthcare systems, nursing practice, and nursing as a profession.NUR 503 Pathophysiology-Infectious Disease.

Chamberlain Program Outcomes

Provide high quality, safe, patient-centered care grounded in holistic health principles
Create a caring environment for achieving quality health outcomes
Engage in lifelong personal and professional growth through reflective practice and appreciation of cultural diversity.
Integrate professional values through scholarship and service in healthcare.
Advocate for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice.

MSN Essentials

Essential I: Background for Practice from Sciences and Humanities

o Recognizes that the master’s-prepared nurse integrates scientific findings

from nursing, biopsychosocial fields, genetics, public health, quality

improvement, and organizational sciences for the continual improvement

of nursing care across diverse settings.

! Essential II: Organizational and Systems Leadership

o Recognizes that organizational and systems leadership are critical to the

promotion of high quality and safe patient care. Leadership skills are

needed that emphasize ethical and critical decision making, effective

working relationships, and a systems-perspective.

! Essential III: Quality Improvement and Safety

o Recognizes that a master’s-prepared nurse must be articulate in the

methods, tools, performance measures, and standards related to quality, as

well as prepared to apply quality principles within an organization.

! Essential IV: Translating and Integrating Scholarship into Practice

o Recognizes that the master’s-prepared nurse applies research outcomes

within the practice setting, resolves practice problems, works as a change

agent, and disseminates results.

! Essential V: Informatics and Healthcare Technologies

5

o Recognizes that the master’s-prepared nurse uses patient-care technologies

to deliver and enhance care and uses communication technologies to

integrate and coordinate care.

! Essential VI: Health Policy and Advocacy

o Recognizes that the master’s-prepared nurse is able to intervene at the

system level through the policy development process and to employ

advocacy strategies to influence health and health care.NUR 503 Pathophysiology-Infectious Disease.

! Essential VII: Interprofessional Collaboration for Improving Patient and

Population Health Outcomes

o Recognizes that the master’s-prepared nurse, as a member and leader of

interprofessional teams, communicates, collaborates, and consults with

other health professionals to manage and coordinate care.

! Essential VIII: Clinical Prevention and Population Health for Improving

Health

o Recognizes that the master’s-prepared nurse applies and integrates broad,

organizational, client-centered, and culturally appropriate concepts in the

planning, delivery, management, and evaluation of evidence-based clinical

prevention and population care and services to individuals, families, and

aggregates/identified populations.

! Essential IX: Master’s-Level Nursing Practice

o Recognizes that nursing practice, at the master’s level, is broadly defined

as any form of nursing intervention that influences healthcare outcomes

for individuals, populations, or systems. Master’s-level nursing graduates

must have an advanced level of understanding of nursing and relevant

sciences as well as the ability to integrate this knowledge into practice. .

Nursing practice interventions include both direct and indirect care

components.NUR 503 Pathophysiology-Infectious Disease.

NONPF Competencies

Scientific foundations

Leadership

Quality

Practice inquiry

Technology and information literacy

Policy

Health delivery system

Ethics

Independent practice

Dr. Rubio and class,

The primary diagnosis for this patient is COPD. Pertinent positives are post bronchodilator spirometry readings showing his FEV1/FV=.52 and his FEV1=.47 which showed little to no improvement from his pre-bronchodilator results and would deem his condition as severe COPD (GOLD, 2019). Other pertinent positives are his persistent, productive cough producing white-yellowish phlegm, a gradual onset 6 months ago, forced expirations with wheezes heard in the bilateral bases, dyspnea that is improved at rest, decreased activity tolerance, cough that is worse in the morning, history of smoking (20 pack-year history), and onset of the condition in his 60’s. Pertinent negatives are lack of chest tightness, cyanosis, weight loss, and extremity edema that can often be seen in COPD patients. NUR 503 Pathophysiology-Infectious Disease.

The IDC-10 code that corresponds with this diagnosis is J44.1 (Chronic obstructive pulmonary disease with acute exacerbation) (MyEvaluations.com, 2019).

Treatment Plan:

This patient is presenting with severe COPD and a treatment plan could include initiation of a short acting bronchodilator as needed, a long acting bronchodilator (LABA) and long acting muscarinic antagonist (GOLD, 2019). An inhaled corticosteroid (ICS) could be added if he has repeated exacerbations after reaching a level of stability with his condition or if his blood eosinophil count is greater than 300 (GOLD, 2019). Combination therapy with a LABA and LAMA for patients with a FEV1 less than 60% predicted is also recommended by the American College of Physicians (Gentry, S. & Gentry, B., 2017).

Prescription Medications:

Proair HFA Inhaler 90mcg/actuation

Disp# 1

Sig: 1-2 inhalations q 4-6hrs prn for shortness of breath

Refill: 1


Tiotropium/olodaterol 2.5mcg/2.5mcg per actuation

Disp# 1

Sig: 2 inhalations once daily at the same time of day

Refill: 1


Additional Testing:

I would want to have the patient complete the COPD Assessment Test (CAT) so that I have a baseline of where he was when the diagnosis was initially made and his progression toward stability can be tracked during follow up visits (GOLD, 2019). I would want to get a CBC, CMP, and BNP to check for anemia, secondary polycythemia, an increase in eosinophils, indication of heart failure as a comorbidity, and kidney and liver function (GOLD, 2019). I would also want to get a cardiac panel to go along with an 12 lead EKG and chest x-ray since acute cardiac dysfunction is often missed in cases of COPD exacerbations and cardiac biomarkers offer additional diagnostic information (Shafuddin et al., 2018).NUR 503 Pathophysiology-Infectious Disease.

with differential should be drawn to assess for anemia in the presence of dyspnea (Hollier, 2018). A CBC with diff can also identify the presence of secondary polycythemia, which occurs as a result of hypoxemia, as well as, detect any elevation in the white blood cell count which is consist with infection. The presence of eosinophils could indicate a more allergic component, which potentially indicative of asthma (Dunphy et al, 2019).

Patient Education:

I would be sure that the patient/family understands the diagnosis and how to best manage the condition. I would emphasize the need to maintain his medication regimen, make sure to not miss his follow up appointments/specialist visit, and avoid smoking/second-hand smoke. I would make sure that he understands how to recognize the symptoms of exacerbation and to be proactive with seeking care (GOLD, 2019). NUR 503 Pathophysiology-Infectious Disease.

Referral:

Since COPD is a condition that can ultimately have detrimental effects on multiple body systems, it’s important to collaborate with specialists when needed (GOLD, 2019). I would refer this patient to a pulmonologist. I would also refer him to a dietician to try and help him cut calories out of his diet, and an occupational therapist that may be able to help him energy conservation and techniques for breathing (GOLD, 2019)

Follow-up:

The Global Initiative for Chronic Obstructive Lung Disease (2019) stated that follow up should occur in 1-4 weeks. I would want to see this patient back in 1 week to see how he is doing with his medication regimen and see how well he is responding. I would also want to monitor his blood pressure closely in the transition period until he has reached a BP below 140/90 (ACP, 2017).NUR 503 Pathophysiology-Infectious Disease.

Active Problem List:

Hypertension

Obesity

Activity intolerance

Cough

Treatment Plan Changes:

I would take the patient off metoprolol and start him on a combination ACE/Diuretic. Metoprolol is cautioned in patients with COPD and is not considered first line management (ACP, 2017). I would start him on

Lisinopril/Hydrochorothiazide 10mg/12.5mg

Disp# 30

Sig: 1 tablet daily

Refill: 1

NUR 503 Pathophysiology-Infectious Disease.