THE ASSIGNMENT: 5 PAGES

Examine 
Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

· Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

· Which decision did you select?

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

· Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past 2 years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much,” but she enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much. She currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. When you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation and self-reported mood. She denies visual or auditory hallucinations, and no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact; however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

·
 Client returns to clinic in four weeks

·
 Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection

·
 Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)

·
 Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned

Decision Point Two

Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety

RESULTS OF DECISION POINT TWO

·
 Client returns to clinic in four weeks

·
 Mrs. Perez reports that when she first received the Valium, it helped her tremendously. She states “I was like a new person. This is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her Valium early

·
 She is asking today for an increase the Valium dose or frequency

Decision Point Three

Continue current dose of Vivitrol, increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue

Guidance to Student

Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.

The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At that point, you would need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.

Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.

Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.

SBAR stands for Situation, Background, Assessment, and Recommendation. SBAR was originally designed as a communication tool for nurses. They soon added the idea that it could also be utilized for reports. The following link gives an example of how to use the SBAR tool as a reporting device.

Instructions:

1. Read the How to Give a Nursing Handoff Report Using SBAR article.
2. Based on the example given, develop a report sheet that contains the categories that are important when giving a report.
3. Save the report sheet, and share it with your colleagues.
4. Please respond to at least one (1) of your classmate’s postings and critique their report sheet as to the utility, usefulness, and orderliness of the sheet.
5. To see the grading rubric, click on the 3-dot menu on the top-right side of screen. 

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional strategies your colleague could implement to bring about needed change in their community.use 3 reference each.

 1.    I am currently employed at a freestanding psychiatric hospital located on the south shore of Massachusetts.  We provide inpatient psychiatric services to adolescents, adults, and geriatric patients who suffer from mental illness.  Since the Covid-19 pandemic, we have seen an increase in the community’s need for mental health services.  A recent study conducted by Blue Cross Blue Shield of Massachusetts found that the need for services has increased exponentially due to the effects of the pandemic.  Currently,  “one in three Massachusetts residents over the age of 19 reported needing behavioral health care for themselves or a close relative; however, 26% percent said they were not able to get it” (Becker, 2022).  As an organization, we need to find a way to increase access to mental health services in our community.

How the Doctor of Nursing Practice (DNP) Prepared Nurse Can Increase Access to Mental Health Services

 As a DNP-prepared nurse, it is my goal to serve as an agent of positive change at the local level to the patients who are under my organization’s care as well as the community at large.  In order to reduce accessibility issues as a DNP-prepared nurse, it will be critical for me to consider the American Association of Colleges of Nursing essential number 8 and “conceptualize new care delivery models that are based in contemporary nursing science and that are feasible within current organizational, political, cultural, and economic perspectives” (American Association of Colleges of Nursing, 2006).  One thought I have for my organization would be to integrate outpatient services such as partial hospitalization programs so that we can increase accessibility to mental health services in the community.  One significant challenge, both nationally and for my organization, is the shortage of nursing staff.  In order to increase the services we provide, it will be imperative for my organization to build partnerships with local agencies.  Wegner et al. (2000) determined that “groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in the area by interacting on an ongoing basis” will have more success.  In order to recruit nurses to my organization, I aim to partner with local universities and colleges to provide a site for their psychiatric clinical rotations.  If student nurses have a positive clinical experience at my organization, they will be more likely to consider employment with us in the future which will, in turn, allow us to expand the services we provide and increase accessibility to mental health care.

References

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf

Becker, D. (2022). The pandemic has led to a surge in mental health need in Mass., survey finds. https://www.wbur.org/news/2022/02/08/massachusetts-pandemic-mental-healthLinks to an external site.

Wenger, E., McDermott, R., & Snyder, W. M. (2000). A guide to managing knowledge: Cultivating communities of practice. Harvard Business School.

2.There is a very large homeless population within my community, and with that unfortunately comes high rate of substance use disorders. The most recent census of this six hundred plus square mile county was approximately 170,000 individuals, ten percent of whom were living below the poverty level (United States Department of Commerce, 2023). Despite the known concerns for homelessness in Monroe County, there remains to be only three small shelters that are seasonally available to those in need, open between the hours of 7:00pm and 5:00am EST. As a very rural area, the lack of available resources leaves individuals living in homeless communities in wooded areas. Multiple individuals have been found to be passed away due to exposure in the winter months. While community members are also aware of the concern for substance use disorders, there have been very direct and disheartening efforts preventing the opening of treatment centers in the area. Signs have been posted in front yards with slogans such as ‘no drug addicts in our back yard.’

            Addressing socioeconomic determinants of health and the wellness of this community is one of many roles of the Doctor of Nursing Practice (DNP) (American Association of Colleges of Nursing, 2006). These two community health issues are very much related. The ongoing gap in access to substance use disorder treatment perpetuates the cycle of substance-related crime, associated health concerns treated in the local emergency department, and inability to treat the often-underlying mental health concerns leading to self-medication (Mitchell et al., 2023). As a social change agent, the DNP can not only research evidence-based interventions to provide community-based care to individuals in need but also educate community members on why this is important, and how their efforts to prevent this from happening harms not only those in need but the populace as a whole (American Association of Colleges of Nursing, 2006).

            The DNP acts as an expert support when advocating for health policy in local, state, or federal government. Meeting with members of local government to provide evidence-based testimony regarding the detrimental impact the blocking of substance use treatment facilities has on the community is one step in creating increased access to care. Individuals in need of substance use treatment often experience shame and ambivalence to seek the support they so greatly need; it is essential to educate lawmakers about how the additional stigma placed upon individuals by the formal supports who should be enabling their ability to access treatment severely impedes community wellness (Stewart et al., 2023).

            Engaging directly with the homeless shelters currently available to review current barriers to availability is the first step to increasing accessibility. Two of the three shelters are run by volunteer organizations, and the third is a locally funded organization that is a part of the community health department. As a DNP, gathering data and evidence to support the implementation of an intervention is essential to buy in from any stakeholder and can be achieved by evaluating the number of individuals who seek shelter at these resources, and those who are able to stay the night (McEwen & Wills, 2019). Presenting this data to local officials to along with evidence-based data regarding the benefits of this community initiative, such as reduction in deaths associated with exposure and the current use of law enforcement to relocate homeless individuals from areas deemed inappropriate for their inhabitation, can support approval for shelter expansions.

References

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf

McEwen, M., & Wills, E. M. (2019). Theoretical basis for nursing (5th ed.). Wolters Kluwer.  

Mitchell, E., Waring, T., Ahern, E., O’Donovan, D., O’Reilly, D., & Bradley, D. T. (2023). Predictors and consequences of homelessness in whole-population observational studies that used administrative data: a systematic review. BMC Public Health, 23(1), 1610. https://doi.org/10.1186/s12889-023-16503-z

Stewart, R. E., Cardamone, N. C., Schachter, A., Becker, C., McKay, J. R., & Becker-Haimes, E. M. (2023). A systematic review of brief, freely accessible, and valid self-report measures for substance use disorders and treatment. Drug and Alcohol Dependence, 243, 1–11. https://doi.org/10.1016/j.drugalcdep.2022.109729

United States Department of Commerce. (2023). QuickFacts: Monroe County Pennsylvania. https://www.census.gov/quickfacts/fact/table/monroecountypennsylvania/PST045222

• Based on your readings, current literature within 5 years, scholarly peer-reviewed journals, and research on the topic of nursing leadership development specific to your program.
• Clearly demonstrate the integration of evidence into nursing practice as it relates to nursing leadership in your program.
• Clearly demonstrate the concepts of nursing leadership and ethical decision-making as they relate to nursing leadership development in your program.
• this should include;
      a. Introduction
         i. Define leadership
         ii. Explain how leadership is developed
         iii. Why is leadership development important for nursing today?
     b. Compare and contrast theoretical leadership theories as they relate to  leadership development
     c. Discuss how leadership is an integral component of the advanced generalist masters prepared Nurse
     d. Examine empowerment as it relates to the development of Nursing leaders
     e. Analyze the process of leading through mentoring as it relates to the creation of future caring followers
     f. Explain effective communication and collaboration strategies that lead to healthy, safe interdisciplinary teams
     g. Guided by Dr. Jean Watson’s (2012) theory of human caring science critically evaluate how caring can be integrated in all levels of Nursing practices
     h. Create your own personal definition of nursing leadership examining concepts you can adopt in your practice setting leading to improved outcomes for patients, families, colleagues, and self.

• 5 pages (not including title page or reference page) using the required title page with your major clearly labeled
• Minimum of 5 scholarly sources not including the textbook to support your facts
• Clear and logically written with proper grammar, spelling, and punctuation
• Proper APA format on citations and sources