NURS 6521 Decision Tree for Neurological and Musculoskeletal Disorders
NURS 6521 Decision Tree for Neurological and Musculoskeletal Disorders
A sample Answer For the Assignment: NURS 6521 Decision Tree for Neurological and Musculoskeletal Disorders
Alzheimer Disease
The case study is about a 76-year-old male Iranian patient suspected of having Alzheimer’s disease. The conclusion is reports based on his eldest son, and during the test, there were no organic disease processes found. The behavioral changes began two years earlier, which involved changes in personality and apathy, accompanied by memory loss, which challenges in recognizing the appropriate words.
During the speech, self-reported euthymic mood and clinical interview confabulation are often noticed. The patient often has an impairment and a lack of impulse control in his insight and judgment. There is no reported ideation of suicide, and because of Alzheimer’s disease, the patient is diagnosed with neurocognitive disorder.
Donepezil 5 mg at bedtime will be used as the first approach. The donepezil use has been studied for decades by patients who have Alzheimer’s disease. The medication is an inhibitor of acetylcholinesterase, which raises the brain’s acetylcholine levels also makes up for the reduced cholinergic neurons function (Čolović, Krstić, Lazarević-Pašti, Bondžić, & Vasić, 2013). An evaluation of randomized clinical trials analyzes the effect that donepezil has on Alzheimer’s patients utilizing randomized control trials.
The results revealed that there is evidence that donepezil is effective in managing this condition in three main fields, including behavior, functional capacity, and cognition (Knowles, 2006, pp. 195–219). These are the key areas in which the patient affected as well as the aim was to reduce his quality of life effect. As demonstrated in the case, he had major personality changes that had a negative impact on his involvement in activities of interest.
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The effects of Donepezil vary as complications may occur along with minimal clinical benefits. The patient-reported side effects documented in patients taking this medication, like appetite, loss of weight, nausea, vomiting, and diarrhea. (Kumar & Sharma., 2019).
The second decision was cognitive behavioral therapy use, that has been shown to have a beneficial effect in early-stage patients of Alzheimer’s disease. In isolated cases, evidence suggesting psychosocial treatments for dementia patients identified (Forstmeier, Maercker, Savaskan, & Roth, 2015). There is also limited empirical information on such approaches, though.
Among patients who have neuropsychiatric symptoms, certain researchers have described behavioral treatments as necessary. This may also be used by the patient to promote behavior, especially directed at reducing apathy & enhancing the patient’s self-control. Mood improvement might have a positive effect on the quality of life as well as the patient’s ability to engage in activities that increase his cognitive status.
In this case, the third decision will involve family members in the therapeutic process, which will continue to improve behaviors that help the patient. The aim is to improve the patient’s support system and also daily interactions, though it has been shown to have a significant effect on the emotional and cognitive well-being of dementia patients.
References
Čolović, M. B., Krstić, D. Z., Lazarević-Pašti, T. D., Bondžić, A. M., & Vasić, a. V. (2013). Acetylcholinesterase inhibitors: pharmacology and toxicology. Curr Neuropharmacol, 11(3), 315–335. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3648782/
Forstmeier, S., Maercker, A., Savaskan, E., & Roth, a. T. (2015). Cognitive-behavioral treatment for mild Alzheimer’s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial. Trials., 16. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650298/
Knowles, J. (2006). Donepezil in Alzheimer’s disease: an evidence-based review of its impact on clinical and economic outcomes. Core Evid., 1(3), 195–219. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321665/
Kumar, A., & Sharma., S. (2019). Donepezil. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK513257/
Introduction
The most common trigger of dementia in senior individuals, which affects many people worldwide, is Alzheimer’s disease. It is classified as a neurodegenerative condition brought on by the harmful progression of age-dependent cognitive decline. There is accumulation of amyloid plaques made up of abnormal deposits of located in the extracellular brain parenchyma and hippocampus. In AD, neurofibril tangles can also form inside of the neuron.
Alzheimer’s disease is characterized by a progressive memory loss and cognitive abnormalities. The case study of Mr. Akkad, a 76-year-old Iranian man who was brought in by his son, will be covered in this essay. Following a clinical assessment and mini-mental state evaluation, the patient is identified as having a significant neurodegenerative illness caused by Alzheimer’s disease (DementiaCareCentral.com, 2020)
Decision 1 Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2weeks
Rivastigmine is a drug containing a cholinesterase inhibitor with the potential benefit of being pseudo-irreversible. The reversible binding and inactivation of cholinesterase by rivastigmine results in an increase in the level of acetylcholine at cholinergic synapses by blocking acetylcholine’s breakdown. The cholinesterase inhibitor rivastigmine is licensed for use in the treatment of mild to moderate dementia associated with Parkinson’s and Alzheimer’s diseases.
Alzheimer’s disease will develop more slowly as a result of the Exelon. The non-cognitive manifestations of Alzheimer’s disease may be treated with this medication. According to published reports, this medicine improves an Alzheimer’s patient’s cognitive functioning. In the instance of Mr. Akkad, this pharmacological therapy seeks to maximize and uphold the patient’s autonomy, functional capacity, and life quality (Rosenthal & Burchum, 2021).
In a certain period, the patient will start to show the potential effects of the medication. Exelon will slow the spread of the condition, but the patient won’t notice any effects right away. Therefore, doctors advised patients to report any potential changes in their health within three to six weeks, with or without improvement.
Following the commencement of treatment, doctors should schedule meetings with the patient and family every three to six weeks to assess any changes in cognitive and behavioral issues and to gauge how the patient is responding to the medicine. Mr. Akkad’s patient visited the clinic again after 4 weeks, however there was no improvement in his conduct or cognitive abilities (Kazmierski et al., 2020)
Decision 2 Increase Exelon to 4.5 mg orally BID
The client has returned, and according to his son, neither his father’s cognitive nor behavioral functioning had improved. Additionally, the MMSE test results showed that the drugs’ recommended dosage was not likely to have any positive effects. Mini-mental status examination is a helpful tool for gauging how well a patient is responding to treatment, and family input is crucial for determining the patient’s daily interests.
The second choice is to raise the dosage of rivastigmine in order to reduce symptoms. Exelon lessens the symptoms and slows the disease’s course, although it could take 6 to 8 weeks before memory and behavior start to improve (Kazmierski et al., 2020).
To achieve the best results, the clinical studies advise titrating the Exelon dose to the highest tolerable level. The patient came back with his son after four weeks. According to his son, he is tolerating the medication, attending religious services with family, and everyone is content. One issue is that his dad still finds humor in things that he once found to be serious (Kim et al., 2021).
Decision 3 Maintain current dose of Exelon
The third option is to keep the present dosage of medicine after assessing the condition of the patient by raising the amount in the second choice. Since this patient is responding effectively to the dosage and because there are no negative side effects from this dosage. The patient’s symptoms are reportedly getting better gradually. Behavioral, cognitive, and daily living activity tests have shown that oral Exelon’s effectiveness is dose dependent (Kim et al., 2021).
The suggested course of treatment lessens symptoms while delaying the onset of the illness. It does not, however, completely reverse the disease. Healthcare professionals have a crucial role in educating patients about Alzheimer’s disease, including its signs, problems, treatment options, and positive and negative impacts. They can also help patients and their families find financial and legal resources.
However, it is vital to explain to the client and his kid that this illness is permanent and medications only help to lessen the clinical manifestations and help improve the patient’s cognitive and behavioral functionality. The patient did not report side effects of the medication during the re- visit. Additionally, you have the choice of increasing the dosage or supplementing it with an additional drug such as Namenda (Rosenthal & Burchum, 2021).
Conclusion
In conclusion, there is no therapy option that can offer a long-term solution for Alzheimer’s disease. The patient’s quality of life, ability to do everyday tasks, and cognitive and behavioral capabilities can all be enhanced by prescribed medications and suggested therapy. It is a neurogenerative condition that develops slowly and places a heavy strain on sufferers and family.
In order to reduce the negative impacts of this condition on patients and their families, it is crucial to create appropriate and effective decisions. Making sure patients with it have enough sleep and rest in between stimulating activities and providing a tranquil environment for these individuals are crucial (DementiaCareCentral.com, 2020).
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Kim, B., Noh, G. O., & Kim, K. (2021). Behavioral and psychological symptoms of dementia in patients with Alzheimer’s disease and family caregiver burden: a path analysis. BMC Geriatrics, 21(1), 160.https://doi-org.ezp.waldenulibrary.org/10.1186/s12877-021-02109 w
DementiaCareCentral.com. (2020, October 7). Mini-mental state exam (MMSE) alzheimer’s /dementia test: Administration, accuracy and scoring. Dementia CareCentral.https://www.dementiacarecentral.com/mini-mental-state-exam/.
Kazmierski, J., Messini-Zachou, C., Gkioka, M., & Tsolaki, M. (2018). The impact of a long- term rivastigmine and donepezil treatment on all-cause mortality in patients with Alzheimer’s disease. American Journal of Alzheimer’s Disease & OtherDementias®,33(6), 385-393
For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.
Photo Credit: KATERYNA KON/SCIENCE PHOTO LIBRARY / Science Photo Library / Getty Images
To Prepare
- Review the interactive media piece assigned by your Instructor.
- Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
- Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
- You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
By Day 7 of Week 8
Write a 1- to 2-page summary paper that addresses the following:
- Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
- Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
- What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
- Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
Integrating Evidence-Based Practices in Complex Pain Management: A Case Study Analysis
Introduction
Complex Regional Pain Syndrome (CRPS), a challenging neurological condition, demands a nuanced and evidence-based approach to alleviate suffering and enhance patients’ quality of life. This in-depth analysis delves into the intricate case of a 43-year-old white male diagnosed with CRPS in his right hip. Through a series of carefully considered decisions, this patient’s journey sheds light on the complexities of managing CRPS while balancing medication side effects and therapeutic outcomes.
Patient Summary
The patient’s ordeal commenced seven years ago, following a fall at work resulting in significant right hip injury. Despite extensive diagnostic tests, he faced skepticism from healthcare professionals, leading to delays in appropriate treatment. The decisions taken included initiating amitriptyline at 25 mg, titrating to 125 mg at bedtime, and later reducing the dosage to 100 mg daily. These decisions were geared towards mitigating pain, enhancing functionality, and minimizing side effects such as grogginess and weight gain.
Evidence-Based Support for Decisions
The initiation of amitriptyline aligns with studies demonstrating its efficacy in managing neuropathic pain, particularly CRPS (Neyama et al., 2020). Amitriptyline, a tricyclic antidepressant, modulates pain perception through multiple pathways, making it a cornerstone in neuropathic pain management (Solomon et al., 2022).
The decision to maintain the dose despite minor weight gain is substantiated by research indicating that the benefits of pain control often outweigh modest side effects (Naguib et al., 2021). Additionally, the avoidance of Qsymia was prudent, considering its potential cardiac risks and the patient’s BMI falling below the recommended threshold for its use (Lei et al., 2021).
In addition to pharmaceutical interventions, exploring alternative therapies such as neuromodulation techniques has gained significant attention. A comprehensive study by Sivanesan, & Goebel (2021) delves into the effectiveness of spinal cord stimulation and peripheral nerve stimulation in managing Complex Regional Pain Syndrome, providing valuable insights into diverse treatment modalities.
You will submit this Assignment in Week 8.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK8Assgn+last name+first initial.(extension)” as the name.
- Click the Week 8 Assignment Rubric to review the Grading Criteria for the Assignment.
- Click the Week 8 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK8Assgn+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 8 Assignment Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 8 Assignment draft and review the originality report.
Submit Your Assignment by Day 7 of Week 8
To participate in this Assignment:
Week 8 Assignment
What’s Coming Up in Week 7?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will continue working on your Assignment started in Week 6, and you will complete your Midterm Exam.
Next Week
Week 6: Neurologic and Musculoskeletal Disorders and Opioids
Sabrina is a 26 year old female who has just been diagnosed with multiple sclerosis. She has scheduled an appointment for a follow up with her physician but has several questions about her diagnosis and is calling the Nurse Helpline for her hospital network. As she talks with the advanced practice nurse, she learns that her diagnosis also impacts her neurologic and musculoskeletal systems. Although multiple sclerosis is an autoimmune disorder, both the neurologic and musculoskeletal systems will be affected by adverse symptoms that Sabrina needs to be aware of and for which specific drug therapy plans and other treatment options need to be decided on.
As an advanced practice nurse, what types of drugs will best address potential neurologic and musculoskeletal symptoms Sabrina might experience?
This week, you will evaluate patients for the treatment of neurologic and musculoskeletal disorders by focusing on specific patient case studies through a decision tree exercise. You will analyze the decisions you will make in the decision tree exercise and reflect on your experiences in proposing the recommended actions to address the health needs in the patient case study.
Learning Objectives
Students will:
- Evaluate patients for treatment of neurologic and musculoskeletal disorders
- Analyze decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
- Justify decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
Learning Resources
Required Readings (click to expand/reduce)
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
- Chapter 11, “Basic Principles of Neuropharmacology” (pp. 67–71)
- Chapter 12, “Physiology of the Peripheral Nervous System” (pp. 72–81)
- Chapter 12, “Muscarinic Agonists and Cholinesterase Inhibitors” (pp. 82–89)
- Chapter 14, “Muscarinic Antagonists” (pp. 90-98)
- Chapter 15, “Adrenergic Agonists” (pp. 99–107)
- Chapter 16, “Adrenergic Antagonists” (pp. 108–119)
- Chapter 17, “Indirect-Acting Antiadrenergic Agents” (pp. 120–124)
- Chapter 18, “Introduction to Central Nervous System Pharmacology” (pp. 125–126)
- Chapter 19, “Drugs for Parkinson Disease” (pp. 127–142)
- Chapter 20, “Drugs for Alzheimer Disease” (pp. 159–166)
- Chapter 21, “Drugs for Seizure Disorders” (pp. 150–170)
- Chapter 22, “Drugs for Muscle Spasm and Spasticity” (pp. 171–178)
- Chapter 24, “Opioid Analgesics, Opioid Antagonists, and Nonopioid Centrally Acting Analgesics” (pp. 183–194)
- Chapter 59, “Drug Therapy of Rheumatoid Arthritis” (pp. 513–527)
- Chapter 60, “Drug Therapy of Gout” (pp. 528–536)
- Chapter 61, “Drugs Affecting Calcium Levels and Bone Mineralization” (pp. 537–556)
Document: Mid-Term Summary & Study Guide (PDF)
Required Media (click to expand/reduce)
Disorders of The Nervous System
Reflect on the comprehensive review of disorders of the nervous system and think about how you might recommend or prescribe pharmacotherapeutics to treat these disorders. (15m)
Alzheimer’s is one of the most common progressive neurological disorders among the elderly caused by dementia. Patients will present with mild to moderate cognitive signs and symptoms at the onset of the disorder, which will progress to severe memory loss with time, as they grow much older (Li et al., 2019).
However, several treatment options have been proven to be effective in the management of Alzheimer’s disorder among the elderly. The purpose of this discussion is to illustrate the decision process in selecting the most effective drug, based on pharmacokinetic and pharmacodynamic factors, for treating an elderly patient diagnosed with Alzheimer’s disease.
Patient Case Study Summary
The assigned case study demonstrates a 76-year-old Iranian male with symptoms of Alzheimer’s disorder. The patient displays strange behavior upon arrival at the clinic reporting symptoms of memory loss, forgetfulness, confusion, and diminished interest in religious activities for the last 2 years.
Pharmacokinetic and pharmacodynamic patient factors which contributed to the selection of drugs for this patient include his advanced age, male gender, Iranian race, and presenting symptoms in addition to the mini-mental exam results of moderate dementia. the patient’s diagnosis of Alzheimer’s disorder will also be considered.
Treatment Decisions
Based on the patient history and the pharmacokinetic and pharmacodynamic factors mentioned above, the most appropriate intervention is to initiate Exelon 1.5mg twice daily. Exelon (rivastigmine) is an FFDA-approved drug for treating mild to moderate Alzheimer’s disease (Fish et al., 2019). Previous studies support great effectiveness, and safety profile for use of the drug among the elderly diagnosed with Alzheimer’s (Khoury et al., 2018).
The second decision was to increase the dose of Exelon to 4.5 mg twice daily as recommended by most clinical practice guidelines for patients who have displayed great tolerance but with minimal effectiveness. The last decision was to increase the dose further to 6mg twice daily, to promote optimal effectiveness as the patient still displayed limited remission of symptoms with the previous intervention.
Expected Outcome
Studies show that Exelon when administered appropriately takes between 8 to 12 weeks to completely manage symptoms of Alzheimer’s among elderly patients. As such, with the initial intervention of 1.5mg Exelon twice daily, the patient was expected to display approximately 50% remission of symptoms (Nguyen et al., 2021). The dose was however to be titrated to obtain the optimum outcome, not exceeding 6mg twice daily. The same results were expected with the second and third interventions with no side effects expected.
Difference Between Expected Outcome and Actual Outcome
Just like expected, the patient displayed a minimal reduction of symptoms of Alzheimer’s with no side effects reported with the first intervention. After the dose was increased in the second intervention, the patient reported further remission of symptoms, but at a slow rate, hence increasing the dose in the last intervention, which led to optimal remission of Alzheimer’s symptoms just as expected (Huang et al., 2020).
Conclusion
Alzheimer’s is a common disorder among the elderly compromising their quality of life and well-being. For the patient in the provided case study, it was necessary to administer Exelon at a starting dose of 1.5 mg which was titrated to 4.5mg then 6.5mg twice daily. The patient displayed great effectiveness with this medication in the management of his Alzheimer’s symptoms, with no side effects reported.
References
Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New approaches for the treatment of Alzheimer’s disease. Bioorganic & medicinal chemistry letters, 29(2), 125-133. https://doi.org/10.1016/j.bmcl.2018.11.034
Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science, 27(1), 1-13. https://doi.org/10.1186/s12929-019-0609-7
Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic Advances in Drug Safety, 9(3), 171-178. https://doi.org/10.1177/2042098617750555
Li, D. D., Zhang, Y. H., Zhang, W., & Zhao, P. (2019). Meta-analysis of randomized controlled trials on the efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease. Frontiers in neuroscience, 13, 472. https://doi.org/10.3389/fnins.2019.00472
Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management, 11(1), 35-48. https://doi.org/10.2217/nmt-2020-0052
The case study concerns a 43-year-old man with a history of chronic pain for several years after sustaining a fall and now ambulates with crutches. He has been referred for a psychiatric evaluation by his family physician after suspecting his pain is psychological, and he has been exaggerating the pain to get a narcotic prescription to get high. He complains of cooling and intense cramping in the right leg. He has been diagnosed with complex regional pain syndrome (CRPS). The purpose of this paper is to explain the interventions for each decision and if they are backed by evidence-based literature.
Decisions Recommended For the Patient Case Study
The first decision was to start Amitriptyline 25 mg PO QHS and increase it by 25 mg every week to a maximum of 200 mg daily. The decision is supported by the study by Shim et al. (2019), which found that Amitriptyline is an effective evidence-based treatment for neuropathic pain disorder and peripheral diabetic neuropathic pain. In decision two, I maintained Amitriptyline and increased the dose to 125 mg with a maximum target of 200 mg.
The patient was to take the medication an hour earlier than usual. Increasing the dose is supported by the article by Eldufani et al. (2020), which recommends slow titration of the Amitriptyline dose if a patient exhibits a positive response to the initial dose. It also recommends taking the bedtime dose an hour earlier to minimize morning sleepiness.
In decision three, I continued Amitriptyline at 125 mg and referred the patient to a life coach for counseling on nutrition and exercise. Weight gain is a documented side effect of Amitriptyline. Brueckle (2020) backs this intervention by asserting that patients on medications associated with weight gain should be counseled on lifestyle modification in diet and exercise for a healthy weight.
What I Was Hoping To Achieve With the Decisions I Recommended For the Patient Case Study
By initiating the patient on Amitriptyline, I hoped it would help improve the client’s mood swings, alleviate pain to 4/10, and ambulate without crutches within four weeks. Komoly (2019) established that Amitriptyline helps alleviate pain and autonomic and motor symptoms in CRPS cases. I hoped that increasing Amitriptyline to 125 mg would alleviate the limb to 3/10, and taking the drug an hour earlier would prevent morning sleepiness.
Taking the medication an hour earlier decreases morning sleepiness (Rosenthal & Burchum, 2021). In decision three, I hoped that referring the client for lifestyle modification counseling would guide him in practicing a healthy lifestyle in dietary and physical exercise habits that would prevent unhealthy weight gain. Aguilar-Latorre et al. (2022) recommend counseling on lifestyle modification to enable patients on TCAs to manage their weight and avoid being overweight/obese.
Difference between What You Expected To Achieve With Each of the Decisions and the Results of the Decision in the Exercise
In the first decision, the pain decreased to a 6/10, and the patient ambulated without crutches. The pain severity was not as anticipated, probably because of the low Amitriptyline dose and duration it takes to have maximum effect. In the second decision, the patient’s pain was reduced to 4/10, comparable to the expected outcome of a pain severity of 3/10.
Conclusion
The PMHNP started the patient on an initial dose of Amitriptyline of 25 mg QHS, which was to be increased by 25 mg weekly to 200 mg. The drug led to a positive response and was increased to 125 mg QHS to improve the patient’s pain. The medication led to weight gain, and the PMHNP referred the client to a life coach for counseling on a healthy lifestyle.
References
Aguilar-Latorre, A., Pérez Algorta, G., Navarro-Guzmán, C., Serrano-Ripoll, M. J., & Oliván-Blázquez, B. (2022). Effectiveness of a lifestyle modification programme in the treatment of depression symptoms in primary care. Frontiers in medicine, 9, 954644. https://doi.org/10.3389/fmed.2022.954644
Brueckle, M. S., Thomas, E. T., Seide, S. E., Pilz, M., Gonzalez-Gonzalez, A. I., Nguyen, T. S., … & Muth, C. (2020). Adverse drug reactions associated with Amitriptyline—protocol for a systematic multiple-indication review and meta-analysis. Systematic reviews, 9(1), 1-8. https://doi.org/10.1186/s13643-020-01296-8
Eldufani, J., Elahmer, N., & Blaise, G. (2020). A medical mystery of complex regional pain syndrome. Heliyon, 6(2), e03329. https://doi.org/10.1016/j.heliyon.2020.e03329
Komoly, S. (2019). Treatment of complex regional pain syndrome with Amitriptyline. Ideggyogyaszati szemle, 72(7-8), 279-281. https://doi.org/10.18071/isz.72.0279
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practicing clinician. British Journal of Anaesthesia, 123(2), e424–e433. https://doi.org/10.1016/j.bja.2019.03.030
JM, 42, Male, African American
Chief Complaint: Low back pain with radiating pain to left leg
Justin Martian is a 42 y/o African American male that presents with lower back pain. The patient reported that the pain began about a month ago and reports that he has not had any known injuries that could have contributed to the pain. The patient states that the pain feels like a tingling sensation or burning sensation that radiates to his left lower leg. The patient describes the pain as a sharp shooting pain that radiates from his lower back to left leg.
The pain is aggravated when standing for long periods of time or with exaggerated movements. The patient rates the pain 8/10 with longer periods of standing or sitting the pain increases to a 10. When resting the patient describes the pain as dull and rates the pain a 2/10 when resting. He states that he has been using ICY Hot, and OTC Motrin to reduce the pain. The patient states that the medication does not relieve the pain and states that is affecting his work life.
Medications: Omeprazole 40 mg, OTC Motrin 400mg,Denies taking herbs or supplements
Allergy-Penicillin ( Rash) , Codeine( Hives)
PMH- GERD,
Past Surgeries: None
Immunizations- Covid Shot 2022- Moderna x2 doses
Flu Shot- October 2022
Tetanus Shot 2022
Last Primary Care Visit- December 2022
Last Dental Visit- 3 years ago
Social/Psychosocial- Pt reports that he drinks 3-4 beers a week. Denies uses of illicit drugs. Denies any history of smoking. Pt is a construction working that specializes in roofing. Pt reports that his back pain is affecting his ability to do his job. The patient has 3 children and is married. The patient reports that he enjoys lifting heavy weights to relieve his stress. Patient reports exercising 2-3 days a week. Pt reports feeling depressed due to his inability to go to work. The patient denies any suicide ideation. Pt reports that his diet consist of red meats such as steak and he rarely eat fruits and vegetables.
Family History- Mother- Living age 78. PMH- Spinal Stenosis, Chronic Back Pain
Father- Deceased age 60- PMH- DM, MI, Chronic back pain.
MGM- Deceased age 90- Rheumatoid Arthritis, Depression
MGF- Living age 87- Colon Cancer
PGM- Living age 90- Fibromyalgia, Spinal Fusion L1,L2
Brother- Living age 28- Obesity, DM type 1
Sister- Living age 30- Hypothyroidism, Obese
General- Pt Is A0x4 and appears to be a good historian. The patient reports that he is fatigue due to the pain making it difficult for him to rest. Denies fever chills, fatigue, and night sweats.
HEENT- Denies eye pain, denies otitis media or hearing loss, and sore throat. Pt denies headache
Cardiovascular- Denies chest pain. Palpations, no history of arrhythmias, denies peripheral edema, denies orthopnea
Respiratory- Denies SOB. Denies history of pneumonia, bronchitis, chest tightness or wheezing
Gastrointestinal- Denies abdominal pain. Reports heartburn after eating greasy foods. Pt takes omeprazole for GERD, Denies Nausea/ Vomiting. Last bowel movement 1/22/23
Genitourinary- Denies hematuria, Denies incontinence, frequency. Reports urine is yellow without odor. Denies burning or hesitancy
Musculoskeletal- Pain in back radiating to left leg. Pt reports pain is increased with bending over, exercising and standing for long periods of time.
Neurological- Denies headache, Dizziness, Reports tingling in left leg. Denies ataxia or difficulties with balance and gait
Hematologic- Denies anemia, denies frequent bleeding/ bruising
Endocrine/ Lymphatics-Denies- recent hair loss or skin changes. Denies polyuria, polydipsia. Denies intolerance temperature
Psychiatric- Denies increased stress levels, but report feeling depressing due to constant back pain that has affected his ability to work. Pt denies thoughts of suicide. Denies hx of anxiety.
Objective-
VS- BP- 123/80 HR- 100, RR-18, T-1-98.3, 02 Sat- 98% RA HT- 5’10 Weight 178
General- Patient appears to be a good historian. Pt is A0x4. Pt appears to be tired. Pt is alternating from standing to sitting due to the lower back pain. The patient is making eye contact and can communicate health concerns and health history effectively.
HEENT- PERRLA, Normocephalic, Nasal Septum intact. Nares patent and pink. No tenderness in sinus no sinus pain noted
Skin- Intact, Warm dry. Mucous membrane pink moist intact. No lesions or petechiae present.
Respiratory- Lung sounds audible in all lung fields and clear. Respirations even and unlabored. Respirations symmetrical. Cap refill less than 3 seconds
Cardiovascular- No gallops, rubs, heaves, or thrills. S1 and S2 audible. No S3 or S4 noted. No peripheral edema. Peripheral pulses 2+ bilateral
Gastrointestinal- Flat, bowel sounds normoactive. No tenderness upon deep palpation. No guarding. No splenomegaly or hepatomegaly noted
Genitourinary- no pain upon palpation of abdomen. No hematuria or burning on urination reported
Musculoskeletal- Gait steady. Sharp shooting pain in lower back. Muscular build. No swelling, or deformities. No pain to joints or redness/warmth noted. No pain in pelvic area. Left hamstring tender with tightness. Left foot drop noted with decreased sensation of left foot.
Neurological- Tingling in left leg. No tremors noted. Dorsiflexion and plantar flexion of left foot intact. Increased pain with extension and flexion of left leg. Decreased ROM in lower extremities
Psychiatric- Cooperative. Non-grandiose and appropriate. Demeanor
Endocrine /Lymph- No lymphadenopathy noted. Thyroid not enlarged and symmetrical. No palpable cyst or lymph nodes.
Diagnostic Results- MRI, Lumbar CT, Xray of lumbar
Differential Dx-
Spinal Stenosis- Being that the patient career requires exaggerated motions for long periods of time with long period of standing in usual positions, this causes the patient to be at an increased risk for Spinal Stenosis (Amin et al.,2021, p.2). The patient is experiencing numbness and tingling that radiates to his left legs which are classical symptoms of spinal stenosis. The patient could be experiencing spinal stenosis in the L5 and S1(Amin et al.,2021, p.2).
The patient also has left foot drop with decreased sensation in his left foot(Amin et al.,2021, p.2). The patient could be experiencing some nerve damage related to spinal stenosis causing the patient foot to drop which are all classical symptoms of spinal stenosis (Amin et al.,2021, p.2).
Herniated Disk- Occurs when the nucleus pushes out of the disk and is exposed to the annulus causing radiating numbness and tingling in lower extremities (Lee et al.,2020, p.1). A herniated disk causes arm, leg, buttocks pain and muscle weakness (Lee et al.,2020, p.1). . The patient is overweight, frequently lifts heavy weights and stands for long periods of time and perform exaggerated motions while at work which places the patient at risk for a herniated disc(Lee et al.,2020, p.1).
Sciatica- presents with symptoms of numbness and tingling on the left side of the body. Sciatica uses effects on side of the body and can present with lower back pain (Lee et al.,2020, p.1).
Lumbosacral muscle strain-Occurs when muscles in the lumb0sacral area are damaged. This can be due to over usage of the muscle area (Hashem et al.,2021, p.2). The patient reports being a heavy weightlifter and works on roofs which can cause sudden and frequent use of lumbar muscles (Hashem et al.,2021, p.2)
Spondylolysis- Typically happens when the vertebra slips out of place causes low back pain and radiating numbness and tingling. Obesity, frequent strain on the back, such as heavy weightlifting can cause spondylolysis (Hashem et al.,2021, p.2). Spondylolysis pain can present as sharp, shooting pain that radiates the extremities (Hashem et al.,2021, p.2)..
References:
Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar Disc Herniation. Current reviews in musculoskeletal medicine, 10(4), 507–516. https://doi.org/10.1007/s12178-017-9441-4Links to an external site.
Lee, B. H., Moon, S. H., Suk, K. S., Kim, H. S., Yang, J. H., & Lee, H. M. (2020). Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review. Asian spine journal, 14(5), 682–693. https://doi.org/10.31616/asj.2020.0472
Hashem, M., AlMohaini, R. A., AlMedemgh, N. I., AlHarbi, S. A., & Alsaleem, L. S. (2022). Knowledge and Attitude of Sciatica Pain and Treatment Methods among Adults in Saudi Arabia. Advances in orthopedics, 2022, 7122643. https://doi.org/10.1155/2022/7122643
Rubric Detail
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Content
Name: NURS_6521_Week8_Assignment_Rubric
| Excellent | Good | Fair | Poor | ||
| Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific. | Points Range: 18 (18%) – 20 (20%)
The response accurately and thoroughly summarizes in detail the patient case study assigned, including specific and complete details on each of the three decisions made for the patient presented. | Points Range: 16 (16%) – 17 (17%)
The response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. | Points Range: 14 (14%) – 15 (15%)
The response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. | Points Range: 0 (0%) – 13 (13%)
The response inaccurately and vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented, or is missing. | |
| Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources. | Points Range: 23 (23%) – 25 (25%)
The response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes specific and relevant outside reference examples that fully support the explanation provided. | Points Range: 20 (20%) – 22 (22%)
The response accurately explains how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes relevant outside reference examples that lend support for the explanation provided that are accurate. | Points Range: 18 (18%) – 19 (19%)
The response inaccurately or vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided. | Points Range: 0 (0%) – 17 (17%)
The response inaccurately and vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature, or is missing. The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing. | |
| What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources. | Points Range: 18 (18%) – 20 (20%)
The response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned. The response includes specific and relevant outside reference examples that fully support the explanation provided. | Points Range: 16 (16%) – 17 (17%)
The response accurately explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. The response includes relevant outside reference examples that lend support for the explanation provided that are accurate. | Points Range: 14 (14%) – 15 (15%)
The response inaccurately or vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided. | Points Range: 0 (0%) – 13 (13%)
The response inaccurately and vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned, or is missing. The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing. | |
| Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples. | Points Range: 18 (18%) – 20 (20%)
The response accurately and clearly explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides specific, accurate, and relevant examples that fully support whether there were differences between the decisions made and the decisions available in the exercise. | Points Range: 16 (16%) – 17 (17%)
The response accurately explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides accurate examples that support whether there were differences between the decisions made and the decisions available in the exercise. | Points Range: 14 (14%) – 15 (15%)
The response inaccurately or vaguely explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides inaccurate or vague examples that may or may not support whether there were differences between the decisions made and the decisions available in the exercise. | Points Range: 0 (0%) – 13 (13%)
vaguely explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise, or is missing. The response provides inaccurate and vague examples that do not support whether there were differences between the decisions made and the decisions available in the exercise, or is missing. | |
| Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. | Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. | Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. | Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. | Points Range: 0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. | |
| Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation | Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors | Points Range: 4 (4%) – 4 (4%)
Contains a few (1–2) grammar, spelling, and punctuation errors | Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3–4) grammar, spelling, and punctuation errors | Points Range: 0 (0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding | |
| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. | Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors | Points Range: 4 (4%) – 4 (4%)
Contains a few (1–2) APA format errors | Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3–4) APA format errors | Points Range: 0 (0%) – 3 (3%)
Contains many (≥ 5) APA format errors | |
| Total Points: 100 | |||||
Name: NURS_6521_Week8_Assignment_Rubric
Week 6 Assignment: Decision Tree for Neurological and Musculoskeletal Disorders
Alzheimer’s is one of the most common progressive neurological disorders among the elderly caused by dementia. Patients will present with mild to moderate cognitive signs and symptoms at the onset of the disorder, which will progress to severe memory loss with time, as they grow much older (Li et al., 2019).
However, several treatment options have been proven to be effective in the management of Alzheimer’s disorder among the elderly. The purpose of this discussion is to illustrate the decision process in selecting the most effective drug, based on pharmacokinetic and pharmacodynamic factors, for treating an elderly patient diagnosed with Alzheimer’s disease.
Patient Case Study Summary
The assigned case study demonstrates a 76-year-old Iranian male with symptoms of Alzheimer’s disorder. The patient displays strange behavior upon arrival at the clinic reporting symptoms of memory loss, forgetfulness, confusion, and diminished interest in religious activities for the last 2 years.
Pharmacokinetic and pharmacodynamic patient factors which contributed to the selection of drugs for this patient include his advanced age, male gender, Iranian race, and presenting symptoms in addition to the mini-mental exam results of moderate dementia. the patient’s diagnosis of Alzheimer’s disorder will also be considered.
Treatment Decisions
Based on the patient history and the pharmacokinetic and pharmacodynamic factors mentioned above, the most appropriate intervention is to initiate Exelon 1.5mg twice daily. Exelon (rivastigmine) is an FFDA-approved drug for treating mild to moderate Alzheimer’s disease (Fish et al., 2019). Previous studies support great effectiveness, and safety profile for use of the drug among the elderly diagnosed with Alzheimer’s (Khoury et al., 2018).
The second decision was to increase the dose of Exelon to 4.5 mg twice daily as recommended by most clinical practice guidelines for patients who have displayed great tolerance but with minimal effectiveness. The last decision was to increase the dose further to 6mg twice daily, to promote optimal effectiveness as the patient still displayed limited remission of symptoms with the previous intervention.
Expected Outcome
Studies show that Exelon when administered appropriately takes between 8 to 12 weeks to completely manage symptoms of Alzheimer’s among elderly patients. As such, with the initial intervention of 1.5mg Exelon twice daily, the patient was expected to display approximately 50% remission of symptoms (Nguyen et al., 2021).
The dose was however to be titrated to obtain the optimum outcome, not exceeding 6mg twice daily. The same results were expected with the second and third interventions with no side effects expected.
Difference Between Expected Outcome and Actual Outcome
Just like expected, the patient displayed a minimal reduction of symptoms of Alzheimer’s with no side effects reported with the first intervention. After the dose was increased in the second intervention, the patient reported further remission of symptoms, but at a slow rate, hence increasing the dose in the last intervention, which led to optimal remission of Alzheimer’s symptoms just as expected (Huang et al., 2020).
Conclusion
Alzheimer’s is a common disorder among the elderly compromising their quality of life and well-being. For the patient in the provided case study, it was necessary to administer Exelon at a starting dose of 1.5 mg which was titrated to 4.5mg then 6.5mg twice daily. The patient displayed great effectiveness with this medication in the management of his Alzheimer’s symptoms, with no side effects reported.
References
Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New approaches for the treatment of Alzheimer’s disease. Bioorganic & medicinal chemistry letters, 29(2), 125-133. https://doi.org/10.1016/j.bmcl.2018.11.034
Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science, 27(1), 1-13. https://doi.org/10.1186/s12929-019-0609-7
Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic Advances in Drug Safety, 9(3), 171-178. https://doi.org/10.1177/2042098617750555
Li, D. D., Zhang, Y. H., Zhang, W., & Zhao, P. (2019). Meta-analysis of randomized controlled trials on the efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease. Frontiers in neuroscience, 13, 472. https://doi.org/10.3389/fnins.2019.00472
Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management, 11(1), 35-48. https://doi.org/10.2217/nmt-2020-0052
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