HH is a 68 yo M who has been admitted to the medical ward with community

Posted: February 15th, 2023

Discussion: Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

Case Study 1
HH is a 68 yo M who has been admitted to the medical ward with community-acquired pneumonia for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, which include ceftriaxone 1 g IV qday (day 3) and azithromycin 500 mg IV qday (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements. He is not tolerating a diet at this time with complaints of nausea and vomiting.
Ht: 5’8” Wt: 89 kg
Allergies: Penicillin (rash)
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting. 2 pages

Case Study 2
A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms. She had felt well until 1 month ago and she presented to her gynecologist for her annual gyn examination and to discuss her symptoms. She has a history of ASCUS about 5 years ago on her pap, other than that, Pap smears have been normal. Home medications are Norvasc 10mg qd and HCTZ 25mg qd. Her BP today is 150/90. She has regular monthly menstrual cycles. Her LMP was 1 month ago.
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting. 2 pages

Women’s and Men’s Health/Infections and Hematologic Systems
As an advanced practice nurse, you will likely encounter many disorders associated with women’s and men’s health, such as hormone deficiencies, cancers, and other functional and structural abnormalities. Disorders such as these not only result in physiological consequences but also psychological consequences, such as embarrassment, guilt, or profound disappointment for patients. For these reasons, the provider-patient relationship must be carefully managed. During evaluations, patients must feel comfortable answering questions so that you, as a key health-care provider, will be able to diagnose and recommend appropriate treatment options. Advanced practice nurses must be able to educate patients on these disorders and help relieve associated stigmas and concerns.
This week, you examine women’s and men’s health concerns as well as the types of drugs used to treat disorders that affect women’s and men’s health. You also explore how to treat aspects of these disorders on other health systems.
Discussion: Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders
As an advanced practice nurse, you will likely experience patient encounters with complex comorbidities. For example, consider a female patient who is pregnant who also presents with hypertension, diabetes, and has a recent tuberculosis infection. How might the underlying pathophysiology of these conditions affect the pharmacotherapeutics you might recommend to help address your patient’s health needs? What education strategies might you recommend for ensuring positive patient health outcomes?

For this Discussion, you will be assigned 2 patient case studies and will consider how to address the patient’s current drug therapy plans. You will then suggest recommendations on how to revise these drug therapy plans to ensure effective, safe, and quality patient care for positive patient health outcomes.
Post a brief description of your patient’s health needs from each patient case study. Be specific. Then, explain the type of treatment regimen you would recommend for treating your patient, including the choice or pharmacotherapeutics you would recommend and explain why. Be sure to justify your response. Explain a patient education strategy you might recommend for assisting your patient with the management of their health needs. Be specific and provide examples.

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Case Study 1
A 68-year-old male with pneumonia, COPD, hypertension, hyperlipidemia and diabetes presents with nausea and vomiting impairing his ability to take in adequate nutrition by mouth. Nguyen, Pham, and Nguyen (2016) conducted a randomized controlled trial studying the effects of dietary counseling on clinical outcomes in patients with COPD. They found that patients who received dietary counseling aimed at eating smaller, more frequent meals had improved nutritional status and pulmonary function compared to the control group. This supports recommending Mr. HH try eating smaller, frequent meals to better tolerate oral intake and aid in his recovery from pneumonia.
Additionally, Acheampong and Agbokey (2022) performed a systematic review and meta-analysis evaluating the efficacy and safety of ondansetron versus metoclopramide for treatment of nausea and vomiting. They found ondansetron to be more effective in reducing nausea with fewer adverse effects compared to metoclopramide. Given Mr. HH’s multiple comorbidities, ondansetron would be a reasonable first-line pharmacologic option to address his nausea in order to improve his oral intake and hydration status. Close monitoring is still needed given his pneumonia is being treated with empiric antibiotics.
Case Study 2
A 46-year-old woman presents with symptoms suggestive of menopause including hot flashes, night sweats and genitourinary issues. She has a family history significant for breast cancer and a past history of abnormal pap smear. Nelson et al. (2019) published guidelines from the American College of Obstetricians and Gynecologists recommending annual screening mammograms starting at age 40 for women with a family history of breast cancer in a first-degree relative. Given this patient’s strong family history, continuing annual mammogram screening is appropriate.
Additionally, Siu (2016) conducted a systematic evidence review evaluating screening mammography in women ages 40-49. The review found the benefits of screening mammography in lowering breast cancer mortality in this age group outweigh the risks of unnecessary biopsy or overtreatment. Transvaginal ultrasound and consideration of endometrial biopsy are also reasonable to evaluate this patient’s irregular bleeding patterns and family history of breast cancer per the guidelines. Optimizing her antihypertensive regimen could also help address her elevated blood pressure at her last visit.
In both cases, a multidisciplinary approach considering all aspects of each patient’s medical and lifestyle factors is recommended to comprehensively manage their conditions. Mackey et al. (2022) stress the importance of health literacy and clear communication between providers and patients to support positive health outcomes. Regular follow-up would allow monitoring of treatment response and make necessary adjustments.

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Main discussion – Week 9
COLLAPSE
Case Study 1

HH is a 68 yo M who has been admitted to the medical ward with community-acquired pneumonia for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, which include ceftriaxone 1 g IV qday (day 3) and azithromycin 500 mg IV qday (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements. He is not tolerating a diet at this time with complaints of nausea and vomiting.

Ht: 5’8” Wt: 89 kg

Allergies: Penicillin (rash)

Health Needs

Nutrition status. The patient is not tolerating diet, related to nausea (N) and vomiting (V). It is unclear in the case scenario when the patient first complained of N and V. It is less likely to be caused by CAP (Baer, 2019). It can be a side effect of the antibiotics (Rxlist, 2018), or related to a condition undiscovered by the provider yet. Further physical examination and a KUB are necessary to determine if the N and V are a side effect of the medications or caused by a different condition.
Hydration status of the patient. The patient has been having N and V. It is essential to maintain the patient well hydrated during recovery time because hydration loosens up the secretion, which makes it easier for the patient to breathe by coughing and clearing up their airway (Ausmed, 2017). Strict intake and output measurement are essential to prevent dehydration.
Length of IV antibiotic therapy. The Infectious Diseases Society of America (IDSA) recommends treating CAP patients who are hospitalized with five to seven days of empiric antibiotics (File, 2020). IDSA recommends to re-evaluate patients by the fifth to the seventh day before stopping the antibiotic, extend the therapy needed if the patient is febrile, needs supplemental oxygen (unless required for a preexisted condition), and patient clinically unstable (HR>100, RR>24, and SBP<90) (File, 2020). Treatment Regimen Metoclopramide 10 mg IV Q6H to control the N and V if no underlining condition was found (Entringer, 2019). If the patient is unable to drink, start the patient on IV fluid replacement therapy with normal saline 0.9 at 75 ml/hr. Total fluid volume per day [weight (kg) x 20 ml/kg/day] = 89 x 20= 1780 ml Infusion rate = total fluid volume per day ÷ 24 hour = 1780 ÷ 24= 74.1= 75 ml/hr (EBM Consult, n.d.). I would recommend continuing the patient’s current antibiotic until day 7. Then, re-evaluate the patient before stopping them. I do not feel the need to change the current antibiotic because the patient’s status is improving, and he requires less O2. Reconcile the patient’s home medications except for the diabetes medications. The most important medication to reconcile is the COPD medication, to prevent COPD exacerbation, which can lead to an increase risk of mortality (Braeken et al., 2014). Sliding-Scale Insulin (SSI) to treat the patient’s high blood sugar. Studies show SSI has better ability to keep patients’ blood sugar within or close to target during hospitalization by administrating short-acting insulin frequently (Ambrus & O'Connor, 2019) Encourage the patient using incentive spirometer (IS). IS can help him practice taking deep breaths, which can help open the airways, prevent fluid or mucus from building up in the lungs, make it easier for the patient to breathe, and lower the O2 supplement demand (Healthwise, n.d.). Education Take Metoclopramide before a meal to prevent N and V and to improve the nutrition status, and hydration status. Teach the patient how to use IS and the benefit of using IS. The patient is above the age of 65 years old and has COPD, which increases the risk of CAP. Educate the patient about getting the pneumonia vaccine before discharge to lower the risk of recurrent pneumonia in the future (Centers for Disease Control and Prevention, 2019). References Ambrus, D. B., & O'Connor, M. J. (2019). Things We Do For No Reason: Sliding-Scale Insulin as Monotherapy for Glycemic Control in Hospitalized Patients. Journal of Hospital Medicine, 14(2), 114-116. doi:10.12788/jhm.3109 Ausmed. (2017). Pneumonia Symptoms, Signs and Treatment. Retrieved July 26, 2020, from https://www.ausmed.com/cpd/articles/pneumonia-explained Baer, S. L. (2019). Community-Acquired Pneumonia in Adults. Retrieved July 26, 2020, from https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/community-acquired-pneumonia-in-adults.html Braeken, D., Franssen, F., Schütte, H., Pletz, M., Bals, R., Martus, P., & Rohde, G. (2014). Increased Severity and Mortality of CAP in COPD: Results from the German Competence Network, CAPNETZ. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 2(2), 131-140. doi:10.15326/jcopdf.2.2.2014.0149 Centers for Disease Control and Prevention. (2019, November 21). Pneumonia Can Be Prevented-Vaccines Can Help. Retrieved July 26, 2020, from https://www.cdc.gov/pneumonia/prevention.html Entringer, S. (2019). Reglan Uses, Dosage & Side Effects. Retrieved July 26, 2020, from https://www.drugs.com/reglan.html EBM Consult. (n.d.). Maintenance Fluid Calculator. Retrieved July 26, 2020, from https://www.ebmconsult.com/app/medical-calculators/maintenance-fluid-calculator?change_to_si=NO File, T. M. (2020). Treatment of community-acquired pneumonia in adults who require hospitalization. Retrieved July 26, 2020, from https://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-who-require-hospitalization Healthwise. (n.d.). Breathing Exercises: Using a Manual Incentive Spirometer. Retrieved July 26, 2020, from https://www.healthlinkbc.ca/health-topics/abj5949 Rxlist. (2018, December 21). Side Effects of Ceftriaxone (Ceftriaxone Sodium and Dextrose Injection ), Warnings, Uses. Retrieved July 26, 2020, from https://www.rxlist.com/ceftriaxone-side-effects-drug-center.htm