anticipatory guidance at each well chid visit?

I know at around 3 months you should tell the parent the infant will start to roll over and to be mindful of that. Anything else? Please give as much guidance as possible please.

Your sister is pregnant with triplet embryos. Because of her small frame ,she has been advised that she will be unable to carry all three children to term and has to undergo a fetal reduction to remove at least one of them. Your sister asks you for your advice oh how to choose which one should be reduced. How would you respond?

During your lunch break at the hospital, you read a journal article on pharmacoeconomics. You think of a couple of patients who have recently mentioned their financial difficulties. You wonder if some of the expensive drugs you have prescribed are sufficiently managing the patients’ health conditions and improving their quality of life.

Explain the ethical and legal implications of the scenario you selected on all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.

Describe strategies to address disclosure and nondisclosure as identified in the scenario you selected. Be sure to reference laws specific to your state.

Explain two strategies that you, as an advanced practice nurse, would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation.

Explain the process of writing prescriptions, including strategies to minimize medication errors.

Explain the FDA’s process for assessing the safety for prescription drugs and over-the-counter drugs and give your opinion the process (is it effective, should anything be changed, are there disadvantages of the current system, it is harmful).

The Older Adult in Critical Care Unit

Mr. J is transferred to the ICU setting where he is intubated immediately for acute respiratory failure secondary to sepsis. He is unconscious. His blood pressure is 80/40 and a central venous line is placed. On intubation, the oral mucosa is friable and bleeding with evidence of massive stomatitis and esophagitis. He is treated empirically with several IV antibiotics and inotropic agents; his prognosis is poor.

Clinical Data

•       Mr. J is unable to speak, but within 72 hours of aggressive therapy, he begins to improve, showing conscious responses to external stimuli, although responses are limited and erratic.

•       Daily spontaneous breathing trials shows signs of improvement and a possibility for extubation exists.

•       However, he begins to pull at his tubing. He has a wide-eyed fearful look as he attempts to mouth words around the endotracheal tubing. Staff can’t understand Mr. J’s communication attempts. He becomes intermittently lethargic then restless, reaching in space for imaginary objects.

•       During this time his blood pressure climbs and heart rate peaks over 120 beats per minute. Staff attribute these vital sign changes to anxiety and tell Mr. J that he is improving. They remind him not to pull the tubing or they will have to restrain his hand.

•       Mr.J’s care and treatment are discussed at the Care Conference with his son. Discussion centers on his mental status, communication difficulties, and ventilator weaning progress. Staff are fearful that he is in danger of harm from accidental medical treatment device (endotracheal tube/central venous line) removal and may need to be physically restrained.

Follow up Care

•       Mr. J’s sepsis resolved, he was extubated, and his physical strength improved over several weeks. Use of physical restraint was avoided. Mr. J gradually began to sit on the side of the bed with nursing assistance and physical and occupational therapy. His pain was managed with oral solutions 15 minutes prior to activity and as assessed as necessary by the nurse. Staff worked to incorporate family participation into Mr. J’s care and recovery.

Take home points

•       Several important decisions were made at crucial points in time and led to the many successful outcomes experienced by Mr. J. These included increased nursing involvement in communication, early identification, care and treatment of delirium, prevention of aspiration, prevention of further deconditioning, and the decision to avoid physical restraint use. A coordinated team approach involving his son coupled with open channels of communication and consultation with other team members who knew this patient earlier in his hospital stay helped contribute to his successful recovery

Patient Outcome

•       Ultimately Mr. J was transferred to a sub-acute rehabilitation setting for care and treatment of reduced mobility, and to increase muscular strength, endurance and independence in daily living.  

•       He developed many friendships with other residents and began to transport himself, via wheelchair, to the cooking club held at the facility. Over the course of several months, he regained muscle strength and endurance in the walking program.

Case Study Questions

1. What additional comorbidities are Mr. J at risk for and how would you determine this?
2. How would you determine the development of delirium?
3. What care strategies need to be addressed for the delirium?
4. What other co-morbidities or other issues need interventions?
5. What modifications in communication strategies need to be used when caring for Mr. J in the ICU setting?

1. What pharmacologic interventions do you expect will be ordered for this patient? What routes of administration will be best indicated for this patient? (Include mechanism of action, indication for use and desired outcomes)
2. What are the nursing implications for the above listed pharmacologic treatments (teaching pearls, things to anticipate, adverse reactions)?

Gladys Young is a 68 year old female that resides in an Independent Living facility with her husband. She presents to her primary care physicians office with complaints of fever, chills, nausea and vomiting. She also states that she has had some mild hemoptysis occasionally with her persistent coughing. She has recently completed treatment with Chemotherapy for Breast cancer and is concerned that she may have an infection. You are the nurse caring for her.

You complete the following assessment:

Subjective Data:

She is able to complete a sentence in its entirety, but she is persistently coughing during the history. She is a former smoker, she smoked ½ pack of cigarettes per day for 30 years and quit when she was diagnosed with breast cancer 6 months ago. She denies shortness of breath or chest tightness. She has not yet gotten her influenza vaccine, but did receive the Pneumovax vaccine last year. She has had problems with persistent coughing at night which has prevented her from getting a good night’s sleep for the past two weeks. She also states that she has been waking up soaked in sweat in the morning.

Objective Data:

• Temp – 38.6 C; HR – 132 beats/min; RR—28; BP – 168/87; O2 sat – 90% on Room Air
• Auscultation: Lungs with faint crackles at bases bilaterally. No wheezing present.
• Patient is flushed and warm to touch.

You failed your classes and you need to write an academic school appeal letter. 200 words

1- Define and describe the three types of dehydration and potential causes.

2- Differentiate between mild, moderate, and severe dehydration.

3- What are different treatment for each type of dehydration based on the CDC guidelines and Up to date?

4- Identify and demonstrate teaching strategies with the parent and child. ( be familiar with oral rehydration and diets for children with fluid and electrolyte imbalances.

5- Who is primarily effected with Rotavirus. What are the signs and symptoms of Rotavirus? How is Rotavirus transmitted? What is the the treatment of Rotavirus?

Case Study: Nutrition & Metabolism

Worldwide, the incidence of obesity, defined as have too much body fat, has more than doubled since 1980. The United States has the largest rate of obesity with nearly 36% of American being obese. Obese is defined as having a body mass index greater than or equal to 30. Obesity greatly increases risks for a number of diseases such as type 2 Diabetes Mellitus, cardiovascular diseases, bone and joint issues, and even some cancers. Many obese patients struggle with weight loss using diet and exercise. For many of these patients, bariatric surgery can assist with the weight loss process.

There are 4 main types of bariatric surgery.

Laparoscopic Adjustable Gastric Band (LAGB or lap-band)

In what is called a lap-band (laparoscopic adjustable gastric banding or LAGB) surgery, a silicone band is placed around the upper part of the stomach. Squeezed by the silicone band, the stomach becomes a pouch with about an inch-wide outlet. After banding, the stomach can only hold about an ounce of food. No removal of GI tissue or re-routing of the GI tract happens in this procedure. This procedure has the least side effects, but also is associated with less weight loss.

Gastric By-Pass

The most common form of weight loss surgery is the gastric by-pass (Roux-en-Y or RYGB). In gastric bypass, the stomach is made smaller by surgically creating a small pouch of the top of the stomach and separating the rest of the stomach into a larger pouch not connected to the esophagus. The smaller stomach is connected directly to the middle portion of the small intestine, bypassing the rest of the stomach and the upper portion of the small intestine. The upper portion of the small intestine is then connected to the upper part of the small intestine.

Sleeve Gastrectomy

The laparoscopic sleeve gastrectomy, often called the sleeve, is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana.

Biliopancreatic Diversion with duodenal switch (BPD/DS)

The Biliopancreatic Diversion with Duodenal Switch (BPD/DS) is a procedure with two components. First, a smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. Next, a large portion of the small intestine is bypassed. The duodenum, or the first portion of the small intestine, is divided just past the outlet of the stomach. A segment of the distal (last portion) small intestine is then brought up and connected to the outlet of the newly created stomach, so that when the patient eats, the food goes through a newly created tubular stomach pouch and empties directly into the last segment of the small intestine. Roughly three-fourths of the small intestine is bypassed by the food stream.

The bypassed small intestine, which carries the bile and pancreatic enzymes that are necessary for the breakdown and absorption of protein and fat, is reconnected to the last portion of the small intestine so that they can eventually mix with the food stream. Similar to the other surgeries described above, the BPD/DS initially helps to reduce the amount of food that is consumed; however, over time this effect lessens and patients are able to eventually consume near “normal” amounts of food. Unlike the other procedures, there is a significant amount of small bowel that is bypassed by the food stream.

1.Compare and contrast the effects of Lap-band (LAGB) vs BPD/DS on protein digestion and absorption.

2.How would a decrease in caloric intake alter metabolism: Would blood glucose levels be high, low or normal? Would glycogen stores be built or degraded, ditto with fat stores and proteins? Does the metabolic rate change?

A 15 year-old female has come to the urgent care complaining about nausea, vomiting, and feeling tired all the time. Her complaints are vague, but the nurse is suspicious she may be pregnant when the girl mentions she is late for her period.

A. What nursing care will you provide to this young lady if she is pregnant.

B. What nursing diagnoses will apply to this situation?

C. What are some expected outcomes?