Subjective

Medical History

Mr. GD, a 78 yr old Caucasian man, is referred by his physician for the development of an exercise prescription. Seven years ago he underwent treatment for prostate cancer that included aromatase inhibitors and is now cancer-free. Mr. GD is 5 ft 11 in. (180 cm) tall with a weight of 165 lb (75 kg). He walks his dog daily for 40 minutes, and he generally keeps himself busy with activities around the home and community, but otherwise he does not follow a regular exercise regimen. He says that his walks are often at a fairly leisurely pace. He plays cards with friends on Wednesday nights.

Diagnoses

He was recently diagnosed with osteoporosis. He was surprised, because he thought it was a woman’s disease. He takes vitamin D (400 IU per day) and calcium (500 mg per day), and consumes calcium-containing foods to get sufficient calcium in his diet. His doctor prescribed Fosamax for his osteoporosis. His mother had a hip fracture when she was 85, and passed away 6 mo later. He is taking medication for his blood pressure, which is well controlled (resting blood pressure is 129/79 mmHg; resting heart rate is 82 beats · min– 1).

Objective and Laboratory Data

Exercise Test Results

He recently underwent an exercise stress test that was normal, but no physiological testing was done other than regular blood chemistries. His 6 min walk distance is 507 m. His occiput to wall distance is 2 cm, and his scapulae appear protracted. His Short Physical Performance Battery score is 14; he could not complete the tandem stand. His knee extension and grip strength are within normal limits for his age but on the low end of normal. He has reduced hip extension range of motion in both legs, but greater on the right.

Assessment and Plan

Exercise Prescription

Mr. GD already walks daily, so you encourage him to time his walks, monitor his heart rate intermittently throughout, and estimate his rate of perceived exertion. Based on the treadmill test, you both agree that he should aim to be at a 5 or 6 on a 0-10 scale for his rating of perceived exertion (RPE) to start, and you suggest that he should feel like his heart is beating faster and he is breathing harder, and that he might be able to carry on a conversation while walking, but he should not be able to sing without stopping to catch his breath. His goal is to complete his 40 min walk, but at least 15 min should be at that pace. He will progress to completing the whole 40 min at the new pace.

He agrees to start a progressive resistance training program but would like exercises that he can do at home rather than having to join a gym. He agrees to attend visits with you twice weekly for 3 wk to practice the exercises and follow up with you every few months to progress the exercises. You ask him about what days of the week would be best, the time of day, and the “trigger” that will remind him to exercise. He suggests that after breakfast on most days would work well. He will start with six exercises, performed on Monday, Wednesday, and Friday mornings. To start, you select counter push-ups, singlearm rows done in standing with elastic tubing, body weight squats, and step-ups with hip extensions, using the stairs in his basement, and having him step up to the second step. You teach him how to do abdominal bracing during each exercise. The step-ups were chosen because they challenge his balance. Before teaching the exercises, you show him how to do a hip hinge so he can apply that to his squats and also his daily activities. He will also add 2-3 sets of 10 longer strides to his walks as a balance challenge, and practice balancing on one foot while brushing his teeth while standing near a counter in case he needs support. The long strides and step-ups with hip extensions are also dynamic range of motion activities targeting his tight hip flexors. He will start with two sets of 8 repetitions of each exercise. He will also add in supine lying with arm lengthener and leg lengthener exercises for his posture and back extensors, which he will do every evening before bed—he will hold each position for 3 s, rest 3 s, and repeat 5 times.

By the end of your sessions with him, you have progressed him to 10 repetitions of each exercise or progressed him to a more difficult version. You have given him suggestions for how to progress the resistance or intensity once he can complete 12 repetitions of an exercise. You tell him to contact you or his doctor if he feels any pain during or after exercise, and suggest to him to make a follow-up appointment in 2 mo.

Case Study Discussion Questions

1. What other information should be obtained from Mr. GD? What risk factors for fracture does he have?

2. What recommendations might you make regarding his gardening? What movement strategies could you teach him?

3. How might you progress his resistance training program or balance challenges?

Discuss how the initiative by the YMCA and UHG represents a new paradigm in health care focused on prevention.

In 2007, the Medicare Fraud Strike Force was created to provide analytics on data on fraud and work withe the "Office of Inspector General, the Department of Justice, Offices of the United States Attorneys, the Federal Bureau of Investigation, local law enforcement, and others" (Office of Inspector General, n.d.) to prosecute and shut down Medicare fraud. On their website, they list all of the recent actions that they have taken and money recovered. With the creation of agencies such as these, Medicare fraud will continue to be reported, watched, and combated.

How important is this organization in reducing risk?

what kind of information does a health care organization need to function smoothly?

1. Your patient must have dialysis-what are your roles before, during and after?
2. Patient teaching UTI and renal transplant?

Should every American be entitled to health care? Free health care?

Why are so many Americans so sick?

What is our problem with health care? How and why did poorer countries figure it out and we can't?

Take a stand and make some claims.

Can you please select the right answer. I did not  get a good score on this quizz. Thank you

Question 6

5 / 5 pts

Define the following terms associated with healthcare insurance:

If the answers do not show in their entirety, they are pasted below:

• The maximum amount an insurer will pay for a certain service
• A health condition written into the health insurance policy indicating what is not covered by the policy
• The amount of expenses the patient must incur before the insurance company begins to pay for covered services
• A medical condition that had been diagnosed or treated usually within 6 months before the date a health insurance policy goes into effect
• A negotiated set amount that a patient pays for certain services

Copayment

            A negotiated set amount that a patient pays for certain services           

Deductible

            The amount of expenses the patient must incur before the insurance company begins to pay for covered services           

Exclusion/Upper Lifetime Limit

            A health condition written into the health insurance policy indicating what is not covered by the policy           

Pre-existing condition

            A medical condition that had been diagnosed or treated usually within 6 months before the date a health insurance policy goes into effect           

Fixed indeminity

            The maximum amount an insurer will pay for a certain service           

Question 7

1 / 1 pts

Medicare under the Affordable Care Act includes all of the following benefits EXCEPT:

Patients get more preventive services, for less

Patients can save money on brand-name drugs

Patients get more doctor support

Medicare coverage has some good benefits, but is not protected

Question 8

1 / 1 pts

How has the Affordable Care Act affected Medicaid?

Medicaid has restricted eligibility to adults with incomes at or below 50% percent of the poverty line, which is just over $40,000 per year for an individual today

Medicaid has restricted eligibility requirements to children whose parent's income is less than $20,000 year

Medicaid has expanded eligibility to adults with incomes at or below 138 percent of the poverty line, which is just over $16,000 per year for an individual today

Medicaid has expanded coverage to older adults (55+ years) regardless of pre-existing conditions

Question 9

1 / 1 pts

What is the health insurance marketplace?

A service that helps people shop for and enroll in affordable health insurance from various providers

The governing body of health insurance that enacts penalties for people who don't have insurance

A place for low income individuals to obtain health insurance

A place for seniors to obtain health insurance

Question 10

4 / 4 pts

Identify the changes under the Affordable Care Act among the following groups:

If the answers do not show in their entirety, they are pasted below:

• Required to pay more taxes
• Most Americans (except exempt) are required to obtain health insurance, or get fined
• Can not be charged higher premiums
• Covered on parent's health insurance until the age of 26

Individual mandate

            Most Americans (except exempt) are required to obtain health insurance, or get fined           

Women

            Can not be charged higher premiums           

Young people

            Covered on parent's health insurance until the age of 26           

Wealthy

            Required to pay more taxes           

PartialQuestion 11

11 / 14 pts

Identify the types of healthcare services provided by the healthcare practitioners:

If the answers do not show in their entirety, they are pasted below:

• Children
• General health
• Skin
• Independent healthcare providers who provide nontraditional forms of healthcare
• Lungs
• Clinical professionals who hold a medical degrees, but do not have an MD or MO degree
• Healthcare workers who focus on preventative heath in different forums (health departments, schools, etc.)
• Feet
• X-ray
• Independent healthcare providers whose remedies produce effects different from those of the disease, and emphasize the interrelationships of the body's systems
• Brain
• Seniors
• Female health
• Ears, nose and throat

Allopathic and Osteopathic providers

            General health           

Gynecologist

            Female health           

Neurologist

            Brain           

Nonallopathic providers

            Independent healthcare providers whose remedies produce effects different from those of the disease, and emphasize the interrelationships of the body's systems           

Public health professionals

            Healthcare workers who focus on preventative heath in different forums (health departments, schools, etc.)           

Pediatrician

            Children           

Pulmonologist

            Lungs           

Otolaryngologist

            Ear, Nose and Throat           

Radiologist

            X-Ray           

Family Practitioner

            Independent healthcare providers whose remedies produce effects different from those of the disease, and emphasize the interrelationships of the body's systems           

Dermatologist

            Skin           

Podiatrist

            Feet           

Gerentologist

            Seniors           

Nurse

            Clinical professionals who hold a medical degrees, but do not have an MD or MO degree           

Question 12

1 / 1 pts

Your rights as a patient include all of the following EXCEPT:

The right to be fully informed of what is being planned for your care

Knowing whether or not the treatment you are receiving is standard or experimental

The right to refuse treatment, but once you consent to receiving it, you can not change or cease treatment at any time

The right to confidentiality of your health care records

The right to receive adequate health care and treated with respect and dignity

PartialQuestion 13

2 / 4 pts

Identify prescription drugs versus Over the Counter Drugs (OTC) based on the descriptions (Choose answers in alphabetical order. For example, Administered under professional supervision should be chosen first for either prescription or OTC)

If the answers do not show in their entirety, they are pasted below:

• Recommended for common conditions, as well as self-diagnosis and self-treatment
• Contains a standard label with the purpose, active ingredients, uses, warnings and directions
• Administered under professional supervision to treat illnesses and diseases
• Contains a label with a particular person's name, and should only be responsibly taken by that person

Prescription Drugs

            Administered under professional supervision to treat illnesses and diseases           

Over the Counter

            Recommended for common conditions, as well as self-diagnosis and self-treatment           

Prescription Drugs

            Contains a label with a particular person's name, and should only be responsibly taken by that person           

Over the Counter

            Contains a standard label with the purpose, active ingredients, uses, warnings and directions           

PartialQuestion 14

1 / 3 pts

Distinguish the various types of insurance:

If the answers do not show in their entirety, they are pasted below:

• An option that enables enrollees to be at least partially reimbursed for selecting a healthcare provider outside of the plan
• Groups that supply pre-paid comprehensive healthcare with an emphasis on prevention
• Organization that buys fixed-rate health services form providers and sells them to consumers

Preferred Provider Organization (PPOs)

            Groups that supply pre-paid comprehensive healthcare with an emphasis on prevention           

Health Maintenance Organizations (HMOs)

            Organization that buys fixed-rate health services form providers and sells them to consumers           

Point of Service Options (POS)

            An option that enables enrollees to be at least partially reimbursed for selecting a healthcare provider outside of the plan           

Question 15

1 / 1 pts

Maximizing care while minimizing costs includes all of the following EXCEPT:

Practice healthy lifestyle behaviors to preserve the quality and quantity of your life

Try the least expensive healthcare options first

Read your policy to understand your coverage and check your bill for accuracy

Use the emergency room first for illness and disease

Avoid unnecessary risks to minimize unintentional injuries

Do your research and choose an insurance plan that provides comprehensive healthcare that you can afford

You have implemented an inter-professional plan for Joe to remain in his home with his family maintaining a rotating caregiver role. During a home visit you notice bruises on Joe’s face and arms in varying degrees of healing. Joe also is unshaven and smells of urine. When you question the family member caring for Joe that day, they state that Joe has had a ‘rough week’ and is doing fine.

What next step should you take and why? Who should be contacted? What legal responsibility do you have as a RN in this situation?

Write the short answers

Q 1. Identify trends in the use of the Internet for healthcare information.

Q 2. Discuss why patient–provider online communications remain relatively uncommon.

Q 3. List three ethical concerns governing provider advice giving over the Internet.

Q 4. Discuss how patients turn to the Internet for information because they are inadequately informed in encounters with their provider.

Describe the feedback you gave and received following any task

include :

1. Who did you share feedback with?

2. What was the nature of your relationship?

3. What feedback were you given? How did this feedback help you?

4. What feedback did you give in return? Describe how you think that feedback was useful to them?

A 75-year-old female client on home health care for post op hip replacement. You are the visiting nurse and you find the patient somulent and only responding to stimulus with nodding. Patient was given prescription for 10 mg oxycodone q4-6 hours. Patient has been out of the hospital for three days. Upon examining the bottle, it is found that 20 tablets were prescribed and only two tablets remain.

a. What measures should the nurse take to ensure an accurate assessment of pain in the client?

b. What patient and family or caregiver education is appropriate in this case? (Be prepared to act as the nurse in a nurse-patient real life scenario.)

For this discussion, examine the practice act for Texas. In your initial post, include a summary of one area in the nurse practice act and include an association you could use to examine the standards of practice. In your response to your peers, discuss the similarities and differences you see in different states.