CHINESE CASE STUDY #1

An elderly, Asian-looking man is admitted to the emergency room with chest pain; difficulty breathing; diaphoresis; vomiting; pale, cold, clammy skin; and apprehension. Three people, speaking a mixture of English and a foreign language to one another, accompany him. The nurse tries to speak English with the man, but he cannot understand anything she says. Accompanying the elderly man are two women (one elderly and very upset and one younger who stands back from the other three people) and one younger man.

The younger man states that the elderly man, whose name is Li Ying Bin, is his father; the elderly woman, his mother; and the younger woman, his wife. The son serves as the translator. Li Ying Bin comes from a small village close to Beijing. He is 68 years old, and he has been suffering with minor chest pain and has had trouble breathing for 2 days. He is placed in the cardiac room, and the assessment continues.

Mr. Li is on vacation, visiting his son and daughter-in-law in the city. His son and daughter-in-law have been married for only 1 year, but the son has lived in the West for 7 years. Mr. Li’s daughter-in-law looks Chinese but was born in the United States. She does not speak very many words of Chinese. Further physical assessment reveals that Mr. Li has a history of “heart problems,” but the son does not know much about them. Mr. Li had been to the hospital in Beijing but did not like the care he received there and returned home as soon as possible. He goes to the local clinic periodically when the pain increases, and the health-care provider in China used traditional Chinese medicine, herbs, and acupuncture. In the past, those treatments relieved his symptoms.

Medications are ordered to relieve pain, and Mr. Li undergoes diagnostic procedures to determine his cardiac status. The studies reveal that he did sustain massive heart damage. Routine interventions are ordered, including heart medications, anticoagulants, oxygen, intravenous fluids, bedrest, and close monitoring. His condition is stabilized, and he is sent to the cardiac intensive-care unit. In the cardiac unit, the nurse finds Mrs. Li covering up Mr. Li until he sweats, and Mrs. Li argues with the nurse every time her husband is supposed to dangle his legs. She complains that he is too cold and brings in hot herbal beverages for him to drink. She does not follow the nurse’s and physician’s orders for dietary restrictions, and she begins to hide her treatments from the staff. Her son and daughter-in-law try to explain to her that this is not good, but she continues the traditional Chinese medicine treatments.

Mr. Li is a very quiet patient. He lies in bed and never calls for help. He frequently seems to be meditating and exercising his arms. When he does talk to his son, he speaks of the airplane ride and the problems of being so high. He believes that may have caused his current heart problem. Mr. Li also wonders if Western food could be bad for his system. Mr. Li’s condition gradually deteriorates over the next few days. Nurses and physicians attempt to tell the family about his condition and possible death, but the family will not talk with them about it. Mr. Li dies on the 5th day.

Study Questions

5. What are the common health risks for the development of chronic obstructive pulmonary disease among Chinese people?

6. What are some of the reasons that Mr. Li waited so long to enter the hospital?

7. Mr. Li did not complain of chest pain in the cardiac intensive-care unit. Is this a common behavior? Why?

8. True or False: The Chinese family will expect health-care providers at the hospital to provide most of the care for Mr. Li.

Particulate material that loses energy more slowly than other particles, travels farther in the air, and can be stopped by materials such as aluminum and other metals, plastic, glass, and clothing is known as: Select one: a. alpha particles. b. gamma rays. c. neutrons. d. beta particles.

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The symptoms and effects of a biological release may not be immediately visible at the scene, because of:

Select one:

a. Historical health records and family DNA

b. Time between exposures and incubation of the disease

c. Biological agent’s life cycle and geographical area

d. Mortality rate and no witnesses

Scenario
Tim is a 40-year-old sustainable farmer who works daily in his farm fields. After a long day getting his fields ready for planting, he comes in and falls into bed, exhausted.

The next morning as he’s taking a shower, he feels a small lump on the back of his leg, behind his knee. Since he can’t really see it, he dries off and asks his wife to look at it. Initially she thinks it looks like a scab, but upon closer inspection she notices it has legs!

She runs for the tweezers and pulls the tick off, and then notices that he actually has three more ticks embedded higher up on the back of his thigh.

Signs and Symptoms
Tim had been bitten by ticks and treated for Lyme disease before, so he decided to wait to see if a rash developed. After checking the spots daily for a week and not seeing anything other than a small, red, raised area around a few of the tick bite sites, he stopped worrying.

About 10 days later, Tim developed a fever and started to have bouts of extreme fatigue that were not alleviated by resting or sleep. The fatigue got to the point that he couldn’t get out of bed. When he started to act disoriented and confused, his wife drove him to the hospital.

Testing
Blood was drawn and sent to the hematology, clinical chemistry, and microbiology laboratories.

Question 1: What symptoms would indicate that Tim’s disease could be due to an infection involving the central nervous system?

Question 2: What is the significance of these findings in the peripheral blood smear?

While his attending physician struggled to figure out what was wrong, Tim became unresponsive. Additional samples were sent to serology to assess his exposure to viruses known to cause encephalitis, specifically West Nile Virus (WNV), Eastern Equine Encephalitis Virus (EEE), and Powassen Virus (POW), as well as tests for other tick-borne diseases common to his area.

Serology Test Results:
WNV, EEE, and POW—negative
Lyme disease serology—equivocal
Babesia microti and B. duncanii —negative
Ehrlichia monocytogenes—negative
Anaplasma phagocytophilium—positive

Question 3: Discuss the results of the collective laboratory tests— are the serology test results consistent with what the hematologist observed in the stained blood smear?

Question 4: Do you think Tim has Lyme disease?

Diagnosis
Tim was diagnosed with anaplasmosis, caused by Anaplasma phagocytophilium.

Question 5: Is it necessary for the hospital to report Tim’s case of anaplasmosis to the CDC for disease surveillance? Why?

Over the next two months, seven other people with Tim’s symptoms were admitted to the same regional hospital. Six tested positive for anaplasmosis and were successfully treated, but the seventh person died before a diagnosis could be reached. She subsequently was found to be positive for Anaplasma. In the previous year, there had been no cases of anaplasmosis diagnosed at the hospital.

Question 6: What epidemiological term(s) apply to this scenario?

Treatment
Once it was affirmed that Tim was infected with Anaplasma, treatment with IV ceftriaxone was immediately started via a peripherally inserted central catheter (PICC). After 2 days on the antibiotic he was alert but still overwhelmingly fatigued. After a week he was feeling well enough to be released from the hospital, but visited an infusion center daily for the rest of the month. He was also given oral doxycycline.

By the end of the year, a total of 26 cases of anaplasmosis were diagnosed at the hospital, which was the only medical facility in Tim’s county of residence. The county population (from census data) that year was 6,982 people.

Question 7: What is the incidence of anaplasmosis in Tim’s county?

Question 8: Is this also the prevalence of anaplasmosis in Tim’s county? Why?

Your reading response must be two pages typed and double spaced, and include a bibliography to support your documentation on any topic related to the environmental crisis & infectious disease.

feelings as though you lost in a negotiation effort most likely means that:

EHRs typically support care planning order entry and management and communication among the care team. true/false

Briefly summarize the complex life cycle of a vector-borne pathogen of your choice. Describe the point in the life cycle at which we should intervene to halt disease progression.

** Summarize the following paragraphs in ONE PARAGRAPH please. **

The opioid crisis in the United States continues unabated despite an overall reduction in the number of prescriptions for opioid analgesics written over the past 5 years.¹ If nothing changes, opioid deaths are predicted to increase almost 100% by between 2016 and 2025 and the number of persons using illicit opioids will increase 61% by the same date.² The number of persons who inject drugs continues to increase, with many of these persons reporting that they used prescription opioid analgesics before they started using heroin. A less-discussed complication of the opioid crisis that may be just as lethal is the increase in serious infections in persons who inject drugs.³ Hospitalizations for infective endocarditis associated with injection drug use increased 50% between 2002 and 2012.³ Admissions for osteomyelitis and septic arthritis increased 54% and 63%, respectively, over the same period.³ Patients with untreated opioid use disorder often receive suboptimal care for their serious infections.⁴ Onset of withdrawal symptoms and cravings for opioids generally occur within 4 to 12 hours after the last use of an opioid, depending on the substance used. Patients who inject drugs are more likely to leave the hospital before completing a course of treatment or may be unable to comply with outpatient discharge instructions and are at higher risk of reinfection, readmission, or death. Patients who are referred for an addiction medicine consultation are less likely to leave the hospital against medical advice.⁵ The National Academies of Sciences, Engineering, and Medicine convened a workshop to develop a response to the increase in hospitalizations for infections of patients who inject drugs.⁶ The workshops resulted in several recommended action steps. Action step 4 calls for all prescribers and other personnel to receive training on Drug Addiction Treatment Act waivers. Clinicians also should be trained on how to safely prescribe methadone to patients before patients are discharged from the hospital.

WHAT IS HOLDING US BACK?

Historically, the amount of time dedicated to education on screening for, diagnosing, and treating substance use disorder is limited in the medical curriculum.⁷ Students may attach a stigma to patients with substance use disorders.⁸ A survey of general internists found that almost a third felt that opioid use disorder was different from other chronic conditions because they believed it was a choice.⁹ Fourteen percent of the respondents felt that medication-assisted treatment was substituting one drug for another.⁹ Twelve percent of hospitalists and 6% of primary care providers believed that persons using drugs committed a crime and should be punished.⁹ Only 9% of the sample felt they were prepared to discuss medication treatments for patients with opioid use disorder.

WHY SHOULD THIS MATTER TO YOU?

Whether you are practicing in primary care, emergency medicine, or a hospital-based specialty, you will encounter patients with opioid use disorder.¹⁰ Clinicians must be able to screen patients for substance use disorders, diagnose patients with opioid use disorder, and manage these patients, whether by treating withdrawal symptoms, initiating medication-assisted treatment (MAT), or referring them to an appropriate level of care. Hospital providers are authorized, without the need for a waiver, to use either methadone or buprenorphine to treat withdrawal symptoms in their patients. However, waiver training gives clinicians the knowledge to use these medications appropriately.¹¹

The nurse is caring for a client with end-stage renal disease (ESDR). Which of the following findings should the nurse follow up first?

Ammonia odor of the breath

Numbness and tingling around the mouth

Nausea

Decrease in urine output

1.      How do differing philosophies of science (received view or logical positivism and perceived view) influence whether nursing is considered a hard, soft, applied, or human science?

2.      Whall (2012/2005, Ch # 9)) states that “Practice is not a ‘stand alone’ phenomenon; rather, it is a direct outcome of philosophic beliefs.” What does this mean in relation to your practice as an APN? Describe assumptions you have about your philosophy of science as it relates to your practice. (DNP Essential: #1 Scientific Underpinnings for Practice; DNP Essential VIII: Advanced Nursing Practice).

When should life-sustaining treatments like breathing machines or feeding tubes be started, continued, or stopped?

I Have practice PICOT questions that I would like to see if my answers are close to correct. Read the scenario, choose the one form of PICOT question that fits the scenario. state if its INTERVENTION ETIOLOGY, DIAGNOSIS OR DIAGNOSTIC TEST, PROGNOSIS/PREDICTION, or MEANING

PICOT Scenarios

1. The patient is a 73-year-old white woman admitted to the hospital with heart failure. She is compliant and seldom misses her medications. On admission, her medications were furosemide 40 mg po qd, enalapril 20 mg po bid, simvastatin 10 mg po qd, and aspirin 325 mg po qd. She usually functions at a NYHA class II level. She now has had two admissions for congestive heart failure in the past 4 months. On this admission, a myocardial infarction has already been ruled out and she remains in sinus rhythm. She has normal renal function with a serum creatinine of 0.7 mg/dL. The patient is particularly concerned about staying out of the hospital because she is very active in her community, lives alone, and has no one to care for her pets and plants. The primary care provider asks the team if digoxin would help shorten her hospital stay or keep her from being readmitted. You are asked to do a PubMed search and bring the answer to morning rounds.

2. Patient is a 73-year-old female in good health with normal cholesterol levels and no chronic diseases. She comes to the clinic because she is starting to notice that she is forgetting things more often and having problems balancing her checkbook and playing brain teaser games with her grandchildren. Her husband says he hasn’t notice anything different about her. But she’s fearful that she might be “getting Alzheimer’s Disease”. She said her neighbor told her that Lipitor is supposed to help with the symptoms or maybe even prevent Alzheimer’s disease. She wants your advice. Would this help? You recall a few patients complaining about memory problems while on statins but don’t know the data on reducing the risk of AD or associated cognitive symptoms. You tell her you’ll get back to her. You ask her about any other medications she might be on and she tells you that she is taking Sporanox for a toe nail infection.

3. The patient is a 68-year-old African American male who has well-controlled hypertension, hyperlipidemia (on a statin) and GERD. He has a h/o MI 2 years ago with a reduced ejection fraction (EF) of 30% (i.e. left ventricular dysfunction). His functional status is NYHA Class III CHF. He is on aspirin, Atenolol, and an ACE-Inhibitor at the time of admission. He expresses concern that, given the state of his heart, he will not survive to see his grandson graduate from law school in 3 years. However, he also states that the quality of his life is important to him, specifically he does not wish to spend time in the hospital or live his life if he cannot be active and interact with his family. The cardiologist tells you that the implantation of a cardiac defibrillator can decrease all causes of mortality in these kinds of patients. However, the cardiologist says that ICD have significant costs and risk associated with them. They both turn to you and ask you to gather the current evidence so they can help the patient make a good decision.

4. AB is a 16-year-old female who was diagnosed with a rare, highly aggressive cancer last year. She has been undergoing intensive chemotherapy for several months and seems to be in remission. But the treatment has left her overwhelmed and depressed. It will take the insurance company 6 weeks to approve visits to a psychiatrist. In the meantime, she is feeling worse and falling into a deep funk. Her parents ask you for help and suggest that Prozac might help her. They tell you they have seen this advertised in magazines. You, however, are aware of the controversy with SSRIs and need to carefully review the evidence before responding to her parents.

5. You are a nursing student rotating in the ED. This is the first day of your rotation. The first case is a 34-year-old male complaining of lower abdominal pain, nausea and vomiting. The team suspects appendicitis and asks you as the new student which is the better diagnostic tool – a scan or an ultrasound? You are overcome with a feeling of uncertainty and a strong urge to review the literature and find some impressive evidence to bring back to your preceptor.

6. You are assessing a 27-year-old female who has trouble with migraines. She has daily headaches and is known to overuse pain medications. She currently uses ibuprofen and if that doesn't work she uses Imitrex. She has tried nortriptyline 25mg before bedtime for the past month without success for prevention. She has no other medical problems and is not taking other medications & is not pregnant. Her vital signs are normal.

7. You are a recent graduate of the School of Nursing and are being oriented to your new position on a cardiothoracic stepdown unit at another hospital. In hopes of improving patient outcomes, bringing down postoperative complication and mortality rates, and decreasing length of stay in the hospital, the unit is investigating changing its practices in order to improve glycemic control in cardiac surgery patients. There has been growing concern among nurses and physicians over the association between poor glycemic control and poor outcomes following cardiac surgery (in non-diabetic as well as diabetic patients). The nurse manager has asked you to do a literature search on the topic and give a presentation at the next in-service conference.

8. A healthy 50-year-old woman comes to her primary care physician’s office. She has early osteoarthritis in her knees, hips, and feet. She has been taking ibuprofen with some relief, but is reluctant to be on long-term medication. She asks if acupuncture could be an effective treatment for her arthritis. Her primary care physician asks you to research this and let him know what you find before the patient’s next appointment.

9. A 46-year-old male had been moving rocks for his rock garden when he felt a twinge and his low back became excruciatingly painful. He's come into the Emergency Room and is extremely unhappy and demanding an MRI. You thought CT was the standard for diagnosis. Is there data to support this?

Case Study – Lower Extremity Presentation/History At the beginning of the soccer season a 20-year-old college student participated in strenuous filed practice extending through the whole afternoon. Later in the evening he experienced severe pain over the anterolateral aspect of his right leg, radiating down toward the angle. The next afternoon he went back to the field and continued to play, but the pain in his right leg became so severe that he had to limp off the field. The pain persisted throughout the night and the next morning he consulted a physician. Examination On examination there is reddening and swelling over the anterolateral aspect of his right leg. On palpation this area is extremely tender, it feels hard and warmer than other parts of the leg. The hardening extends from two inches below the tibial tuberosity to the junction of the middle and lower thirds of the leg and seems to correspond to the belly of the tibialis anterior muscle. Dorsiflexion of foot and toes is severely limited. The pulses in the anterior tibial and dorsalis pedis arteries are present. His body temperature is slightly elevated. Discussion The condition is caused by an acute impairment of the intramuscular circulation in the muscles of the anterior compartment of the leg. It is assumed that heavy exercise, particularly in an individual who is not conditioned, causes a swelling of the musculature, perhaps also some tearing of muscle fibers and small hemorrhages inside the muscles. This increase in bulk compresses the smaller vessels within the muscle bellies which in turn leads to degeneration and necrosis of muscle fibers. Identify the muscles in the anterior compartment of the leg. The tibialis anterior is particularly affected, and the extensor hallucis longus is affected to a greater extent and more commonly than the extensor digitorum longus and peroneus tertius. 1) Describe the configuration of the anterior compartment that makes this region particularly liable to increase in intra-compartmental pressure (6). In that dorsiflexion of the ankle may be interfered with by anoxia of the muscles within the compartment just as likely as it is interfered with by nerve involvement, a differential diagnosis is necessary. 2) Name the major blood vessel and the major nerve in the compartment that may also be affected by the elevation in pressure (2). 3) Identify the muscle that may be tested in the differential diagnosis of circulatory versus nerve involvement. In your consideration, best to identify the muscle supplied by the deep peroneal nerve that lies outside the compressed compartment, the paralysis of which could be taken as an indication of direct nerve involvement. Note: Its paralysis would prove that the compression involves the deep peroneal nerve within the compartment (1) . Deficiencies in the sensory supply of the skin would also demonstrate that the deep peroneal nerve is directly affected. 4) Identify the area of the skin that would be tested for sensory loss (1). The presence of arterial pulse in the anterior tibial and dorsalis pedis arteries seems to prove patency of the main stem, although, occasionally, a well-established collateral circulation in the distal leg (by means of branches from the arteries in the posterior compartment) may simulate patency in a vessel blocked higher up. The variations in susceptibility of the three main muscles of the anterior compartment to impaired circulation can be explained by differences in the development of the intramuscular arterial anastomoses. Another explanation, frequently offered, is the fact that the anterior tibial muscle has its sole supply from the anterior tibial artery, the less involved extensor hallucis longus receives additional blood from the perforating branch of the peroneal artery, while the extensor digitorum longus obtains its supply from the three major arteries of the leg, including the posterior tibial by way of perforating branches. This latter explanation of the preferential involvement of the anterior tibial muscle presupposes interference with blood flow in the main stem of the anterior tibial artery by elevation of pressure inside the compartment, before its branches enter the musculature. While this occurs, presence of pulsatory excursions in the anterior tibial artery distally and in its continuation, the dorsis pedis artery, as was found in this case, makes such an event improbable.

A 25-year-old Arab American man is one day post-operative following vascular surgery. There have been no post-surgical complications. He tells his family that he is “in terrible pain,” and he reports ratings of 2 to 3 on 0-10 numeric rating scale to the nursing staff. He requests pain medication every two to three hours, and will not get out of bed or ambulate.

Identify the actual and potential physiological and psychological responses to the pain/discomfort, for your assigned client.