Instructions for Discussion Replies to 6 DQS

DO NOT JUST REPEAT SAME INFORMATION, DO NOT JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED TO ADD NEW INFORMATION TO DISCUSSION.

1- Each reply should be at least 200 words.

2- Minimum One Peer reviewed/scholarly reference ( NO MAYO CLINIC/ AHA)

3- APA 7th edition style needs to be followed.

4- Each response should have reference at the end of each reply

5- Reference should be within last 4 years

Q-1

Overall the differences between acute rehab, skilled care, long-term care, and hospice patients depend on the category of the facility and their services offered (Alina Health, n.d.); (Differences Between LTACHs, IRFs and SNFs, 2021); (Smith, Kulhari, Wolfram, & Furlan, 2017). Some examples include the complexity of medical care in which intensive care needs to be provided continuously so an LTACH would be most appropriate such as long-term weaning from a trach or a ventilatior (Differences Between LTACHs, IRFs and SNFs, 2021). Another example would be the level of therapy offered,

and an LTACH may offer some, but not as intense or as skilled as an Inpatient Rehab Facility for those who need aggressive rehab to get back to a prior level of functioning (Differences Between LTACHs, IRFs and SNFs, 2021). A skilled nursing facility tends to be the middle ground for patients who don’t qualify for inpatient rehab due to medical conditions holding them back, but those medical conditions don’t require intensive care so they don’t qualify for an LTACH (Differences Between LTACHs, IRFs, and SNFs, 2021). In the question of dialysis, both LTACHs and SNFs can provide either onsite dialysis or transportation to dialysis centers depending on the facility capabilities, but rehab facilities usually do not thus renders the patient unable to be placed (Differences Between LTACHs, IRFs and SNFs, 2021). However, in my career I have seen people be admitted to rehab facilities, but then have additional arrangements for transportation to a dialysis center, but their medical requirements were extremely low on discharge. 

Hospice is unique from the others in the fact that the admission criteria include a terminal diagnosis (Matthews & Daigle, 2020). Notably, the most major difference between hospice and the others is that the goal of hospice is not to restore the patient to the prior level of functioning or to decrease their therapies, but to provide a comfortable, dignified experience while the patient passes on (Matthews & Daigle, 2020).

An example of an intermediate care facility that helps to precipitate progression to an independent living facility would be that if someone had an acute stroke (Smith, Kulhari, Wolfram, & Furlan, 2017). There are several factors that play into the placement of an acute stroke patient, such as the severity of the stroke, neurological deficits, and hours of therapy that are estimated to either get the patient back to their baseline, or to a point of which they can care for themselves (Smith, Kulhari, Wolfram, & Furlan, 2017). This is also dependent on the ability of the patient to be involved in and participate in set hours of rehabilitation therapy or days of rehabilitation therapy (Smith, Kulhari, Wolfram, & Furlan, 2017). Most acute strokes usually are able to be placed in a short or intermediate-length acute care facility depending on the factors mentioned previously (Smith, Kulhari, Wolfram, & Furlan, 2017). These patients are able to utilize the intense therapy to regain the ability that they have lost from the stroke, and then once they improve to a point of self-care, they can then be transitioned to an independent living facility (Smith, Kulhari, Wolfram, & Furlan, 2017). Ultimately this bridge program is a plan in place for that patient, but the ultimate goal is to restore all of the patient’s functions and send them back to their prior living arrangement (Smith, Kulhari, Wolfram, & Furlan, 2017).

References:

Alina Health (n.d.). Guidelines for Admission to the Acute Inpatient Rehabilitation Units at Abbot Northwestern and United Hospitals. AlinaHealth. Retrieved from [PDF]: 

https://www.allinahealth.org/-/media/allina-health/files/uploadedfiles/ckri-inpatient-guidelines

Differences Between LTACHs, IRFs and SNFs (2021). Post Acute Medical. Retrieved from: 

https://postacutemedical.com/company/company-updates/differences-between-ltachs-irfs-and-snfs

Matthews, B., & Daigle, J. (2020). Connecting the dots between caregiver expectations and perceptions during the hospice care continuum: Lessons for interdisciplinary teams. International Journal of Healthcare Management, 13, 120–132. 

https://doi-org.lopes.idm.oclc.org/10.1080/20479700.2018.1453575

Smith, A. L., Kulhari, A., Wolfram, J. A., & Furlan, A. (2017). Impact of Insurance Precertification on Discharge of Stroke Patients to Acute Rehabilitation or Skilled Nursing Facility. Journal of Stroke and Cerebrovascular Diseases, 26(4), 711–716. 

https://doi-org.lopes.idm.oclc.org/10.1016/j.jstrokecerebrovasdis.2015.12.037

Q-2

Inpatient rehabilitation is an acute rehabilitation facility that is intended for patients that require intense multidisciplinary rehabilitation (Ang & Dave, 2017, p. 463). Patients should have one of the following diagnosis based on Medicare Inpatient Rehabilitation Facility: stroke, spinal cord injury, amputation, congenital deformity, major multiple traumas, femur fracture, brain injury, neurological disorders, active polyarticular rheumatoid arthritis, systemic vasculitides with joint inflammation, severe or advanced osteoarthritis, hip or joint replacement to qualify for the rehabilitation (Ang & Dave, 2017, p. 466). Patients should need rehabilitation and should tolerate an average of 3 hours of therapy per day at least five days a week with a minimum of two disciplines such as physical therapy, occupational therapy, and speech therapy.

A patient should go to a skilled nursing facility if the patient requires a continuity of care that is typically started before discharge from the hospital. A patient should be seen by a nurse practitioner or a doctor at least one to two times per week, nursing needs of at least three to four hours per day with the therapy of at least zero to one and half hour per day (Ang & Dave, 2017, p. 465).

Hospice care is a facility that caters to the patient who has reached a terminal phase of life with an expected prognosis of fewer than six months (p. 466). It helps in decreasing the uncomfortable physical symptoms such as pain, dyspnea, constipation, nausea, and excessive mucus production. It can be done at home or in a facility in a non-resource patient. According to Medicare.gov (n.d.), patients who agree to hospice care means that they are agreeing for comfort care instead of cure to their illness (Medicare.gov, n.d.). Pain relief medication, symptom management, durable medical equipment, aide, homemaker services, spiritual and grief counseling for the patient and their families are free.

The long-term care facility is an area wherein the patient requires medically intense care and the care is handled by the hospitalists. The long-term care facility only receives a full Medicare payment rate if: the patient has spent at least three days in an intensive care unit and the patient remains on a ventilator in the long-term care hospital for at least 96 hours (Ang & Dave, 2017, p. 465). Patients who have complex comorbidities not requiring ICU or ventilator at the LCTH, those who have complex psychosocial factors impending discharge, those who have complex wound care that requires extensive dressings and those who are new oncology patient that evolves chemotherapy and radiation plan that requires numerous outpatient care or labwork does not qualify for full payment in a long term care hospital setting.

I started working as a nurse a few years back in the skilled nursing facility, then transfer to a long-term care facility, did a prn job at an inpatient rehabilitation facility. So far, my favorite job is working in an inpatient rehabilitation facility. It is because the majority of my patient is awake, alert, can follow commands and pretty much independent that they require physical therapy or occupational therapy. It is always a joy to see my patient recovers and go home. I enjoyed every minute that I can communicate and help my patient as they transition from the hospital to home.

References:

Ang, E. & Dave, J.K. (2017). Postacute care rehabilitation options. S.C. Mckean, J.J. Ross, Dressler, D.D. & Scheurer, D.B. Principles and practice of hospital medicine (2nd edition) (p. 463- 468). Mcgrawhill education

Medicare. Gov (n.d.). Hospice Care Coverage. Retrieved from https://www.medicare.gov/coverage/hospice-care

Q-3

Malnutrition is described by the American Society for Parenteral and Enteral Nutrition that requires two of the following attributes such as insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, diminished functional status (Farris & Mattison, 2017, p. 1346). It is commonly seen in hospitalized patients over 65 years old with 40 % of the patients are estimated to be malnourished (Farris & Mattison, 2017, p. 1346). Patients who have malnutrition should be worked up for complete blood count, metabolic panel, thyroid function, vitamin B12, iron, thiamine, liver biochemical, and functional tests.

A patient who has malnutrition is often checked for albumin and pre albumin levels. The normal albumin level is 4 to 6 g/dL (Ferri, 2019, p. 139). Patients who have elevated albumin may be at risk for dehydration and intravenous albumin infusion. Patients who have a decreased albumin level may have liver disease, nephrotic syndrome, poor nutritional status, rapid intravenous hydration, protein-losing enteropathies, severe burns, neoplasia, chronic inflammatory disease, pregnancy, prolonged immobilization, lymphomas, hypervitaminosis A and chronic glomerulonephritis. According to Jensen (2018), albumin lacks sensitivity and specificity of malnutrition but can be a potential risk indicator for morbidity and mortality (Jensen, 2018, p. 2322).

One treatment or modality that helps promotes wound healing is the application of dressings in the wound. There are two types of dressing that we can apply in geriatric patients or patients with wounds. It can be semi-occlusive or occlusive dressings. The semi-occlusive dressings are semipermeable gases such as O2, CO2, and moisture. These are the dressings that provide a moist wound healing environment and are considered impermeable to liquids and increase the chance of wound healing (Robinson,2017, p. 1173). On the other hand, occlusive dressings are the ones that lack the permeability to gases and liquids.

References:

Farris, G. & Mattison, M. (2017). Malnutrition and weight loss in hospitalized older adults. S.C. Mckean, J.J. Ross, Dressler, D.D. & Scheurer, D.B. Principles and practice of hospital medicine (2nd edition) (p. 1346- 1349). Mcgrawhill education

Ferri, F.F. (2019). Ferri’s Best Test. A practical guide to clinical laboratory medicine and diagnostic imaging. Elsevier.

Jensen, G.L. (2018). Malnutrition and Nutritional Assessment. J.L. Jameson, D.L. Kasper, D.L. Longo, A.S. Fauci, S.L. Hauser, J. Loscalzo (Eds). Harrison’s principles of internal medicine (20th ed., Volume2) (p. 2319-2323). Library of Congress Cataloging- in Publication Data.

Robinson, M.V. (2017). Cleaning, irrigating, culturing and dressing an open wound. AACN Procedure Manual for High Acuity, Progressive and Critical Care. D.L., Wiegand (7th edition). Elsevier.

Discussion Replies Week 2

Name of Student

Course Title & Course Code

Institute Name (Department + Affiliation)

Instructor Name

Date

Q-1

Sepsis characterized by unresponsive hypotension and lactic acidosis (serum lactate >2 mmol/L) requiring vasopressor therapy to maintain MAP> 65 mmm of Hg despite adequate fluid resuscitation. It is a condition of infection with acute organ dysfunction which is associated with high mortality, long term morbidity for those who survive. Approximately 19 million people develop sepsis every year and only 14 million survives to hospital discharge with varying prognosis (Prescott, & Angus, 2018). The survival depends on pre-sepsis health status, the severity of acute sepsis episode, quality of hospital treatments. The resuscitation and management initiated immediately within 1 hour. The interventions were measuring lactate level, re-measuring if initial lactate is >2 mmol/L, obtain cultures prior to administration of antibiotics, administer broad-spectrum antibiotics, begin rapid administration of 30 ml/kg crystalloids for hypotension or lactate >4 and apply vasopressors if the patient is hypotensive during and after fluid resuscitation to maintain MAP>65 (Levy, Evans, & Rhodes, 2018). Sequential Organ Failure Assessment (SOFA) score equal to or > 2 points are the diagnostic criteria.

SIRS-Systemic inflammatory response syndrome is a condition of the excessive inflammatory response of the body to an infectious or non-infectious process such as burns, pancreatitis, autoimmune disorders, ischemia, and trauma. The diagnostic criteria based on the presence of two out of five categories which were temperature above 100.4 or below 98.6, Heart rate over 90 beats per minute, resp. rate over 20, PaCO2 less than 32 mmHg, WBC over 12000 or less than 4000.

Severe sepsis/ septic shock- Severe sepsis is a condition of prolonged sepsis leading to multi-organ failure. The patient will be presented with positive signs and symptoms of septic shock which are persistent hypotension even after fluid resuscitation and while being on vasopressors with signs of poor perfusion such as low urinary output, cold/clammy/cyanotic extremities/digits, and altered mental status.

The sepsis protocol used in the Ascension facility (Ascension library services, 2021), is based on recognizing the signs and symptoms using the tools and automated EHR alerting the staff for screening the patients and use clinical judgments and notify MD for concern of sepsis even if the screening tool is negative. The criteria were any hypotension with MAP <65 mm of Hg, SBP <90, or decrease > 40 mm of Hg. Our hospital follows a 3-hour bundle goal which is measuring serum lactate, draw blood cultures prior to antibiotics administration, and starting of broad-spectrum antibiotics within 1 hour if possible, at least within 3 hours, and fluid replacement for any hypotension or lactate >4 with 30 ml/kg of crystalloids. 6-hour bundle includes re-measuring lactate if initial lactate elevated >2 mmol/L, starting of vasopressors for persistent hypotension, and reassess for volume status by CVP, ScvO2, and fluid challenge assessment. ICU required for patients requiring vasopressors and consider ICU placement for sepsis patients with lactate >4 mmol/L upon presentation and CVP or ScvO2 if appropriate catheter present.

The initiation of the sepsis bundle is central to the implementation of the Surviving Sepsis Campaign (SSC) 2016 guidelines are intended to be initiated within 1 hour of recognizing sepsis leads to improved sepsis survival. The new approach in the treatment of sepsis treatment is the revision of the SSC is that the 3-h and 6-h bundles have been combined into a “single hour-1 bundle” with the intention of beginning resuscitation and management immediately (Levy, Evans, & Rhodes, 2018).

References

Prescott, H. C., & Angus, D. C. (2018). Enhancing recovery from sepsis: A review. Jama, 319(1), 62-75. Retrieved from https://jamanetwork.com/journals/jama/article-abstract/2667727

Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The surviving sepsis campaign bundle: 2018 update. Intensive care medicine, 44(6), 925-928. Retrieved from https://link.springer.com/article/10.1007/s00134-018-5085-0

Ascension library services. (Updated on 2/9/2021). Nursing point-of-care tools: Sepsis. Retrieved from https://ascension-wi.libguides.com/c.php?g=814937&p=6592174

Reply 1

Septic shock or sepsis-3 is an advanced stage of sepsis that presents severe symptoms. Its criteria include hypotension, organ failure, & lactic acidosis. Perfusion-related problems cause an increased level of lactate (>2 mmol/L) and decreased blood pressure instead of fluid resuscitation(Doshi et al., 2018).

Hypotension

can damage the organs and lead to death. So, sepsis-3 could be fatal. Vasopressors are given as first-line treatment to manage sepsis-3(Shi, Hamzaoui, De Vita, Monnet, & Teboul, 2020). The blood vessels tighten up by initiating vasopressin therapy. As a result, the blood pressure increases.

I support your opinion; SOFA score = or > 2 diagnoses is sepsis-3. I strongly agree the increased heart rate, respiration rate, hypothermia, and leukocytosis are the diagnostic criteria for SIRS. The patients presenting symptoms of sepsis-3, like low urinary output (due to low BP) and mental retardation, may follow the diagnostic procedures. Blood cultured test with antibiotic administration & the serum lactate levels is checked. High lactate levels (>4 mmol/L) shifts the patient to ICU. Timely management of sepsis-3 may save lives, according to Surviving Sepsis Campaign (SSC). Additionally, if vasopressin therapy remains ineffective, epinephrine is given with it as a second-line treatment in sepsis-3.

References

Doshi, P. B., Park, A. Y., Banuelos, R. C., Akkanti, B. H., Darger, B. F., Macaluso, A., . . . Chambers, K. A. (2018). The Incidence and Outcome Differences in Severe Sepsis with and without Lactic Acidosis. Journal of emergencies, trauma, and shock, 11(3), 165-169. doi:10.4103/JETS.JETS_102_17

Shi, R., Hamzaoui, O., De Vita, N., Monnet, X., & Teboul, J.-L. (2020). Vasopressors in septic shock: which, when, and how much? Annals of translational medicine, 8(12), 794-794. doi:10.21037/atm.2020.04.24

Q-2

Sepsis

This is a condition that is potentially life-threatening that usual occurs when the body or the immune system declines or fails to act on the invading pathogen. The body is overwhelmed by the invading agent and is unable to mount an adequate response therefore leading to disseminated spread of the infection throughout the body. The criteria for diagnosing sepsis required the presence of an ongoing infection plus 2 or more of the following:

Hypotension

Defined as SBP <90mmHG

<70mmHg MAP

Increased lactate levels

Defined as > 1 mmol/L

Mottled skin

Decreased capillary refill

Febrile of >38 degrees C

And

Tachypnea

Increased in heart rate and respiratory rate

Alterations in mental status

Increased WBC count

Increased in CRP levels

Increased procalcitonin levels

Decreased paO2

With significant hypoxemia

Decreased in urine output

Defined as <0.5ml/kg/hr. for at least 2 hours despite administration of fluid resuscitation

Decreased platelet count (Evans, 2018)

Severe sepsis

This is a continuation of sepsis that is complicated by the onset of an organ failure. Criteria for diagnosing severe sepsis requires the following criteria:

Hypoperfusion exemplified by renal failure

Organ dysfunction

At least one organ involved

Fever

Decreased mean arterial pressure (MAP)

Defined as <60mmHg

Increased in creatinine levels

Alterations in mental status

Abnormal coagulation studies

Abnormal PT/APTT or thrombin time results

Increased bilirubin (>2.0mg/dl) (Evans, 2018)

SIRS

Defined as systemic inflammatory response to infection may it be suspected or confirmed by clinical evaluation. Criteria of SIRS are the presence of at least 2 of the following:

Fever of >38 degrees Celsius

Hypothermia of <36 degrees Celsius

Tachycardia

Tachypnea

Increased WBC count (Evan, 2018)

Septic shock

This is the consequence of an untreated or unsuccessfully treated sepsis that leads to circulatory collapse exemplified by a significant drop in blood pressure levels. Criteria for diagnosis include the persistence of the following despite adequate fluid resuscitation:

Hypotension

Decreased MAP

Increased lactate levels (Evans, 2018)

For the current hospital protocol regarding positive severe sepsis and/or septic shock assessments, the RN will immediately initiate an electronic order for lactate level and the RN will administer antibiotic(s) and/or IV fluids as ordered by the physician. Administration of the antibiotic(s) and fluids must be documented in the patient’s medication administration record. Blood cultures should be drawn prior to administration of antibiotics and documentation should reflect blood culture collection (Dellinger & Levy, 2018).

Approaches to severe sepsis and septic shock continue to evolve with strategies put forward and discarded regularly. The focus for sepsis shock is now on timely fluid resuscitation, antibiotics, and, if necessary, vasopressor agents. However, the Holy Grail seems to have always been to intervene in the inflammatory cascade, shutting down what is often a deleterious set of forces that contribute to death. Complicating factors have been that sepsis is such a heterogeneous condition, not only in the infectious causes but in the host immune responses. However, despite some initial successes, there was never enough convincing data to suggest sufficient bang for the buck with respect to mortality reduction. Nevertheless, trial continue including high-dose vitamin C, employed with corticosteroids and thiamine in sepsis, and it appears preliminarily to show benefit (Singer & Sepsis Definitions Task Force, 2016).

References

Dellinger, R.P. & Levy M., (2018). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: Critical Care Medicine (36) 1394-1396. Retrieved from http//:CritCareMed2018.org/39874

Evans T. (2018). Diagnosis and management of sepsis. Clinical medicine (London, England), 18(2), 146–149. https://doi.org/10.7861/clinmedicine.18-2-146

Singer, M., & Sepsis Definitions Task Force (2016). Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 775–787. https://doi.org/10.1001/jama.2016.0289

Reply 2

The presence of an infection within the body initiates a cascade of reactions. The body does not show a potent immune response because of pathogens. This is the first stage of sepsis. This leads to a life-threatening state. I strongly agree with sepsis’s diagnostic criteria as hypotension, elevated heart and respiratory rate, lactic acidosis, and tachypnea. Some conditions are secondary to these conditions, such as hypotension cause low urinary output. Like other organs, hypotension cause dysfunction of the CNS. The deterioration in CNS results in mental retardation (Czempik, Pluta, & Krzych, 2020). Platelet count is decreased due to invading pathogens. Organ damage may cause hypoxemia. Organ damage is the characterization of second-stage (or severe) sepsis. The diagnostic criteria are different in this stage.

I support your criteria; organ damage results in perfusion abnormality and high creatinine levels in case of kidney failure (Peerapornratana, Manrique-Caballero, Gómez, & Kellum, 2019) abnormal PT/APTT, coagulation, and anti-coagulation (thrombin) studies.

In my opinion, liver damage causes hyperbilirubinemia. The body shows a systematic inflammatory response to infection. The criteria to assess SIRS are hypothermia, tachycardia, and high WBCs count. If sepsis is not treated, it develops an acute stage septic shock. The diagnosis is made by blood cultures, clinical presentation, and blood tests. Studies are conducted to reduce septic mortality.

References

Czempik, P. F., Pluta, M. P., & Krzych, Ł. J. (2020). Sepsis-Associated Brain Dysfunction: A Review of Current Literature. International journal of environmental research and public health, 17(16), 5852. doi:10.3390/ijerph17165852

Peerapornratana, S., Manrique-Caballero, C. L., Gómez, H., & Kellum, J. A. (2019). Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney international, 96(5), 1083-1099. doi:10.1016/j.kint.2019.05.026

Q-3

Sepsis, SIRS, Severe Sepsis, and Septic Shock are all related to one another and can appear in a patient at any stage. The first, SIRS, or systemic inflammatory response syndrome (SIRS) which is defined as an exaggerated defense response of the body to an external stressor like infection by dysregulation of pro and anti-inflammatory pathway occurring at the same time (Chakraborty, & Burns, 2020). In this scenario, we can say that an infection has triggered SIRS, and then it’s a ladder approach into the subsequent definitions. Sepsis has been defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (Vucelic et al., 2020). Severe sepsis builds on the sepsis definition and adds that it has now gotten to the point where there is now tissue or organ hypoperfusion and subsequent ischemic damage (Vucelic et al., 2020). The final step, septic shock, is the most severe form of sepsis and occurs when hypoperfusion and ischemic damage is so great that it causes systemic hypotension by compromising the circulatory and metabolic homeostatic processes (Mahapatra& Heffner, 2020).

My current clinical sepsis protocol is pretty standard, it starts with recognizing and identifying a possible sepsis patient, and then it moves to determine what stage they are in. Is it SIRS, Sepsis, Septic Shock, or Severe Sepsis? We begin by assessing the patient’s vital signs, and most of the time they are hypotensive at this point. We then start with fluid resuscitation with 0.9% NS, a full blood panel including blood cultures, and then subsequent broad-spectrum antibiotics to cover a wide variety of possible infectious diseases. Then depending on if the patient needs vasopressors or even a ventilator, will eventually determine where the patient will be admitted to.

One new approach to sepsis management is based on the question how much fluid do we give, or is the patient even a fluid responder? This brings about new light to the subject as there are people who can be fluid responders or non-fluid responders which can only be aided by vasopressors (Krige, Bland, &Fanshawe, 2016). While this idea has been around for a little while, how to measure it has been in the spotlight more recently, with devices such as utilizing ECHOs or TEEs (Krige, Bland, &Fanshawe, 2016). While the passive leg raise can provide 150-300 mL of blood to the thoracic component of the body, it will also show an increase in cardiac output due to an increase in preload, subsequently raising afterload and overall blood pressure (Krige, Bland, &Fanshawe, 2016). While measuring this with an ECHO or TEEs we are looking for ventricular variability, whereas greater than 4% indicates dehydration and the ability to accept more fluid, and up to greater than 12% which indicates the need for massive fluid resuscitation (Krige, Bland, &Fanshawe, 2016). In addition to maintaining blood pressure and blood flow, we also want to make sure that the output is balanced as well, in order to prevent fluid volume overload, but this is unlikely if a patient is in full-blown septic shock (Krige, Bland, &Fanshawe, 2016).

References

Chakraborty, R.K., Burns B. (2020). Systemic Inflammatory Response Syndrome. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK547669/

Krige, A., Bland, M., &Fanshawe, T. (2016). Fluid responsiveness prediction using VigileoFloTrac measured cardiac output changes during passive leg raise test. Journal of Intensive Care, 4(1). https://doi-org.lopes.idm.oclc.org/10.1186/s40560-016-0188-6

Mahapatra, S., Heffner, A.C. (2020) Septic Shock. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK430939/

Vucelić, V., Klobučar, I., Đuras-Cuculić, B., GverićGrginić, A., Prohaska-Potočnik, C., Jajić, I., Vučičević, Ž., &Degoricija, V. (2020). Sepsis and septic shock – an observational study of the incidence, management, and mortality predictors in a medical intensive care unit. Croatian Medical Journal, 61(5), 429–439.

Reply 3

Patients are immunocompromised; they can develop sepsis at any stage. The sepsis, if remains untreated, leads to severe sepsis and septic shock. An inflammatory response elicited by the body against pathogens causes systematic inflammatory response syndrome (SIRS). I agree with your point, the immune system first induces a pro-inflammatory response, an anti-inflammatory response then follows it. It is correct to say that infections lead to SIRS(Ye-Ting & Dao-Ming, 2018). The impaired immune response is the major cause of sepsis that results in organ dysfunction. The organ dysfunctioning contributes to organ hypoperfusion in the next stage of sepsis i.e. severe sepsis.

In my opinion, sepsis becomes severe sepsis if treatment is not initiated at the time. The third stage, sepsis, is the advanced and most severe stage. It is called septic shock. The severity of sepsis leads to metabolic and homeostatic fluctuations resulting in hypotension and accumulation of lactic acid. You are right sepsis diagnostic protocol begins with assessing the possible etiology of infection. Vital signs like hypotension help in the evaluation of the stage of sepsis(Hébert, Boucher, Guimont, & Weiss, 2017). Broad-spectrum antibiotics are helpful in blood culturing. The measurement of fluid is a novel approach.The cardiac output increased in fluid-responders measured with ECHO. Balance cardiac output indicates optimal blood pressure & blood flow.

References

Hébert, A., Boucher, M.-P., Guimont, C., & Weiss, M. (2017). Effect of measuring vital signs on recognition and treatment of septic children. Paediatrics & child health, 22(1), 13-16. doi:10.1093/pch/pxw003

Ye-Ting, Z., & Dao-Ming, T. (2018). Systemic Inflammatory Response Syndrome (SIRS) and the Pattern and Risk of Sepsis Following Gastrointestinal Perforation. Medical science monitor : international medical journal of experimental and clinical research, 24, 3888-3894. doi:10.12659/MSM.907922

Q-1

Opioid dependence must be identified when patients come in for medication reviews or by a drug search. It is reasonable to assume a patient who has been on the maximum or exceeded the maximum recommended dose of an opioid analgesic continuously should be assessed further. A patient assessment can be carried out by any of the practice clinical staff: GPs, advanced nurse practitioners, mental health practitioners, clinical pharmacists, and practice nurses with relatively little additional training. However many providers do not feel confident, trained, or experienced in managing drug dependence. Opioid dependence is suggested by the factors such as overt drug-seeking behavior, lost or misplaced prescriptions, frequent requests for additional medication, use of additional over-the-counter medication, requests for medication for out-of-hours medical services, walk-in centers, or other surgeries and a previous history of drug or alcohol dependence (Becker & Liebschutz, 2018). Thus my response would be to ask how often is he taking his OxyContin, review the prescribed dosage, emphasis how long the prescription should last him, and ask how history of previous addiction. I would then offer non-narcotic alternatives, assist to find alternative ways to cope with chronic pain and stress which may be contributing to his pain and refer to pain clinic if needed.

Becker, W. C., & Liebschutz, J. M. (2018). Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study. Journal of general internal medicine, 33(2), 166–176.

https://doi.org/10.1007/s11606-017-4211-y

Q-2

In this scenario, the patient’s appropriate treatment involved a multitude of therapies to appropriately treat the underlying cause (Azadfard, Heucker & Learming, 2020); (Wolfe, 2021); (Shah & Heucker, 2021). With this patient presentation I believe he is currently withdrawing from his recent abuse of opioids, and would need to have that addressed appropriately prior to entering a post-acute facility rehabilitation center (Azadfard, Heucker & Learming, 2020); (Wolfe, 2021); (Shah & Heucker, 2021). With this being said I would like to admit him to the hospital for investigation of his abdominal pain and withdrawl symptoms (Azadfard, Heucker & Learming, 2020); (Wolfe, 2021); (Shah & Heucker, 2021). I would also order Zofran 4mg IV Q6 PRN nausea, but also an EKG to check his QT prolongation due to his other home medications as well as combining it with methadone (Shah & Heucker, 2021). I would also want to order a non-contrast CT Scan of his abdomen due to his intractable abdominal pain as it may be an ileus due to the recent abuse of opiates (Beach & De Jesus, 2021).

I would like to consult Neurosurgery to see if there is anything they can provide from a surgical standpoint or treatment management. I would also like to consult psychiatry for the patient’s admittance of opioid addiction and abuse and an appropriate treatment plan (Azadfard, Heucker & Learming, 2020).

The patient’s signs and symptoms of nausea, vomiting, abdominal pain, intermittent piloerection and diaphoresis are some cardinal signs of opiate withdrawal (Shah & Heucker, 2021). The recommended treatment for this is to begin a weaning course with methadone beginning at 10mg dose every 4-6 hours and weaning it as tolerated (Shah & Heucker, 2021). In Florida, ACAGNP are able to prescribe Schedule II-IV as defined in Florida Statues, including methadone, however the drawback is that they can only be prescribed by an NP in the acute-care facility (Important Legislative Update regarding HB 423, 2016).

Since the patient has admitted to an addiction issue, as well as wanting help we still have to go through the normal process of reporting healthcare provider prescription abuse (Impaired Practitioner Programs, 2021). On the other hand, he admits to abusing his own prescriptions, but does not state when he uses and abuses such as being at work and unable to function. Ethically we should report him regardless as he is responsible for the safety of others as an ACNP. In Florida, there are impaired practitioners programs that help all ranges of providers get through this exact issue and should be provided to the patient (Impaired Practitioner Programs, 2021).

References:

Azadfard, M., Huecker, M.R., Leaming, J.M.(2020). Opioid Addiction. StatPearls Treasure Island StatPearls Publishing. Retrieved from: 

https://www.ncbi.nlm.nih.gov/books/NBK448203/

Beach, E.C., De Jesus, O. (2021). Ileus. StatPearls Treasure Island StatPearls Publishing. Retrieved from: 

https://www.ncbi.nlm.nih.gov/books/NBK558937/

Impaired Practitioner Programs. (2021). Florida Board of Health, Medical Quality Assurance. Retrieved from: 

https://flhealthsource.gov/board-members-impairment-programs

Important Legislative Update regarding HB 423. (2016). Florida Board of Nursing. Retrieved from: 

https://floridasnursing.gov/new-legislation-impacting-your-profession/

Wolfe, D. (2021). “Biotechnologies and the future of opioid addiction treatments”. The International journal of drug policy (0955-3959), 88 , 103041.

Shah, M., Huecker, M.R. (2021) Opioid Withdrawal. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK526012/

Q-3

Ethically and professionally, what are your concerns for this patient and his own ACNP practice? What resources are available to you as a prescriber to track this patient’s opioid use/abuse? What resources are available to a provider of medical care who suffers from addiction?

Substance abuse by medical professionals raises many concerns, including significant legal consequences and threats to patient care. This patient is at high risk for making procedural errors, wrong diagnoses, and prescribing improper medications. The chance of going through withdrawal also makes him a threat to his patient’s safety. Bartlett et al. (2017) explain that healthcare professionals who use opioids are at a significantly higher risk of relapse than the general population, requiring more intensive post-treatment monitoring and continuing care recovery plans.

Like most states, New Mexico requires reporting health practitioners suspected of impairment. I would have an ethical, moral, and legal duty to identify and report a fellow healthcare worker who is impaired and risking patient safety. Luckily there are many helpful resources such as state-run professional associations that assist professionals who have substance abuse problems. The New Mexico Health Professional Wellness Program for instance provides a number of services including substance use issues as well as medical, psychiatric, emotional, or situational stresses. Other resources include the International Doctors in Alcoholics Anonymous, New Mexico Medical Board, and NM Medical Society (New Mexico state board of nursing, 2019).

Bartlett, R., Brown, L., Shattell, M., Wright, T., & Lewallen, L. (2017). Harm reduction: compassionate care of persons with addictions. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses, 22(6), 349–358.

D’Souza, R. S., Lang, M., & Eldrige, J. S. (2020). Prescription Drug Monitoring Program. In StatPearls. StatPearls Publishing.

Marie, B. S., Sahker, E., & Arndt, S. (2015). Referrals and Treatment Completion for Prescription Opioid Admissions: Five Years of National Data. Journal of substance abuse treatment, 59, 109–114. https://doi.org/10.1016/j.jsat.2015.07.010

New Mexico state board of nursing. (2019). Retrieved March 25, 2021, from https://www.nmsbon.gov/discipline-and-complaints/alternative-to-discipline