Nursing Journal

Introduction 

When elements in a system have a common goal then it is easier for the system to meet its objectives, improve its operations and be innovative. The new thing I have learned in this article is that value should always be measured around the customer, output, instead of input. Initially, I believed that value is determined by the inputs like the availability of equipment and qualification and experience of the healthcare providers because this determines the quality and cost of services patients receive. Since inputs in a system determine the outputs of the same system, it is new to me that value in healthcare should be measured based on the outcomes. 

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The three-tiered hierarchy whereby in the first tier, survival and the degree of health or recovery are dependent on each other. Also in the second tier, process of recovery, I agree that the time of recovery and treatment process also depend on each other. Moreover, in the third tier (sustainability of health) it is true that sustainability of health and long-term consequence of health depend on each other. However, I disagree with the fact that value in healthcare should always be measured based on customer or outcomes. This is because in the article it is stated that patients’ needs are determined by patients’ conditions. For instance, the care of diabetes should integrate the care for vascular disease, renal disease, hypertension, and retinal disease. According to my understanding, integration of these cares can only be achieved by qualified and experienced healthcare service providers and availability of relevant equipment to monitor the condition. 

Week 8 Part one- reflection on Stevens-Johnson syndrome (SJS) geriatric patient

Stevens-Johnson syndrome (SJS) is a rare but a serious disease that leads to blistering and peeling off of skin and affects mucous membrane too. The occurs can occur because of the medicines that ne has taken. Also, blisters can form in the internal body parts leading to difficulty to pee, eat, and swallow. As a result, to protect body organs from a lasting damage, it is important to get treatment immediately. The conditions begin with symptoms like those of flu followed by blisters and red or purple-like rash that spreads. The top layer of the affected skin area dies and pills off as a result. SJS is a medical emergency that requires immediate hospitalization (Burr, 2012). The symptoms of SJS several days before development of rushes include coughs, fever, burning eyes, fatigue, and sore mouth and throat. Given the fact that SJS is an unpredictable and rare condition, it is hard for doctors to identify its real cause but infection and medication usually trigger the condition. Medical reaction can start two weeks after or during the usage of medication. Some of the drugs that cause SJS include infection medications like penicillin; pain relievers like cetaminophen (Tylenol); naproxen sodium (Aleve), and ibuprofen (Advil and Motrin IB); anti-gout medication like allopurinol; and mental illness and seizure medications like anticonvulsants and antipsychotics with increased risks when a patient goes for radiation therapy. Other than the therapy and medication causes, SJS result from infectious causes like Hepatitis A, HIV, Herpes and Pneumonia. 

There are different factors that increase the risks of people developing SJS. First, people with HIV infection exhibit 100 times more chances of developing SJS than the general population. A weakened immune system which may be caused by autoimmune disease, organ transplants, and HHIV/AIDS also increases the chances of developing SJS. besides, people with a history of the diseases stand high chances of reoccurrence of the disease (Nizamoglu et al., 2018). Likewise, a historical background like family history of SJS related symptoms makes individuals more susceptible to developing the disease. Lastly, people with HLA-B 1502 have increased chances of developing SJS especially when takes drugs for mental illness, seizures, and gout. Families of Indian, southeast Asian, and Chinese also have increased chances of developing SJS. 

Just like any other disease, people can prevent themselves from developing SJS. The first step to prevention is to consider genetic testing before getting a prescription of certain drugs. For instance, families from Indian, southeast Asian, and Chinese decent should talk to their doctors before carbamazepine (Carbatrol, Tegretol) prescription. This drugs are used in the treatment of bipolar disorders and epilepsy among other conditions but people with HLA-B*1502 gene have increased chances of developing SJS when they use this drug (Burr, 2012). Other than genetic prevention, it is important to avoid medications that trigger the development of SJS if one’s doctor says that it cause is medication. As a result, one can be in a better position to prevent the reoccurrence of the condition which is considered worse that the first occurrence. Also, family members of the individuals should consider avoiding such drugs because family history of SJS can work against them. 

Case study 

In my practicum site, I did not encounter a geriatric patient with SJS syndrome. However, a critical case study that is worth sharing is that of a medication reaction that cause SJS and death in an elderly patient (Nizamoglu et al., 2018). The 86-year-old was a resident of a nursing home and had a medical history of arteriosclerotic heart disease, diabetes, hypertension, cerebral vascular accident, hydronephrosis, and inability to swallow requiring placement of a gastronomy tube. Within a span of three to four months, the patient was between the nursing home a hospital for recurrent UTI infection and later readmitted in the hospital for scrotal cellulitis and urosepsis (Burr, 2012). During an assessment, a nurse discovered rashes on the lags and the back of the patient. As a result, the infectious disease physician ordered the patient be administered with imipenem and cilastatin with a belief that E-Coli and other dangerous organisms were the cause of the infection. The following day the infectious disease physician was notified that the patient had developed new rushes on his chest and hands, a sign that the administered imipenem and cilastatin were the cause of the rushes. As a result, the physician treated the rushes with diphenhydramine whereas the administration of imipenem and cilastatin continued (Morah, 2018). After a week, vancomycin was added to the man’s regimen to treat right scrotal drainage consistent with an abscess. During the surgery, the man’s right tactical was removed on the basis of gangrenous scrotal tissue even though the pathologist did not confirm the presence of the tissue. 

After a week, steroids were administered and vancomycin was stopped and an improvement in the spread of the rash was noted. The man was transferred back to the nursing home where assessment reveled presence of dry red rashes on his back, legs, and chest. After few days, nurses noted additional formation of rushes and blisters and he was transferred back to the hospital and after ten days the man died (Morah, 2018). As a result, the man’s estate settled with the hospital before filing a suit against the infectious disease physician and attending physician on the grounds that they failed to monitor and treat the man’s scrotal cellulitis which lead to abscess surgery (Nizamoglu et al., 2018). The suit also stated that the physicians failed to monitor complications associated with imipenem and cilastatin which in turn cause SJS. Consequently, all the factors showed that the plaintiff had a substantial contribution to the death of the man and the verdict was returned against the two physicians. 

Effectiveness of patient care

From the case, it is evident that the patient care plan was poor. The evidence that During the surgery, the man’s right tactical was removed on the basis of gangrenous scrotal tissue even though the pathologist did not confirm the presence of the tissue is a sign that there lacked proper plan in the treatment (Morah, 2018). Also, the man developed rushes but he was not tested to determine the origin, cause, and why the rashes were occurring. If the he was properly tested, the man could have been diagnosed with SJS and his condition managed through withdrawal of the imipenem and cilastatin drugs that were the major cause of SJS. As a result, the man died as a failure of proper diagnostic, management, and treatment of medical conditions that he was undergoing.

References

Burr, S. (2012). Identifying common lesions and rashes in the elderly. Nursing & Residential Care, 14(5), 239-242. Retrieved from: https://eds-b-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=1&sid=91c1d896-3464-4fab-ad94-575d30971048%40sessionmgr102.

Morah, R. (2018). Application- Diagnosing and Treating Skin Wounds. Retrieved from: https://class.waldenu.edu/webapps/assignment/uploadAssignment?content_id=_46930341_1&course_id=_16409938_1&group_id=&mode=view.

Nizamoglu, M., Ward, J. A., Frew, Q., Gerrish, H., Martin, N., Shaw, A., Barnes, D., … Dziewulski, P. (2018). Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience. (Burns.)

Ma, L., Du, X., Dong, Y., Peng, L., Han, X., Lyu, J., & Bai, H. (2018). First case of Stevens-Johnson syndrome after rabies vaccination. (British journal of clinical pharmacology.)

Marta, V., Cecilia, M., Natalia, G., Andrea, R., Pietro, F., Antonella, C., & Carlos, A. (August 29, 2018). Lamotrigine-Valproic Acid Interaction Leading to Stevens–Johnson Syndrome. Case Reports in Medicine, 2018.

Rajesh Kumar, Anupam Das, & Sudip Das. (January 01, 2018). Management of stevens-johnson syndrome-toxic epidermal necrolysis: Looking beyond guidelines!. Indian Journal of Dermatology, 63, 2, 117-124.

Part 2: reflection on a patient with end stage renal disease decision whether to be on dialysis or not

    Population across the world is aging and diseases like systemic arterial hypertension and diabetes mellitus are increasing the risk of patients developing chronic kidney disease thus increasing the prevalence of patients on dialysis. The increased health services ion the process has ensured that health services is expanded to reach more patients which in turn has increased dialysis survival. Patients on dialysis are continuing to grow with greater and older comorbidities. Despite the fact that dialysis is meant to ensure hydro electrolytic and metabolic balance, it is associated with improvement in quality of life for majority patients. Thus, the importance of observing patients against their individual dialysis treatment is paramount. The investigation means reflections on maintaining, initiating, and discontinuing treatment. As a result, the healthcare service providers in this stage should have proper understanding of multidisciplinary approach involved in caring for dialysis patients so that patients and their relatives are handled in a humanitarian and ethical way. Patients with end stage renal diseases cause conflict between multidisciplinary team and between legal surrogates, caregivers, and family on whether to conduct dialysis or not. 

Inappropriate polypharmacy and adhering to medication in older adults is a very significant health challenge to the public today. The burden is bound to increase with the increase in the ageing population and many people suffering from multiple long term diseases. As a result, there are no evidence-based solutions, since healthcare delivery models and medical researches direct their focus towards intervening for disease separately leading to polypharmacy (Alsyouf & Ishak, 2018). Due to single disease intervention and limited solutions range, there is a need for healthcare resources to address polypharmacy this challenge as unhealthy and burdensome. Recent research on polypharmacy found out that more than 11% of unplanned patient admission is because of medicinal harm and more than 70% of the admissions are older adults on multiple medicines (Finkelstein et al., 2016). Managing polypharmacy could save about 0.3% of the entire global health expenses. 

The need to manage polypharmacy has led to the recommendation of using risk stratification. It identifies patients who are vulnerable to polypharmacy besides being a very collaborative role for physicians, pharmacists, and patients. Effective and timely interventions can also reduce adverse chances of polypharmacy. Therefore, this requires a proper understanding of polypharmacy to manage it effectively (Pisano & Beizer, 2018). For a physician, a pharmacist and any other health profession to help reduce polypharmacy, he or she must at least have general knowledge about polypharmacy. For example, they should be aware of the type of polypharmacy (Contratherapeutic Polypharmacy and Therapeutic Polypharmacy) and their role in when it comes to managing it, besides other basic things.

Tracking care improvement for in electronic health records requires proper information management, patient encounters, patient communication, appointment process, and medication management. Concerning information about appointment process, using Electronic Health Record to track times between patient appointment and availability of appointment to identify possible in efficiencies in scheduling in a health facility (DeVoe, et al., 2018). Discovering the inefficiency using Electronic Health Record can help quality improvement. 

Likewise, information about patient encounters in Electronic Health Record can help in improving care delivery. Electronic Health Record documents reasons for revisiting of chief complaints and generated reports that identify trend of communicable diseases (Klapman et al., 2017). Ones the trends are identified; registered nurses can use the information to manage various aspects of their practice. Moreover, Electronic Health Record documents problem list for patients and enforces appropriate review list documentation of changes in health status of patients, and acknowledgement of the physician. In addition, Electronic Health Records should have a method of storing patient and family health history (Alsyouf & Ishak, 2018). The system can use information entered into patient or family history to generate reminders and alerts of patient health to initiate creation of more comprehensive approach to patient care and develop preventive screening (DeVoe, et al., 2018). Besides, having patient education information in the Electronic Health Record can help registered nurse to determine the appropriate educational materials to give their patients. As a result, quality of healthcare delivery is improved. 

After analyzing audit data, the results are communicated in a positive way to the individuals present in practice. The communication process can be done in different forms. For example, providing personal result during a periodic performance review or presenting aggregate results in a meeting with all the staff. 

After analyzing and communicating the audit results, the step that follows is development and implementation of corrective action plan according to the understanding of the root of the problem (Klapman et al., 2017). The process involves the identification of best practices for the data comparison. Planning and implementation of corrective actions call for commitment and involvement from the entire team (Alsyouf & Ishak, 2018). Implementation of the corrective actions does not mark the end of the audit since there is a need to ensure consistent application of the changes and whether improvement occurs; thus, the importance of auditing after implementation.

References

Alsyouf, A., & Ishak, A. K. (2018). Understanding EHRs continuance intention to use from the perspectives of UTAUT: practice environment moderating effect and top management support as predictor variables. (International journal of electronic healthcare.)

DeVoe, J. E., Hoopes, M., Nelson, C. A., Cohen, D. J., Sumic, A., Hall, J., Angier, H., … Gold, R. (May 10, 2018). Electronic health record tools to assist with children’s insurance coverage: a mixed methods study. Bmc Health Services Research, 18, 1, 1-13.

Finkelstein J, Friedman C, Hripcsak G, & Cabrera M. (January 01, 2016). The potential utility of precision medicine for older adults with polypharmacy: a case series study. Pharmacogenomics and Personalized Medicine, 2016, 31-45.

Gray, S. L., Hart, L. A., Perera, S., Semla, T. P., Schmader, K. E., & Hanlon, J. T. (February 01, 2018). A meta-analysis of Interventions to Reduce Adverse Drug Reactions in Older Adults. Journal of the American Geriatrics Society, 66, 2, 282-288.Perrier, A., Escher, M., Dayer, P., Perneger, T. V., Rudaz, S., & Perrier, A. (n.d). Impact of Advance Directives and a Health Care Proxy on Doctors’ Decisions: A Randomized Trial. Journal of Pain and Symptom Management47(1), 1-11.

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