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Weekly Clinical Experience 7
Selvia Beshay
NUR-612CL-AP2
St. Thomas University
Dr. Nancy Woelki
Clinical Experience for this Week
This week, I encountered a variety of geriatric patients with diverse medical conditions and
was exposed to various aspects of healthcare. Since this was a community clinic, one of the
challenges I faced was the high influx of patients which required me to multitask and manage my
time more efficiently. However, this allowed me to enhance my adaptability and prioritization
skills.
Patient Assessment
During my assessments, I encountered a 74y/o male patient who presented with shortness of
breath, productive cough, and wheezing. Upon further examination of this patient, I observed
that they exhibited chest tightness and had an increased respiratory rate. The signs and
symptoms, observations, along with the patient’s medical history and physical exam results all
indicated bronchial asthma. The plan of care included interventions such as prescribing
bronchodilators like the short-acting beta-agonists, to relieve acute symptoms and prevent further
exacerbations. Further, an inhaled corticosteroid was prescribed to help reduce inflammation and
prevent future attacks. The patient was also educated on how to avoid triggers like irritants and
allergens, as well as the importance of proper inhalation techniques.
Possible Differential Diagnoses
The three possible differential diagnoses include;
1. Chronic Obstructive Pulmonary Disease (COPD): COPD is a common illness among
elderly patients and it shares some similarities with bronchial asthma such as
shortness of breath. However, COPD is usually associated with a history of smoking
and a more gradual onset of symptoms (Hopkinson et al., 2019).
2. Congestive Heart Failure (CHF): CHF symptoms such as wheezing and shortness of
breath are similar to asthma. In this case, a careful evaluation of the patient’s medical
history, physical exams, and diagnostic tests, can help differentiate CHF from other
similar conditions (Koshy et al., 2020).
3. Gastroesophageal Reflux Diseases (GERD): GERD is a disease with symptoms such
as a productive cough, wheezing, and chest tightness, which may be mistaken to be
asthma (Iwakiri et al., 2022). In this case, the patient’s evaluation of their symptoms,
including their meals and how they sleep, can help differentiate the conditions related
to GERD.
Health Promotion
Some of the strategies to promote the health and well-being of this patient would include;
first, the patient may use asthma self-management education and a medical approach, where the
patient will be educated on how to identify the disease, understand their triggers, proper
medication, and identifying the signs of worsening symptoms (Jia et al., 2020). Secondly, the
patient will be advised on the importance of engaging in regular physical activity, as this will
help improve lung function and the overall health of the patient. Thirdly, the patient will be
educated on maintaining a healthy diet and nutrition as this will help support the overall
respiratory health of the patient. Lastly, regular follow-up visits and monitoring are essential for
this patient to assess their asthma control, adjust medication where necessary, and address any
concerns and questions from the patient. Note that, monitoring of asthma is usually done through
objective measures such as peak flow monitoring.
What I Learned
Generally, this week’s clinical experience was enlightening and provided me with valuable
insights into geriatric patient care and other practices that will be beneficial to me as an advanced
practice nurse. I learned the importance of effective time management in a fast-paced clinical
setting, as well as the significance of building a rapport with the patients. Witnessing the impact
of the various interventions and treatments on the patient’s well-being reinforced my passion for
nursing. I also realized the need for constant learning and staying up-to-date with evidence-based
practices. Overall this clinical experience re-affirmed my commitment to providing
compassionate and competent care to patients.
References
Iwakiri, K., Fujiwara, Y., Manabe, N., Ihara, E., Kuribayashi, S., Akiyama, J., … & Koike, K. (2022).
Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2021. Journal of
Gastroenterology, 57(4), 267-285. https://doi.org/10.1007%2Fs00535-022-01861-z
Jia, X., Zhou, S., Luo, D., Zhao, X., Zhou, Y., & Cui, Y. M. (2020). Effect of pharmacist‐led
interventions on medication adherence and inhalation technique in adult patients with asthma or
COPD: A systematic review and meta‐analysis. Journal of Clinical Pharmacy and
Therapeutics, 45(5), 904-917. https://doi.org/10.1111/jcpt.13126
Hopkinson, N. S., Molyneux, A., Pink, J., & Harrisingh, M. C. (2019). Chronic obstructive
pulmonary disease: Diagnosis and management: Summary of updated NICE guidance. Bmj,
366. https://doi.org/10.1136/bmj.l4486
Koshy, A. O., Gallivan, E. R., McGinlay, M., Straw, S., Drozd, M., Toms, A. G., … & Witte, K. K.
(2020). Prioritizing symptom management in the treatment of chronic heart failure. ESC Heart
Failure, 7(5), 2193-2207. https://doi.org/10.1002/ehf2.12875
Module 7 Discussion
Emily Diaz
Dr. Woelki
St. Thomas University
NUR-612- AP1
October 3, 2023
Module 7 Discussion
Mrs. P. was diagnosed with acute bronchitis and was prescribed doxycycline, prednisone
15 mg, and tiotropium inhaler. Upon auscultation her lungs
were clear and there was no evidence of lower extremity edema. Due to this, the patient has no
need to continue to take the doxycycline, prednisone, or the
tiotropium inhaler. She also presented with no lower extremity edema, therefore, furosemide
should be deprescribed for the time being. Mrs. P has also had no
symptoms of GERD for the past 6 months and should stop taking pantoprazole. Taking
pantoprazole for over a year may increase the chance of side effects
such as bone fractures, gut infections, and vitamin B12 deficiency. (Pantoprazole, 2023) Mrs. P
reports minimal arthritic pain due to use of acetaminophen and
increased activity. Tramadol is considered at class IV drug and its use should be limited. (Dhesi
et al., 2023) Her pain is well controlled with acetaminophen so
the tramadol should be deprescribed.
The patient should complete tapering of the prescribed prednisone. If prednisone is not
tapered properly, symptoms could worsen and cause chronic
recurring symptoms to flare up. Patient reports taking acetaminophen 650 mg twice a day.
Overuse of acetaminophen may cause liver damage with symptoms
such as abdominal pain, irritability, weakness, loss of appetite, jaundice, diarrhea, nausea,
vomiting, and in severe cases kidney damage, confusion, and death.
Mrs. P has a history of hypertension and regular daily intake of acetaminophen can increase
systolic BP. Tylenol should be removed as a daily dose and be
taken on an as needed basis and to not exceed 3,000 mg per day. (MacIntyre et al., 2022)
Given the absence of heart failure exacerbation, her heart failure medications should be
modified. The patient has made lifestyle changes by decreasing
sodium intake and increasing physical activity. Dietary sodium restriction is arguably the most
frequent self-care behavior recommended to patients with heart
failure. For her heart failure, she was previously prescribed furosemide to help eliminate fluid
overload and retention. Furosemide is a loop diuretic which
excretes potassium from the body through urine. Due to this diuretic being used to treat the heart
failure, the patient was prescribed potassium 20 mEq twice a
day to replace the potassium which was excreted. Therefore, since the furosemide should be
held, the potassium should be held as well to help avoid
hyperkalemia. The patient should be reevaluated for fluid buildup and for potassium levels. The
patient should also have their lipid panel drawn to see if their
diet change and daily walks have helped decrease her hyperlipidemia. Depending on the results,
if her hyperlipidemia has improved, then the provider should
consider removing the atorvastatin from her medication regime. Also, statins should be taken
with caution with those older than 70 years old because it
increases the risk of developing a rare side effect called myopathy. (Statin Considerations, 2022)
Some side effects of statins in the elderly are gait
disturbances, increased blood glucose levels, development of cataracts, liver toxicity, and muscle
complications such as rhabdomyolysis.
Reference
Dhesi, M., Maldonado, K., & Maani, C. (2023, April 16). Tramadol. National Library of
Medicine. Retrieved October 3, 2023, from
https://www.ncbi.nlm.nih.gov/books/NBK537060/#:~:text=It%20is%20considered%20
a%20class,as%20non%2Dopioid%20pain%20medication.
MacIntyre, I., Turtle, E., Farrah, T. E., Graham, C., Dear, J. W., Webb, D. J., McCallum, M. J.
A., Melville, V., Fok, H., McCrae, J., Sule, A. A., Caparrotta, T.
M., Kirkby, N. S., & Mitchell, J. A. (2022). Regular acetaminophen use and blood
pressure in people with hypertension:
the PATH-BP trial. Circulation, 145(6), 416–423.
https://doi.org/10.1161/circulationaha.121.056015
Pantoprazole. (2023, July 5).
nhs.uk. https://www.nhs.uk/medicines/pantoprazole/#:~:text=Taking%20pantoprazole%20for%
20more%20than,ulcers%20and%20pins%20and%20needles
Statin Considerations. (2022, October 24). NHS. Retrieved October 3, 2023,
from https://www.nhs.uk/conditions/statins/considerations/#:~
:text=Statins%20should%20be%20taken%20with,being%20over%2070%20years%20ol
d
Weekly Clinical Experience 7
Adriana Hernandez Calderon
Department of Nursing, St. Thomas University
NUR612CL: Advanced Geriatrics Clinical
Dr. Woelki
October 5, 2023
Weekly Clinical Experience 7
The last week of clinical experience has been successful. Throughout my clinical
experience, I have had an excellent opportunity to evaluate various older adult patients
presenting with many health conditions. This clinical has supported my skills in practice, and I
feel confident in my abilities and in caring for future patients.
This week, I had the pleasure of meeting T. L., a 73-year-old Hispanic male presenting
with erectile dysfunction (ED). The patient claims that he has been struggling with his symptoms
for some time now and has decided to seek help for his condition. The patient states that his
symptoms started about a year ago and have progressively worsened, causing him to be
embarrassed and depressed about being unable to perform as before with his partner. He has had
trouble with arousal and having an erection long enough for his sexual encounters. The patient
does not complain of pain in his problem area, and symptoms are usually present when trying to
arouse. The patient has not resorted to treatment for his condition and has not started any new
medications. The patient claims to have mild health conditions, such as hypertension, high
cholesterol, gastric acidity, and chronic back pain. The patient is currently on lisinopril for his
hypertension and atorvastatin for his cholesterol. He takes over-the-counter Pepcid and ibuprofen
for his gastric acidity and back pain.
The primary diagnosis for this patient is ED, which is the inability to sustain an erection
in the penile region necessary for successful sexual activity. Frequent risk factors for ED are
hypertension, dyslipidemia, obesity, diabetes, heart disease, testosterone deficiency, and a higher
incidence in older men. Differential diagnoses for this patient are hypogonadism, loss of libido,
and depression with low mood (Sooriyamoorthy & Leslie, 2023). Due to a pituitary or
hypothalamic disorder, hypogonadism is a clinical illness characterized by sexual symptoms and
low serum testosterone levels. Loss of libido is having little to no sex drive, often related to lifechanging events and stress. Depression or other psychological symptoms can cause a patient to
have a low sex drive and symptoms of ED (Ide & Antonio, 2020).
The plan of care and health promotion for this patient includes differentiating between
genuine erectile dysfunction and other sexual problems that can cause ED symptoms. It was
essential to conduct a mental health examination to ensure that the symptoms of ED have not
been caused by depression and to evaluate if the depression came on after the signs were
presented (Sooriyamoorthy & Leslie, 2023). Appropriate blood testing includes a complete blood
count and comprehensive metabolic panel, lipid levels, hemoglobin A1c to screen for diabetes,
testosterone levels, and thyroid function. Since the patient has comorbidities, it is necessary to
rule out other causes before providing a treatment plan for his condition (Sooriyamoorthy &
Leslie, 2023). Since the patient has a history of high blood pressure and is currently on lisinopril,
it is essential to start treatment through lifestyle modifications and to improve his current health
in hopes of improving his health conditions. The patient was educated on physical activity and a
low-fat diet to improve overall cholesterol and blood pressure levels. The patient was counseled
on eliminating the use of alcohol and tobacco products as this can also contribute to ED. The
patient was educated on supplements such as L-Arginine, an amino acid supplement that
produces nitric oxide and has been proven effective in improving symptoms of ED
(Sooriyamoorthy & Leslie, 2023). The patient will be seen back in the office in four weeks to
discuss drug therapy if symptoms persist despite lifestyle changes. It is vital to be cautious when
prescribing phosphodiesterase-5 inhibitors to treat ED and consider the patients’ laboratory work
before making this decision. Testosterone therapy may also be considered, depending on the
patient’s blood levels (Sooriyamoorthy & Leslie, 2023). A referral to a urologist may also be
beneficial for further management.
As primary care clinicians, we are responsible for treating some of the most complicated
patients, including those with various chronic health conditions, impaired functioning, complex
prescription regimens, and varying levels of caregiver engagement (Sooriyamoorthy & Leslie,
2023). Even for an experienced practitioner, managing patients might present problems and
require complicated treatment regimens. To give patients the most comprehensive care possible,
healthcare professionals must complete the patient’s evaluation and connect any information that
may need to be noticed. One of the most essential duties of primary care professionals is to
encourage self-care through education. This responsibility should constantly be ingrained in
daily practice.
References
Ide, V., Vanderschueren, D., & Antonio, L. (2020). Treatment of men with central
hypogonadism: Alternatives for testosterone replacement therapy.
International Journal of Molecular Sciences, 22(1), 21.
https://doi.org/10.3390/ijms22010021
Sooriyamoorthy, T., & Leslie, S. W. (2023). Erectile dysfunction. StatPearls
Publishing.https://www.ncbi.nlm.nih.gov/books/NBK562253/
Michelle Sheffield
September 29,2023
Module 7 Discussion
Medications to De-Prescribe
Pantoprazole 40 mg- is a medication vital in treating GERD disease among patients. It helps
relieve symptoms such as heartburn and the acid that can cause ulcers (Ben Ghezala et al., 2022).
The patient got the medication due to a history of GERD. However, her condition shows that she
no longer has GERD symptoms and no lower extremities oedema. The medications are no longer
needed since the symptoms are gone. It would help to review it and discontinue it from the list.
Atorvastatin 10 mg- is a vital medication that could help treat cholesterol and fats
detrimental to the patient’s health (Bauersachs, 2021). It slows down the production of
cholesterol in the body, thus reducing the buildup on the walls of the blood vessels and reducing
the risk of heart issues. The medication was critical given that the patient has hyperlipidemia,
heart failure, and high blood pressure. The current state of the patient’s health shows that she is
developing a positive lifestyle, such as regular exercise and diet, which is essential. When the
medication gets administered, it is alongside lifestyle adjustments such as diet and exercise. The
program seems to be working, as the patient is not showing any symptoms related to the
condition. Also, she has lost weight and is eating right. The medication can thus be considered
for discontinuation once the tests show that the cholesterol levels are not high and detrimental to
her health.
Lisinopril 10 mg is a medication that helps treat high blood pressure among older adults.
The fact that the patient was taking 10 mg means that the blood pressure was elevated, given that
the dosage is between 2.5mg and 10 mg per day (Bauersachs, 2021). The patient’s current
condition is that there are no signs of high blood pressure. It is crucial to evaluate the patient and
determine what improved her situation. Currently, the patient is living with her daughter, which
helps her get the support she needs. She is exercising more and eating right, which is critical.
Assessing the high blood pressure is crucial in determining whether the patient needs to
discontinue the medication. However, I recommend that she discontinue it and get a blood
pressure monitor that she can use to track her blood pressure to help inform the way forward.
Furosemide 40 mg- The medication helps treat fluid retention among patients undergoing
heart failure treatment (Bauersachs, 2021). Given that the patient had heart failure, it would
explain why they need to take it. It worked by lessening the symptoms such as swelling in the
abdomen and also the shortness of breath. However, the patient’s current state is that she
exercises, meaning she doesn’t have shortness of breath. She also reports that the abdominal
swelling went away, meaning that the medication has been effective, and she no longer needs to
continue taking the medications.
Tramadol 25 mg is a medication that helps address the patient’s pain (Roy et al., 2020).
Since the patient has acetaminophen 650 mg to help with pain, it is essential to discontinue this
so that she can only use one relevant given her history of osteoarthritis.
Medication to Reduce After Symptom Assessment
Acetaminophen 650 mg is a necessary medication that helps when it comes to pain
management. The patient used to take it, given the pain she felt with her osteoarthritis (Roy et
al., 2020). However, she mentioned that she no longer feels the pain, given that she takes the
medication. It is thus wise that she continues taking the medication, given that it is helping her
with the condition and alleviates her pain.
Metoprolol succinate- the medication is vital when addressing the issues of chest pain, high
blood pressure, and heart rhythm disorders. The patient had heart failure, hypertension, and acute
bronchitis, which necessitated medication use (Morris & Dunham, 2023). However, given her
lifestyle change and decreased severe symptoms. It would be wise to reduce the dosage and
observe the symptoms to ensure that the patient heals well.
Other Medication Adjustments to Consider
Potassium chloride 20 mEq- It is a mineral supplement that helps address the potassium
shortage levels in the blood. It helps ensure the heart and muscle cells work well (Brand et al.,
2022). When the patient has heart failure, it was given to help the heart beat well and ensure
blood flow. The patient mentioned that she changed her diet and is not eating foods that provide
the same nutrients. She avoids taking sodium, which is critical in reducing the adverse effects of
heart functioning. I would advise discontinuing the supplement and encouraging the patient to
continue taking the proper diet.
References
Bauersachs J. (2021). Heart failure drug treatment: The fantastic four. European Heart
Journal, 42(6), 681–683. https://doi.org/10.1093/eurheartj/ehaa1012Links to an external site.
Ben Ghezala, I., Luu, M., & Bardou, M. (2022). An update on drug-drug interactions associated with
proton pump inhibitors. Expert opinion on drug metabolism & toxicology, 18(5), 337–346.
https://doi.org/10.1080/17425255.2022.2098107
Brand, A., Visser, M. E., Schoonees, A., & Naude, C. E. (2022). Replacing salt with low-sodium salt
substitutes (LSSS) for cardiovascular health in adults, children, and pregnant women. The
Cochrane database of systematic reviews, 8(8), CD015207.
https://doi.org/10.1002/14651858.CD015207
Morris, J., & Dunham, A. (2023). Metoprolol. In-Stat Pearls. Stat Pearls Publishing.
Roy, P. J., Weltman, M., Dember, L. M., Liebschutz, J., Jhamb, M., & HOPE Consortium (2020).
Pain management in patients with chronic kidney disease and end-stage kidney disease. Current
opinion in nephrology and hypertension, 29(6), 671–680.
https://doi.org/10.1097/MNH.0000000000000646
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