Peer Response: Unit 5, Due Sunday by 11:59 pm CT
Read the SOAP notes constructed by your course colleagues.
Review the ‘P’s posted by your peers from your advanced practice nursing role perspective – educator, leader or practitioner. From your advanced practice mindset reflect on a discussion you would like to have with two of your course colleagues about their ‘P’.
Post a response individually to each of them that expresses your advanced practice nursing role perspective of their ‘P’.
Use scholarly resources relevant to your advanced practice nursing role to support the key elements of the peer discussions you construct. [For example – if you are a nurse educator (clinical or academic) what are your thoughts about the patient education provided in the ‘P’, or do you want to comment on the fact that a peer put N/A for educational, etc.?’; if you a nurse leader what are your thoughts about the risk profile or cost effectiveness of the ‘P’, or adherence to the Patient Bill of Rights, etc.?; if you are a nurse practitioner did your peer develop a ‘P’ that aligns with EBP/CPG guidelines and/or the foundational basic sciences, etc.?
Please be sure to validate your opinions and ideas with citations and references in APA format.
USE UPDATED REFERENCES FOR BOTH PEER POST I WILL PROVIDE PEERS POST BELOW
PEER#1 AND PEER#2
Collapse SubdiscussionKacie Louque
WednesdayAug 11 at 5:18am
Unit 5 Discussion 2 – Anticoagulant Therapy
Subjective: The patient is a 77-year-old male that presents with a complaint of feeling SOB, dizziness, fatigue, and irregular palpitations that are intermittent, lasting for about a day over one year. The patient reports that now his symptoms have lasted three days. The patient reports he takes lisinopril 20mg daily for hypertension for fifteen years and metformin 1000mg daily for type two diabetes for twenty years.
Objective: Patient appears pale and slightly grey, skin is warm. BBS clear, HR irregular rhythm
Assessment: BP 172/100, HR 123 irregular, RR 20
Plan: The initial course of treatment for this patient is to obtain a 12-lead EKG to determine the cause of his irregular tachycardia. Atrial fibrillation is suspected since he complains of SOB, palpitations, and dizziness. If confirmed, the patient should have blood work obtained such as CBC with diff, CMP, PT, PTT, INR, thyroid function test, liver profile, and D-Dimer. A chest x-ray and echocardiogram can be used to assess atrial and ventricular function. If A-fib is confirmed, the goal of treatment is to prevent TIA or CVA with anticoagulants, correct and maintain sinus rhythm, and control ventricular rate (Arcangelo et al., 2017). Due to the patient’s history of diabetes and high blood pressure, the patient should be instructed on the FAST acronym to identify and act upon a possible stroke quickly: facial drooping, arm weakness, speech difficulty, and time to call 911. If the patient’s A-fib is determined to be nonvalvular, it would be appropriate to begin the patient on an oral anticoagulant such as Pradaxa, Xarelto, or Eliquis (Arcangelo et al., 2017). A review published in Clinical Therapeutics reports that patients treated with Eliquis had a 21% stroke risk reduction versus those treated with Coumadin (Almutairi et al., 2017). The patient is to be educated on numerous topics when taking an anticoagulant. It is essential that the patient maintains compliance with his medication regimen. The patient should also be instructed to notify the provider before taking over-the-counter medications such as NSAIDs since they interact with anticoagulants. The patient should avoid alcohol. Since there are no antidotes for DOACs, the patient should also be educated on the signs and symptoms of bleeding and what to do if it occurs (Arcangelo et al., 2017). The patient needs to notify all other providers of anticoagulant use. It is recommended that a cardiologist evaluate this patient for a complete and thorough cardiovascular assessment.
Arcangelo, V. P., Peterson, A. M., Wilbur, V. F., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: a practical approach (4th ed.). Wolters Kluwer.
Almutairi, A. R., Zhou, L., Gellad, W. F., Lee, J. K., Slack, M. K., Martin, J. R., & Lo-Ciganic, W. (2017). Effectiveness and safety of non-vitamin K antagonist oral anticoagulants for atrial fibrillation and venous thromboembolism: A systematic review and meta-analyses. Clinical Therapeutics, 39(7), 1456-1478.
Collapse SubdiscussionLauren Hasler
ThursdayAug 12 at 3:16am
Lauren Hasler’s Main Post
Unit 5 Discussion 2: Anti-coagulant Therapy
Demographic information about the patient – 77-year-old white, male
Chief Complaint: complains of feeling dizzy, short of breath, easily fatigued and having a sensation of his heart ‘skipping beats’ for the last 3 days.
History of Present Illness (HPI): The patient is a 77-year-old, white, male who presents today complaining of feeling dizzy, short of breath, easily fatigued, and having sensation of his heart ‘skipping beats’. He reports that he has had these same symptoms numerous times over the last year or so, but they only lasted for about a day. He thought that since he has been experiencing them now for about 3 days he should come in and get checked out. Patient was diagnosed with type 2 diabetes mellitus 20 years ago and hypertension 15 years ago. The patient is taking 20 mg of Lisinopril, daily and 1000 mg of Metformin, daily.
Past Medical History: Patient was diagnosed with type 2 diabetes mellitus 20 years ago and hypertension 15 years ago.
Medications: The patient takes 20 mg Lisinopril by mouth daily and 1000 mg of Metformin by mouth daily.
Review of Systems: Patient complains of feeling dizzy, short of breath, easily fatigued, and is having a sensation of his heart ‘skipping beats’.
Past Medical History:
Type 2 Diabetes Mellitus (diagnosed 20 years ago)
Hypertension (diagnosed 15 years ago)
Lisinopril 20 mg, PO, daily
Metformin 1000 mg, PO, daily
VS: BP 172/100, P 123, R 20
Integumentary/Skin: skin is warm, pale with a slight gray cast
Cardiovascular (CV): tachycardic; Heart rhythm sounds irregularly irregular upon auscultation
Lungs: lungs are clear to auscultation
#1 Atrial Fibrillation
Atrial fibrillation is an irregularly irregular rhythm with no discernible, consistent atrial activity (Schwinghammer et al., 2021). Ventricular rate is usually 90-170 beats per minute and the pulse is irregular (Schwinghammer et al., 2021). Patients with atrial fibrillation may complain of rapid heart rate, palpitations, chest pain, dyspnea, dizziness, and fatigue (Schwinghammer et al., 2021). The goals of treatment for atrial fibrillation include restoring sinus rhythm or rate control of atrial fibrillation, preventing thromboembolic complications, and preventing further reoccurrences (Schwinghammer et al., 2021).
The incidence in atrial fibrillation increases with advancing age and is highest in those older than 65 years old (Arcangelo et al., 2017). Underlying cardiovascular conditions that can cause atrial fibrillation include hypertension with left ventricular hypertrophy, heart failure, coronary artery disease, and rheumatic valvular disease (Arcangelo et al., 2017).
#3 Stroke Prevention in Atrial Fibrillation (SPAF)
The need for anticoagulation is determined by the patient’s risk of stroke (Arcangelo et al., 2017). Risk factors for stroke in atrial fibrillation include hypertension (HTN), increasing age, heart failure with impaired systolic function, and diabetes mellitus (DM). Stroke prophylaxis is essential in patients with atrial fibrillation that are older than 75 years old (Arcangelo et al., 2017). This specific patient’s risk factors for stroke include that he is older than 75 years old, he has hypertension, and type 2 DM. CHA2DS2-Vasc Risk Scoring System is used to determine the appropriate regimen to initiate for chronic antithrombotic therapy to prevent stroke in patients with atrial fibrillation (Schwinghammer et al., 2021). Patient scores at least four with the information I currently know on the CHA2DS2-Vasc risk scoring system which puts the patient at high risk (Schwinghammer et al., 2021). Oral anticoagulation is recommended for individuals that are high risk according to the CHA2DS2-Vasc risk scoring system (Schwinghammer et al., 2021).
I would ask the patient further questions about the history of the present illness including when does he feel like he is having palpitations or fast heartbeat, if there is anything that makes it worse or better, how long it lasts, and if he is experiencing any chest pain or shortness of breath with it. I would ask the patient about his past medical history; if he has any allergies to food or medications; and if he is currently taking any other prescription medications, over-the-counter medications or herbal supplements. I would ask the patient if he takes his medications regularly or if he forgets to take his medications. I would ask him about social history and family history. I would also ask the patient about health maintenance including questions about exercise, diet, and immunizations. I would obtain a full set of vital signs including height, weight, blood pressure, heart rate, oxygen saturation, respiratory rate, and temperature. I would then complete a full head-to-toe assessment.
I would order an electrocardiogram (ECG) to confirm the diagnosis of atrial fibrillation (Schwinghammer et al., 2021). I would obtain a complete blood count (CBC), current thyroid-stimulating hormone (TSH), chest x-ray, serial cardiac enzymes (troponin, CK, CK-MB) as indicated, put the patient on continuous telemetry monitoring, and would want an echo to be completed to assess for the presence and severity of structural heart disease (Michigan Medicine, 2017). Also before starting anticoagulation therapy, I would obtain baseline lab values including PT, INR, aPTT, urinalysis, CBC (with platelet count), and a liver profile (Arcangelo et al., 2017).
After confirming atrial fibrillation, I would consult cardiology so they can determine if they would like to perform cardioversion on the patient or use an oral or intravenous medication for rate control (Arcangelo et al., 2017). Beta-blockers are a class of medications with antiarrhythmic effects that result from antiadrenergic actions (Schwinghammer et al., 2021). Beta-blockers are most useful in slowing ventricular response in atrial tachycardias, such as atrial fibrillation by effects on the atrioventricular (AV) node (Schwinghammer et al., 2021).
Before starting anticoagulation therapy, I would determine if the risk of hemorrhage outweighs the benefit of anticoagulation therapy (Arcangelo et al., 2017). I would make sure that the there are not any contraindications present for the patient to be started on anticoagulation therapy including if the patient had a recent hemorrhagic stroke, recent trauma or traumatic surgery, active major bleeding in the central nervous system (CNS) or gastrointestinal (GI) tract, or has any aneurysms or central nervous system tumors with a high bleeding risk (Arcangelo et al., 2017).
Lisinopril 20 mg, PO, daily
Metformin 1000 mg, PO, daily
Warfarin, 5 mg, PO (dosing based INR; pharmacy will dose)
Warfarin is used for stroke prevention in atrial fibrillation (SPAF) (Arcangelo et al., 2017). The initial dose of warfarin is typically 5 to 10 mg per day orally administered for one to three days (Arcangelo et al., 201). During the initial titration phase, daily dosage decreases or increases are usually made in 2 to 2.5 mg increments based on international normalized ratio (INR) values
Educational: The patient should continue taking his lisinopril and metformin as prescribed. Medication compliance is crucial. The patient should begin taking warfarin and the dose and schedule will be determined by the pharmacist based on their INR. The anticoagulation effect of warfarin is monitored with the INR, which will show an initial prolongation one to three days after the first administration (Arcangelo et al., 2017). The full antithrombotic effects of warfarin are not present for the first eight to 14 days (Arcangelo et al., 2017). The prothrombin time (PT) is the clotting test used to measure the effect of warfarin which measures the time it takes for a clot to form (Hull et al., 2021). The PT is used to compute the measure most commonly used to adjust the warfarin dose, the INR (Hull et al., 2021). The target INR range is between two and three and warfarin will be dosed based off of the INR (Hull et al., 2021). The most important complication to note of warfarin is bleeding, therefore it is important the patient monitors for signs of bleeding (Hull et al., 2021). Within the first couple days of warfarin initiating warfarin therapy, dark red or black areas on the skin can occur in patients with protein C deficiency, leading to necrosis or gangrene which should be reported if it occurs (Hull et al., 2021). The patient should seek help if they have persistent nausea, stomach upset, or vomiting blood or other material that looks like coffee grounds; headache, dizziness, or weakness; nosebleeds; dark red or brown urine; blood or dark-colored stool; a serious fall or head injury even if there are no other symptoms; or a car accident or other serious injury that could cause bleeding (Hull et al., 2021). It is also important to notify your healthcare provider if you have any bleeding from the gums after brushing the teeth, swelling or pain at an injection site, bruising, diarrhea, vomiting or inability to eat for more than 24 hours, fever, a medication prescribed by another clinician, or a planned surgery or procedure (Hull et al., 2021). Warfarin should be taken on a schedule and exactly as directed (Hull et al., 2021). The patient should reduce the risk of bleeding by always using a seatbelt, wearing a helmet when riding a bicycle, avoid using non-prescription medications that contain a nonsteroidal anti-inflammatory drug (NSAID) or other over-the-counter medications without discussing it with a provider, and always tell any healthcare provider you are taking warfarin (Hull et al., 2021). Consult a healthcare provider before making any major dietary changes because some foods and supplements can interfere with warfarin’s effectiveness (Hull et al., 2021). It is important to not have large day-to-day variations of the amount of vitamin K intake from food because changes in the daily amount of vitamin K intake can alter the INR (Hull et al., 2021). Try and eat about the same amount of vitamin K-containing foods each week to keep your INR stable (Hull et al., 2021). Foods that have a high level of vitamin K include broccoli, kale, spinach, turnip greens, lettuce, cabbage, and brussel sprouts (Hull et al., 2021). Grapefruit and cranberry juice should be limited to one to two glasses per day (Hull et al., 2021). Alcohol should be limited to one to two servings per day to minimize effects on INR (Hull et al., 2021). Patients taking warfarin should wear a bracelet, necklace or similar alert tag at all times (Hull et al., 2021). Warfarin requires routine lab monitoring of the INR at least every four to six weeks (Arcangelo et al., 2017).
Consultation/Collaboration: I would consult cardiology for further assistance with echocardiogram, potential cardioversion or medication management of heart rate and rhythm, and further management and monitoring of cardiac status.
Arcangelo, V., Peterson, A., Wilbur, V., & Reinhold, J. (2017). Pharmacotherapeutics for Advanced Practice a Practical Approach. (4th ed.). Wolters Kluwer.
Hull, R., Garcia, D., & Vazquez, S. (2021). Patient education: Warfarin (beyond the basics). UpToDate. https://www.uptodate.com/contents/warfarin-beyond-the-basics
Michigan Medicine. (2017). Management of acute atrial fibrillation and atrial flutter in non-pregnant hospitalized adults. University of Michigan. https://www.med.umich.edu/1info/FHP/practiceguides/Afib/afibfinal.pdf (Links to an external site.)
Schwinghammer, T., DiPiro, J., Ellingrod, V., & DiPiro, C. (2021). Pharmacotherapy Handbook. (11th ed.). McGraw Hill.
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Peer Response: Unit 5, Due Sunday by 11:59 pm CT