In “A Seperate Peace” Does Gene “kill” his innocence? Explain.

In “A Seperate Peace” Does Gene “kill” his innocence? Explain.

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PharmacolRespond

1

Respond to 2 people. Heidi and Pearl, by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.

Heidi 

Week 1 Discussion

Top of Form

It is important when prescribing medication to consider a patient’s medical history and current medication regimen.  The way that a patient responds depends on numerous factors that all need considered to provide safe care.

Patient Case

            At a previous job I worked in the surgical department of a rural, critical access hospital.  We had an orthopedic surgeon who performed numerous joint replacements each week.  As with almost any surgery, patients need to stop anticoagulation therapy at least five days prior to the procedure unless otherwise indicated by the cardiologist.  We had a female patient with a history of atrial fibrillation and pulmonary embolism, taking coumadin, scheduled for a knee replacement.  Our protocol in surgery was to have patients hold anticoagulants five days prior to surgery after consulting the cardiologist, getting cardiac clearance, and orders for holding anticoagulants if permitted to do so.

Pharmacokinetic/Pharmacodynamic Processes

Coumadin is quick to be absorbed and has a half life of 1.5-2 days (Rosenthal & Burchum, 2018, p. 460).  The way that coumadin works in the body is by blocking the vitamin k dependent clotting factors (RxList, n.d.).  The patient described needed to be on anticoagulant therapy for prevention of blood clots, but for surgical purposes could be dangerous to continue.  The patient was relatively healthy with no comorbidities other than the atrial fibrillation and history of a prior pulmonary embolism.  The patient’s kidney function was good, her PT/INR were in therapeutic range, and she was in her mid 50’s.  This patient did have decreased mobility, which is why she was undergoing a total knee replacement, which put her at risk postoperatively for a DVT or embolism.

Personalized Plan of Care

The first plan of care that I would address is to obtain cardiac consultation and clearance by the patient’s cardiologist.  I would plan care based on their recommendations on how long to hold anticoagulant therapy.  One option would be to dose the patient with a Lovebox bridge, that is short acting, so that they can still have some type of anticoagulant in their system and it won’t affect the surgical procedure.  Atrial fibrillation is a major factor that increases the risk for a blood clot (Douketis & Lip, 2019). Interruption of anticoagulant therapy could be dangerous for a person with atrial fibrillation. Collaboration with anesthesiologist, cardiologists, and surgeons is needed for best practice consideration for holding anticoagulants.  A decrease in mobility is another consideration.  Patients who undergo joint replacement are less mobile than others. Anticoagulants should be started as soon as they can be safely administered after the procedure to reduce the risk of clot formation.  Other non-pharmacological interventions are SCD sleeves during surgery and starting physical therapy quickly after surgery.

References

Douketis, J. D., & Lip, G. Y. (2019, May 21). UpToDate. Retrieved from https://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s Pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

RxList. (n.d.). Coumadin (Warfarin sodium): Uses, dosage, side effects, interactions, warning. Retrieved from https://www.rxlist.com/coumadin-drug.htm#clinpharm

1 day ago

PEARL E

Discussion 1

COLLAPSE

Top of Form

Pharmacodynamics and Pharmacokinetics

Healthcare providers need to know pharmacokinetics and pharmacodynamics of medications and the effects they have on patients. Drugs can have many effects reaction to the body. The relationship between the drug and the body is that the body affects the drugs and the drug affects the body. Pharmacodynamics is how the drug initiates its therapeutic or toxic effects at the cellular and systemic levels and pharmacokinetic is the process through which the drug is absorbed, distributed and eliminated from the body (Arcangelo, Peterson, Wilburg, & Reinhold, 2017).

Scenario of selected patient

Mrs. Fisher, an 80-year-old patient was admitted to the hospital for a fall. Prior to the fall, she has been having diarrhea from a course of antibiotics for urinary tract infection treatment. Pt was unable to rest at night due to her frequent diarrhea. Her caregiver stated that Mrs. Fisher took one tablet of Benadryl to help her sleep at night and requested for more sleeping medication be given to her at night. Ambien 5mg one tablet by mouth, at bedtime was prescribed by the provider. Patient was also given hydrocodone 5/325 mg to help with her pain from fall. Ambien was given the first night it was ordered. On the second night of taking the medication, patient started showing some side effects which may be from the medicine. Mrs. Fisher became agitated, confused and combative. The provider was notified of the patient’s confusion and agitation and all medication patient took while in the hospital. The provider ordered Ativan 0.5mg to be given intravenously to help with agitation. Mrs. Fisher after getting the Ativan 0.5mg ordered seems like it made her agitation worse.

Factors influencing pharmacokinetics and pharmacodynamics

Healthcare providers need to apply the knowledge of pharmacokinetics to drug therapy which will help to maximize beneficial effects while minimizing harm (Rosenthal & Burcham, 2018). Many factors influence the pharmacodynamics and pharmacokinetics of medications, including the patients age, gender, and actions. The Food and Drug Administration recommends the dose of Ambien for geriatric women to be 5mg for immediate release and 6.25mg for Ambien CR extended release (Ulrich, 2009). Side effects from Ambien can present as sleepwalking, sleep driving, increased falls, disorientation, anxiety, and delirium which is most common with elderly (Rosenthal & Burcham, 2018). Mrs. Fisher took both hydrocodone, Ativan and Ambien. The interaction between these medications could have easily caused her increased confusion and agitation. According to Markota, Rummans, Bostwick, and Lapid (2016), the American Geriatrics Society has placed all benzodiazepines in the list of drugs that should be discouraged in patients over the age of 65. This is due to older adults have increased sensitivity to benzodiazepines and reduced metabolism of long acting agents, resulting in an enhanced danger of cognitive impairment, delirium, falls, fractures and car accidents. American Geriatric society also recommends long acting benzodiazepines such as Xanax instead of short acting such as Ativan if they must be prescribed (Markota et al., 2016).

Plan of care. Nonpharmacological techniques such as removing background noise should be encouraged to relieve anxiety and encourage sleep in the elderly. Pain management should be adequately treated to reduce discomfort. Arcangelo et al. (2017), recommends Haldol over any benzodiazepines due to drugs such as valium could have a half-life of about 70 hours in the elderly. It is recommended to give psychoactive medications for the behavioral disturbance resulting from the somatic conditions, such as aggressiveness only for a limited time. Home medications also needs to be considered in other to address polypharmacy which is very common with the older population.

Conclusion

When caring for the elderly, the providers needs to understand the physiological changes that occur in the body. It is important to review medications that are prescribed to the patient before prescribing anything new. Patient education is key to providing care. The patient and family must understand the need to bringing all their medications or list of all patient’s medications to all medical appointments.  Teaching must also be provided for the patient to report any changes, signs or symptoms that can be seen in new medications.

References

Arcangelo, V. P., Peterson, A. M., Wilburg, V., & Reinhold, J. A. (2017). Pharmacotherapeutics

For Advanced Practice: A Practical Approach. (4th Ed.). Wolters Kluwer Lippincott

Williams & Wilkins.

Markota, M., Rummans, T. A., Bostwick, J. M., & Lapid, M. I. (2016). Benzodiazepine use in

Older adults: Dangers, management, and alternative therapies. Mayo Clinic Proceedings,

91(11), 1632-1639.

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice

Providers. St. Louis, MO: Elsevier.

Ulrich, K. (2009). Pharmacokinetics and drug metabolism in the elderly. Drug Metabolism

Reviews, 41(2), 67-76.

 

 

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Explain the desired outcome(s) or goal(s) for improvement related to the health concern. Overall goal to improve health concern.

Write a narrative description of your field project by doing the following:
1. Assessment
Describe the community where your fieldwork by identifying esch of the following items:
� geographical area (e.g.,county)
� area size
� population size
� demographics
2. Discuss the health concern you studied in your fieldwork. Obesity in Salt Lake County � Detailed description
a. Provide background information in relation to Healthy People 2020 and local public health data that characterizes the health concern.
b. Provide data from national, state, and/or local levels related to the health concern,
Describe the target population affected by the health concern you studied in your fieldwork, including each of the following components:
� gender
� age
� demographics, including socioeconomic status and educational level
Need data. What specific population that you plan to reach out to in action plan. Health Disparity (Stan-Hope)
a. Explain how the health concern is linked to a health inequity/health disparity for the population of interest.
i. Provide specific data to support the health inequity/disparity conclusion.
3. Discuss the primary community resources and partners currently involved with the health concern.
a. Describe how your fieldwork interviews support your chosen health concern, including a summary of the interviews. Describe fieldwork. (Longest Portion)
4. Discuss aspects of the population health concern not being addressed despite the efforts of the partners involved. Based on interviews, what are the system level gaps? Why is it still a problem?

B. Outcomes Identification
1. Explain the desired outcome(s) or goal(s) for improvement related to the health concern. Overall goal to improve health concern. Make sure it is in line with the national standard.

Note: This outcome or goal should be in alignment with Healthy People 2020 objective.

C. Planning
1. Create a nursing action plan to address the identified population health concern.
a. Recommend two population-focused specific objectives. (mini goals)

Note: The recommended objectives should be measurable ones.

b. Recommend two population-focused specific nursing interventions to improve the health concern. What is needed to reach each objective? Change within the community.

Note: Use the attached �Minnesota Intervention Wheel� as an aid in selecting the broad areas for nursing action. Select primary and secondary prevention activities only. For example, explain how you and other nurses might work with the community and your chosen target population of interest to improve the health concern. (File Attached)

2. Discuss potential public and private partnerships from your field experience that could be formed to implement your recommendations from parts C1a and C1b. Various organizations and key leaders and what they bring to the table

3. Create a specific timeline for your population-focused nursing interventions.

D. Evaluation
1. Explain how you would evaluate the effectiveness of the nursing action plan created in part C
a. Identify the measurable tools necessary to perform the evaluation. Must be measurable. (ie. Survey, BMI, etc.)

F. Conclusion
1. Reflect on how your perspective of the community�s health and the national, state, and local efforts toward a healthier population has changed as a result of your fieldwork.

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Revision of case study

Double check Please.

Dear previous writer:

What you put down for the Pilon case as I think in that case, the small claims decision was upheld but I think the last line of that section says that it should remain with the family court.

Please make your corrections on this.

Pilon v. Lavine, 2016 Case Brief

Full Title: Pilon v. Lavine, 2016 ONSC 1965 (Div. Ct.)

Court: Division Courts.

Procedural History

The case involved a $12,000 debt following a divorce between Lavine and Pilon. According to the plaintiff, before their separation Lavine had offered the loan to Pilon and wanted the settlement of the loan to be part of the separation agreement. The loan payment therefore had to do with the settlement of the outstanding properties and debts and thus applied much to either the small claims debts or property litigations or in the higher courts levels of hearing the case. While the claimant maintains that she wants to hear the case in the small claims court, the defendant is pleading to keep the case in the family court. The judgment of the case should therefore depend on whether the court will find that the transaction was within the contexts of family law relations and not in the claims court or the other way around.

Issue

The main issue was whether the small claims court was the appropriate place for hearing the case. Essentially, the decision would highly depend on the nature of the claim and the nature of the transaction or agreement between the parties during the exchange.

Holding

The main points of contention have to do with the fact that if the case is to be heard in the family law relationship, then it means that the defendant is absolved of the debts and will only pay half of the amount since they are supposed to share the credit under the regulation. On the other hand, if the case is to be heard under the simple claims courts, it means that there was a business transaction and the defendant will be liable under the informal contract in the exchange to make a refund of the money. The hearing will therefore involve defining the nature of the exchange during the time of the exchange and determining whether the nature of the transaction would lead to a binding contract. Contexts that would leave the defendant free with no further arguing of the case include instances, where, for example, the plaintiff may have given the amount as a gift or a similar case.

Rules

The loan agreement and the nature of the transaction will determine how the defendant should pay back and the amounts that he should pay

The court will determine the existence of the loan agreement and the boundaries of the payment schedules and nature of the payment transactions

Reasoning

The main reasoning in the case has to do with the Uniform Marital Property Act that emerged in 1983 to define the way that the family should handle property and wealth during divorce and separation. Accordingly, the case suggests that there was a pending debt during the relationship that had to be arbitrated at the time of the separation. The court is to make a decision whether or not the debt qualifies in the case considering that

the couple is separated and each individual is leading their own lives. The legal notion is that if the debt belonged to an asset that the couple shared then it would be judged under the family law relationship and both the defendant and Lavine will have to repay the debt.

Facts

Lavine and Pilon are separating from a marital relationship and have to mitigate the separation of properties and debts among the couple

According to the financial history, Pilon owed Lavine a sum of $24,000 of which Pilon payed half the amount as per the payment schedules of the loan agreement

At the end of the relationship, Pilon still owed the plaintiff $12,000 which Lavine requested to be settled as a small claims settlement.

The court found that the loan, which was evidenced by the agreement and payment schedule still fell under the family law relationship and would be heard as such since they were contingent to the contexts of marriage between the two.

Pilon v. Lavigne, 2016 ONSC 1965 (Div. Ct.)