Psychotherapy replies
Reply separately to two of your classmates posts (See attached classmates posts, post#1 and post#2).
INSTRUCTIONS:
Your responses should be in a well-developed paragraph (300-350 words) to each peer. Integrating an evidence-based resource!
Note: DO NOT CRITIQUE THEIR POSTS, DO NOT AGREE OR DISAGREE, just add informative content regarding to their topic that is validated via citations.
– Utilize at least two scholarly references per peer post.
Please, send me the two documents separately, for example one is the reply to my peers Post #1, and the second one is the reply to my other peer Post #2.
– Minimum of 300 words per peer reply.
– TURNITINAssignment.
Background: I live in South Florida, I am currently enrolled in the Psych Mental Health Practitioner Program, I am a Registered Nurse, I work in a Psychiatric Hospital.
POST # 1 JOHN
ML is a retired registered nurse (RN) who has been given the diagnosis of Stage A heart failure. She knows from her RN education that she will definitely be placed on digoxin as a therapy. She remembers something about halos as something to be attuned to.
1. Explain the pathophysiology of Stage A heart failure.
According to the American Heart Associate Stage A heart failure the patient is at a high risk for developing but the heart has not gone any structural changes. Our esteemed textbook by Woo and Robinson corresponds Stage A HF with the New York Heart association Class I heart failure. One thing of note is that Class I heart failure would have some asymptomatic left ventricle dysfunction. Regardless the three goals of therapy are improvement of symptoms, reduction in morbidity and reduction in mortality (Woo & Robinson, 2020)
.
2. What is the rational drug choice for treatment of this individual?
The drug of choice would be ab Ace Inhibitor. The overreaching goal here is to reduce the preload/afterload thereby reducing stress on the heart and helping to prevent remodeling. They have been shown to improve symptoms, lower mortality and increase life expectancy in all populations. They reduce both preload and afterload and decrease heart remodeling. They are the only drug class to address all the pathological mechanisms of HF (Woo & Robinson, 2020). Therefore Lisinopril 2.5 mg daily would be prescribed. Increase by no more than 10 mg increments. Target dosing is usually in the 20 40 mg daily range (Lexicomp, 2017).
3. Address the patients concern about halos should digoxin be prescribed.
While Digoxin is not a first line treatment for Stage A heart failure. Digoxin is most effective when Ejection Fraction (EF) is less than 40%. Halos are a sign of digoxin toxicity. Digoxin has a narrow therapeutic range of 1.0 to 2.0 ng/ml. Toxicity occurs in as many as 25% of patients. Digoxin half-life is 26- 48 hours and is cleared by kidneys. Renal function would an important consideration for dosing. Digoxin levels closely trend Creatinine levels. Digoxin must be used with caution with calcium channel blockers and diuretics. Patients K+ level also has to be monitored (Woo & Robinson, 2020).
4. Are there gender considerations related to medication treatment in this scenario? If so, what are they? For example, do men and women differ in their side effect profile and/or complications (for instance, from digoxin)?
Gender differences play a role in HF because men and women have different symptoms. Women are more likely to delay seeking care heart disease symptoms than men. Women also have more complications, rehospitalizations, recurring cardiac events, and heart failure after a cardiac event than men. More women die within 5 years of an MI than men. Women are more likely to attribute Cardiac symptoms to other causes delaying care. Women tend to have atypical symptoms such as fatigue and nausea. One paradoxical finding was that women who tend to have higher health literacy rates than men had higher instances of misattribution of symptoms to non-cardiac causes. Men on the otherhand tend to have classic symptoms and have been trained by society to seek medical care when the present (Biddle, Fallavollita, Homish, Giovino & Orom, 2020).
On the other end of the health literacy scale women with low health literacy rates tended to fair poorer. Low health literacy can lead to communication gaps with patients and doctors. Which in turn leads to lack of disease knowledge, inappropriate selfcare, and medication errors. Several studies have shown that this is especially true for women and HF. One-year hospital readmission rates are higher in women than in men and can be considered a predictor of negative outcomes for readmission and mortality in patients with HF. This may be attributed to lack of understanding of the symptoms (Son, & Won, 2020).On page 295 of our textbook it Woo & Robinson stated in 2020 Woo & Robinson state that women fare worse on CGs (digoxin) but they fail to elaborate (Woo & Robinson, 2020, p. 295).
5. Discuss monitoring of the pharmacological agent(s) selected.
Monitor blood pressure, WBC values, weight change and fluid status. Creatinine levels should be monitored. For patients with renal impairment urine protein should be monitored before initiation of therapy and after dosage changes. (Woo & Robinson, 2020).
References
Biddle, C., Fallavollita, J. A., Homish, G. G., Giovino, G. A., & Orom, H. (2020). Gender differences in symptom misattribution for coronary heart disease symptoms and intentions to seek health care. Women & Health, 60(4), 367381.
https://doi.org/10.1080/03630242.2019.1643817
Lexicomp. (2017). Drug information handbook for advanced practice nursing (17th ed.). Hudson, OH: Wolters Kluwer Clinical Drug Information.
Son, Y., & Won, M. H. (2020). Gender differences in the impact of health literacy on hospital readmission among older heart failure patients: A prospective cohort study. Journal of Advanced Nursing (John Wiley & Sons, Inc.), 76(6), 13451354.
https://doi.org/10.1111/jan.14328
Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). Philadelphia, PA POST # 2 LINDSEY
The purpose of this discussion is to evaluate ML for her recent diagnosis of Stage A heart failure and discuss what pharmacological agents suit her best. Roughly about 6.2 million Americans suffer from heart failure and it is very costly for our healthcare system (Virani, Alonso, Benjamin, Bittencourt, Callaway, Carson,& Tsao, 2020). Heart failure is aprogressive, chronicdisease in whichthe heart muscle is unable to pump enough blood, seen with the ejection fraction,to meet the body’s required needsto provide adequate amount ofblood and oxygen to vital organs and tissues (AHA, 2020). This diseasecan involve the hearts left side, right side or both sides, usually affecting the left side first (AHA, 2020). The heart is unable to keep up with the desired workloadandtries to compensate by workingand contracting stronger which eventually leads toenlargement,more muscle mass, and pumpingfaster (AHA, 2020). Unfortunately, this disease is not curable and these temporary compensatory measures only last forso long, resulting in the heartto not be able tokeep up. As a result, the patient will experiencesymptoms such as fatigue and respiratory problems which usually warrant medical treatment (AHA, 2020).
There are four stages to heart failure including, A, B, C and D. Per the American Heart Association (AHA, 2020) Stage A heart failure, also considered”pre-heart failure”are patients who are considered high risk for heart failure but they are without structural heart disease or symptoms of heart failure. Patients who would be considered high risk for heart failure include, hypertension, atherosclerosis, diabetes, obesity, metabolic syndrome, patients using cardiotoxins, and someone with a family history of cardiomyopathy (AHA, 2020).Given that ML is a retired registered nurse with an extensive medical background, she is not wrong that digoxin is one of thedrugs of choicethat treats heart failure. For her case, she would not be prescribed digoxin due to the stage of heart failure she is in based of the AHA (2020) recommended guidelines for management of heart failure. As an APRN, the patient would be educated on this current data, but I would also address her concerns about the side effects of digoxin, if she was to ever need this medication down the road. Halos, also known as xanthopsia,is a classicside effect of digoxin when the patient has toxic levels in the blood causing an appearance of yellow halos around the light (Haruna, Kawasaki, Kikkawa, Mizuno, & Matoba, 2020). To avoiddigoxin toxicity, it is importantforpatient to get their levels drawn accordingly (Haruna, Kawasaki, Kikkawa, Mizuno, & Matoba, 2020). To avoiddigoxin toxicity, it is importantforpatient to get their levels drawn accordingly.Based off these current guidelines ML in the pre-heart failure stage, would be prescribed an ACE inhibitor, andor angiotensin-receptor blocker if she has vascular disease or diabetes, as well as a statin if necessary (AHA, 2020).Based off these current guidelines ML in the pre-heart failure stage, would be prescribed an ACE inhibitor, andor angiotensin-receptor blocker if shewas to havevascular disease or diabetes, as well as a statin if necessary (AHA, 2020).
When prescribing patients medications as an APRN it is important to note the gender-related differences in the anatomy and physiology of the cardiovascular system, for example body composition, role of hormonal changes during menstruation, pregnancy, and menopause (Tamargo, Rosano, Walther, Duarte, Niessner, Kaski,& Agewall, 2017). A recent study also notes that there are also gender-related differences in the pharmacokinetics and pharmacodynamics of cardiovascular drugs. Given that ML would most likely be started on an ACE inhibitor, this study notes that there isno mortality benefit in women with asymptomatic left ventricular systolic dysfunction and women are 2 to 3 timesmore likely to experience the common side effect of a dry cough than men (Tamargo et al., 2017).Before starting an ACE inhibitor, it is important to check blood levels, specifically urea, creatinine, potassium, and sodium values (Edren, 2018). Evidence shows major risk factors from ACE inhibitorsare hyperkalemiaand deterioration of impaired renal function (Edren, 2018). Given the blood levels are adequate, thedrug can be started with arecommendation to check blood levelsand blood pressure within one week (Edren, 2018). If titration of the drug is warranted, it is recommended to continue monitoring blood levels and blood pressure until at desired dose (Edren, 2018).Given that digoxin was a concern to ML and a popular drug therapy for heart failure, it is notable that women have an increased risk of mortality on digoxin and require lower doses and plasma serum levels, recommended level being <0.08ng/ml. Given the blood levels are adequate, thedrug can be started with arecommendation to check blood levelsand blood pressure within one week. If titration of the drug is warranted, it is recommended to continue monitoring blood levels and blood pressure until at desired dose.Given that digoxin was a concern to ML and a popular drug therapy for heart failure, it is notable that women have an increased risk of mortality on digoxin and require lower doses and plasma serum levels, recommended level being <0.08ng/ml (Tamargo et al., 2017). Women appear to have higher serum digoxin levels due to reduced volume of distribution and lower clearance than men (Tamargo et al., 2017). References American Heart Association (AHA). (2020). Stages of Heart Failure and Recommended Therapy by Stage 1 / 1. Retrieved from https://www.heart.org/-/media/data-import/downloadables/8/c/2/rahf-guidelines-toolkit-algorithm-pdf-ucm_492569.pdf?la=en American Heart Association (AHA). (2020). What is Heart Failure? Retrieved from https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure Edren. (2018). ACE Inhibitors: How to start. Retrieved from http://edren.org/ren/gp-info/ace-inhibitors-how-to-start/ Haruna, Y., Kawasaki, T., Kikkawa, Y., Mizuno, R., & Matoba, S. (2020). Xanthopsia Due to Digoxin Toxicity as a Cause of Traffic Accidents: A Case Report.The American Journal of Case Reports,21. Tamargo, J., Rosano, G., Walther, T., Duarte, J., Niessner, A., Kaski, J., . . . Agewall, S. (2017). Gender differences in the effects of cardiovascular drugs. European Heart Journal - Cardiovascular Pharmacotherapy, 3(3), 163-182. Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., . . . Tsao, C. W. (2020). Heart Disease and Stroke Statistics2020 Update: A Report From the American Heart Association. Circulation, 141(9).
