Consider the ethical implications of disclosure and nondisclosure. Research federal and state laws for advanced practice nurses. Reflect on the legal implications of disclosure and nondisclosure for you and the health clinic.

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The Ethics and Legalities of Medication Error Disclosure

Order Description

American writer Nikki Giovanni once said: “Mistakes are a fact of life. It is the response to the error that counts” (Goodreads, 2012). Whenever you make an error when writing a prescription, you must consider the ethical and legal implications of your error—no matter how seemingly insignificant it might be. You may fear the possible consequences and feel pressured not to disclose the error. Regardless, you need to consider the potential implications of non-disclosure. How you respond to the prescription error will affect you, the patient, and the health care facility where you practice. In this Assignment, you examine ethical and legal implications of disclosure and nondisclosure of personal error.
Consider the following scenario:
You are working as an advanced practice nurse at a community health clinic. You make an error when prescribing a drug to a patient. You do not think the patient would know that you made the error, and it certainly was not intentional.
To prepare:
Consider the ethical implications of disclosure and nondisclosure.
Research federal and state laws for advanced practice nurses. Reflect on the legal implications of disclosure and nondisclosure for you and the health clinic.
Consider what you would do as the advanced practice nurse in this scenario including whether or not you would disclose your error.
Review the Institute for Safe Medication Practices website in the Learning Resources. Consider the process of writing prescriptions. Think about strategies to avoid medication errors.
To complete:
Write a 2- to 3- page paper that addresses the following:
Explain the ethical and legal implications of disclosure and nondisclosure. Be sure to reference laws specific to your state.
Describe what you would do as the advanced practice nurse in this scenario including whether or not you would disclose your error. Provide your rationale.
Explain the process of writing prescriptions including strategies to minimize medication errors.
This Assignment is due by Day 7 of this week.
Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.

 

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Consider the ethical implications of disclosure and nondisclosure. Research federal and state laws for advanced practice nurses. Reflect on the legal implications of disclosure and nondisclosure for you and the health clinic. Consider what you would do as the advanced practice nurse in this scenario including whether or not you would disclose your error.

/in /by

The Ethics and Legalities of Medication Error Disclosure

Order Description

American writer Nikki Giovanni once said: “Mistakes are a fact of life. It is the response to the error that counts” (Goodreads, 2012). Whenever you make an error when writing a prescription, you must consider the ethical and legal implications of your error—no matter how seemingly insignificant it might be. You may fear the possible consequences and feel pressured not to disclose the error. Regardless, you need to consider the potential implications of non-disclosure. How you respond to the prescription error will affect you, the patient, and the health care facility where you practice. In this Assignment, you examine ethical and legal implications of disclosure and nondisclosure of personal error.
Consider the following scenario:
You are working as an advanced practice nurse at a community health clinic. You make an error when prescribing a drug to a patient. You do not think the patient would know that you made the error, and it certainly was not intentional.
To prepare:
Consider the ethical implications of disclosure and nondisclosure.
Research federal and state laws for advanced practice nurses. Reflect on the legal implications of disclosure and nondisclosure for you and the health clinic.
Consider what you would do as the advanced practice nurse in this scenario including whether or not you would disclose your error.
Review the Institute for Safe Medication Practices website in the Learning Resources. Consider the process of writing prescriptions. Think about strategies to avoid medication errors.
To complete:
Write a 2- to 3- page paper that addresses the following:
Explain the ethical and legal implications of disclosure and nondisclosure. Be sure to reference laws specific to your state.
Describe what you would do as the advanced practice nurse in this scenario including whether or not you would disclose your error. Provide your rationale.
Explain the process of writing prescriptions including strategies to minimize medication errors.
This Assignment is due by Day 7 of this week.
Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.

 

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Controlled Terminology and Standards What are the advantages of standardizing coding terminologies? And what is the best way to achieve consistency for information systems?

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Controlled Terminology and Standards

Order Description

Controlled Terminology and Standards

What are the advantages of standardizing coding terminologies? And what is the best way to achieve consistency for information systems?

As Dr. John Glaser notes in the “What Is Health Informatics?” media presentation (assigned in Week 1), a group of physicians may use many different terms to describe one patient’s painful experience. This simple example can be extrapolated to guide your thinking about the obstacles that have arisen for information system development because of the varied and complex nature of health care.

In this week’s Discussion, you evaluate the interoperability and coding challenges encountered in today’s health care organizations.

To prepare:
Think about how controlled terminology and standards facilitate information sharing, for example, sharing data between an emergency care clinic and a pharmacy or between a primary care physician’s office and a specialist’s office.

Reflect on the national health IT agenda as presented in the Learning Resources.

Consider challenges health care providers are facing in light of the national health IT agenda related to sharing data across information systems and/or controlled terminology standards. What strategies could a health care organization use to address interoperability challenges? Conduct additional research as necessary to determine possible solutions.
Write a cohesive response that addresses the following:
Evaluate the challenges that health care organizations may face when sharing data across systems.

Using your professional experience and/or information gathered through research, provide at least two specific examples of interoperability challenges.

Propose at least two strategies a health care organization might implement to address interoperability challenges.

Readings

Course Text:Nursing Informatics: Where Technology and Caring Meet
Chapter 13, “Standards and Interoperability”

This chapter introduces the definition, standards, and challenges of interoperability. The authors also detail the impact that interoperable systems will likely have on the future of electronic health records (EHRs) in response to the national health IT agenda.

Course Text: American Nurses Association (2015). Nursing informatics: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
“Trends in Care Delivery Models and Innovation” (pp. 63-66)
This excerpt gives examples of projects that are being used to accelerate informatics implementations in organizations.

Article: Grain, H. (2010). Clinical terminology. Studies in Health Technology and Informatics, 151, 70-83.
Retrieved from the Walden Library using the MEDLINE with Full Text database.

In this article, the author outlines the impact that electronic health records (EHRs) and standardized terminologies have on clinicians, administrators, governments, patients, and consumers. Strategies for terminology utilization and management are given.
Article: Halley, E. C., Sensmeier, J., & Brokel, J. M. (2009). Nurses exchanging information: Understanding electronic health record standards and interoperability. Urologic Nursing, 29(5), 305-314.
Retrieved from the Walden Library using the ProQuest Central database.

This article begins with an historical overview of computer use in the health care industry. Then it takes an in-depth look at the incentives being used to increase the percentage of practice settings that comply with the integration of electronic health records and interoperable technologies.
Article: Hovenga, E. J. (2010). National standards in health informatics. Studies in Health Technology and Informatics, 151, 133-155.
Retrieved from the Walden Library using the MEDLINE with Full Text database.

This article provides an in-depth review of the development of national standards. It includes a look at the components of standards and how they affect the interoperability of systems.
Article: Kuperman, G. J., Blair, J. S., Franck, R. A., Devaraj, S., & Low, A. F. H. (2010). Developing data content specifications for the Nationwide Health Information Network Trial Implementations. Journal of the American Medical Informatics Association, 17(1), 6-12.
Retrieved from the Walden Library using the PubMed Central database.

The authors of this article use the experiences of the Nationwide Health Information Network’s Trial Implementations project to describe the process and challenges of developing content specific standards.
Article: Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal 39(2), 37-39.
Retrieved from the Walden Library using the Academic Search Complete database.

Real-world examples are used in this article to predict how the management of health information will change as standardized terminologies are implemented within practice settings.
Web Resource: American Nurses Association (2006). ANA recognized terminologies and data element sets.
Retrieved from http://www.nursingworld.org/npii/terminologies.htm

By navigating through this website, you can see the table that shows the data sets recognized by the American Nurses Association.
Web Resource: Centers for Disease Control and Prevention. (2009). Health data standards.
Retrieved from http://www.cdc.gov/nchs/about/health_data_standards.htm

This website provides a link to two organizations that focus on health standards and statistics. The first organization that you may choose to view is the National Committee on Vital and Health Statistics, which was established by Congress and advises the Department of Health and Human Services. The second is called the Public Health Data and Standards consortium, a not-for-profit organization that works with a variety of agencies, associations, and organizations.
Website: Logical Observation Identifiers Names and Codes (LOINC®). (2011).
Retrieved from http://loinc.org

Access this website to gain information on LOINC’s universal coding system for laboratory and clinical observations.
Website: Saba, V. (2011). Clinical Care Classification System.
Retrieved from http://www.sabacare.com/

At this website, you can view the framework of the Clinical Care Classification (CCC) coding structure. Use the side tabs to view the features that make this coding terminology widely accepted as a means to document patient care in electronic health care records.
Website: U.S. National Library of Medicine. (2011). Unified Medical Language System® (UMLS®).
Retrieved from http://www.nlm.nih.gov/research/umls

The Unified Medical Language System uses its three tools, or Knowledge Sources, named Metathesaurus, Semantic Network, and SPECIALIST Lexicon and Lexical Tools to combine many popular standards and terminologies used in the health care industry. This integrated system facilitates interoperability between computer systems.

 

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Ask yourself: Do the research question involve a comparison of groups or the relationship of variables? How many independent variables do I have? Dependent variables? What are they? Is the independent variable categorical or continuous? Is the dependent variable categorical or continuous?

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Levels of Measurement

Order Description

Levels of Measurement

There are many different methods for analyzing quantitative data; each method is dependent on the type of data gathered as well as the research question being addressed. The first step in analyzing data is to determine what kind of data you have—the level of measurement. Determining the level of measurement is a method of classifying the variables within a research study. Classifying a variable into its appropriate level of measurement helps a researcher determine the most appropriate statistical analysis for those data and to interpret the data the variable generates.

In this Discussion, you identify independent and dependent variables in your research problem, which you identified in the Week 2 Discussion. You classify these variables into their appropriate levels of measurement and determine suitable ways of analyzing the data generated by each variable.

To prepare:

Review the materials presented in Chapter 1 of the Polit textbook.

Consider Dr. Pothoff’s comments in this week’s media presentation on data analysis.

Recall your research problem statement developed for the Week 2 Discussion. Based on your problem statement, develop a research question to address the problem.

Ask yourself:

Do the research question involve a comparison of groups or the relationship of variables?

How many independent variables do I have? Dependent variables? What are they?

Is the independent variable categorical or continuous?

Is the dependent variable categorical or continuous?

What might be the advantages, or disadvantages, of each variable’s level of measurement?
Post by Day 4 a cohesive summary of the following:

Post your research question. Describe the independent and dependent variables.

Identify the level of measurement of both the independent and dependent variables. Provide a brief rationale for your classification of each variable.

Discuss considerations of analyzing data related to each variable based on its level of measurement. Identify any advantages or challenges you might encounter in your statistical analysis of each variable.

Readings

Course Text: The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence
Chapter 21, “Introduction to Statistical Analysis”

This chapter discusses the concepts of statistical analysis with regard to hypothesis testing. The chapter also identifies and defines common statistical terminology.
Course Text: Polit, D. (2010). Statistics and data analysis for nursing research (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc.
Chapter 1, “Introduction to Data Analysis in an Evidence-Based Practice Environment”

This chapter provides an introduction to quantitative and qualitative data in evidence-based practice. The chapter introduces levels of measurement and types of statistical analyses relevant to different types of research studies.
Chapter 2, “Frequency Distributions: Tabulating and Displaying Data”

Chapter 2 discusses frequency distributions as well as the different methods of presenting data, especially when data are very extensive. The chapter includes information on the use of bar charts, pie charts, histograms, and frequency polygons.
Chapter 3, “Central Tendency, Variability, and Relative Standing”

This chapter examines the many ways data distribution for a quantitative variable can be described through shape, central tendency, and variability.
Software

IBM SPSS Statistics Standard GradPack (current version). Available in Windows and Macintosh versions. Please refer to the IBM SPSS Software area on the left navigation bar for more information on how to install, register, and license this software
Optional Resources

Article: Bilheimer, L. T., & Klein, R. J. (2010). Data and measurement issues in the analysis of health disparities. Health Services Research, 45(5), 1489–1507. doi:10.1111/j.1475-6773.2010.01143.x
Retrieved from the Walden Library databases.
Article: Granberg-Rademacker, J. S. (2010). An algorithm for converting ordinal scale measurement data to interval/ratio scale. Educational & Psychological Measurement, 70(1), 74-90.
Retrieved from the Walden Library databases.
Website: Statistics Help for Students. (2008). Retrieved from http://statistics-help-for-students.com/

This site provides step-by-step procedures and screenshots for working with SPSS.
Tutorial: Walden University. (n.d.). Descriptive statistics. Retrieved August 1, 2011, from http://streaming.waldenu.edu/hdp/researchtutorials/educ8106_player/educ8106_descriptive_stats.html

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Consider methods that were used to garner the support of stakeholders and decision makers to move the project forward. Write a cohesive response that addresses the following: Describe an example of a HIT project implemented at your organization and analyze how that project was identified and moved forward.

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HIT Projects and Decision Makers

Order Description

HIT Projects and Decision Makers

A nurse leader sought to implement greater security in the children’s wing of the hospital by installing a new alarm and monitoring system. Due to budget constraints, the CNO rejected the proposal, stating that current security methods were sufficient. Shortly after this failed proposal, an individual did in fact breach the children’s wing security and abducted a young child. Thankfully, the child was found and returned to her parents; and the CNO quickly found the money to install the new security system.

Not all HIT projects have such high-profile stakes. The main takeaway from this example is the importance of getting key stakeholders and decision makers on board when planning a new HIT project.

To prepare:
Bring to mind a HIT project implemented in your organization. Which leaders identified the project? Which stakeholders and decision makers helped moved the project forward?

Consider methods that were used to garner the support of stakeholders and decision makers to move the project forward.
Write a cohesive response that addresses the following:
Describe an example of a HIT project implemented at your organization and analyze how that project was identified and moved forward.

Evaluate the impact of key decision makers on moving the HIT project forward.
Read a selection of your colleagues’ postings

By Day 6 respond to at least two of your colleagues in one or more of the following ways:
Ask a probing question, substantiated with additional background information, evidence, or research.

Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.

Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.

Validate an idea with your own experience and additional research.

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Return to this Discussion in a few days to read the responses to your initial posting. Note what you learned and/or any insights you gained as a result of the comments made by your colleagues.

Be sure to support your work with specific citations from this week’s Learning Resources and any additional sources.

Readings

Course Text:Nursing Informatics: Where Technology and Caring Meet
Chapter 17, “Disruptive Innovation: Point of Care”

This chapter uses real-world integration examples to illustrate the visions and challenges that characterize Smart Point of Care systems.
Course Text: American Nurses Association (2015). Nursing informatics: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
“Standards of Nursing Informatics Practice” (pp. 67-79)
This excerpt presents the specific measurement criteria found within each nursing informatics standard.

Article: Madsen, M. (2010). Knowledge and information modeling. Studies in Health Technology and Informatics, 151, 84-103.
Retrieved from the Walden Library using the MEDLINE with Full Text database.

Within this article, the overall design models of information systems are linked to the metastructures, data, information, knowledge, and wisdom.
Article: Peleg, M. (2011). The role of modeling in clinical information system development life cycle. Methods of Information in Medicine, 50(1), 7-10.

Peleg, M. The Role of Modeling in Clinical Information System Development Life Cycle. Methods Inf Med 2011; 50: 7-10.

The author of this article discusses the role of conceptual modeling in health information technology systems and how it has been an effective component of system development.
Article: Philip, A., Afolabi, B., Adeniran, O., Oluwatolani, O., & Ishaya, G. (2010). Towards an efficient information systems development process and management: A review of challenges and proposed strategies. Journal of Software Engineering and Applications, 3(10), 983-989.
Retrieved from the Walden Library using the ProQuest Central database.

This article examines the phases and methodologies found within the Systems Development Life Cycle (SDLC), and proposes a framework for establishing the crucial roles that participants must play during the SDLC.
Article: Szydlowski, S., & Smith, C. (2009). Perspectives from nurse leaders and chief information officers on health information technology implementation. Hospital Topics, 87(1), 3-9.
Retrieved from the Walden Library using the ProQuest Central database.

Qualitative research is used in this article to examine the trends, goals, outcomes, barriers, and mistakes that hospital leaders may experience when implementing health information technology systems.
Optional Resources

Article: Burgess, L., & Sargent, J. (2007). Enhancing user acceptance of mandated mobile health information systems: The ePOC (electronic Point-Of-Care Project) experience. Studies in Health Technology and Informatics, 129(Pt 2), 1088-1092.

 

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Diagnosis Association-NANDA; Nursing Intervention Classification-NIC; Nursing Outcomes Classification-NOC) and develop an appreciation of the relationship between standardized terminologies and the data-information-knowledge-wisdom continuum. •For a selected patient scenario (from your personal practice experience), you will identify standardized terminologies (NANDA; NIC; & NOC) elements to your selected patient scenario. Describe in detail the data, information, knowledge, and wisdom

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Applying standard terminologies in practice

Applying standard terminologies in practice

Order Description

From my instructor: paper is 3-5 excluding title and reference page,provide an opportunity for you to apply standardized terminologies (North American Nursing

Diagnosis Association-NANDA; Nursing Intervention Classification-NIC; Nursing Outcomes Classification-NOC) and develop an appreciation of the relationship between

standardized terminologies and the data-information-knowledge-wisdom continuum. •For a selected patient scenario (from your personal practice experience), you will

identify standardized terminologies (NANDA; NIC; & NOC) elements to your selected patient scenario. Describe in detail the data, information, knowledge, and wisdom

that guided you. The scenario is one that you choose, in a context familiar to you so that you can provide the detail requested and apply your learning from this point

forward. •IN PREPARING YOUR PAPER o Required texts may be used as references, but a minimum of three sources must be from outside of course readings. o All aspects of

the paper must be in APA format as expressed in the 6th edition. o The paper (excluding the title page and reference page) is 3–5 pages in length. o Ideas and

information from professional sources must be cited correctly. o Grammar, spelling, punctuation, and citations are consistent with formal academic writing. •I suggest

you provide headings to organize each section of your paper (i.e., Introduction, NANDA/NIC/NOC Elements, DIKW, Conclusion). This will provide an outline of your paper,

so as to not miss any content. •Read and follow exactly the “Applying Standardized Terminologies in Practice-Guidelines With Scoring Rubric” located under Doc Sharing

silver tab. •Read your “Lesson” provided under your WK 3 tab. •The Center for Nursing Classification and Clinical Effectiveness provides an overview of NIC and NOC by

clicking the links provided on the main page at the following URL: https://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/index.htm •The

Nanda website provides an overview and fact sheet for Nanda-I/NIC/NOC at the following URL:https://www.nanda.org/nanda-i-nic-noc.html

https://www.nanda.org/assets/images/Alliances/NNN-Fact-Sheet.pdf Also it states I am to also include how the DIWK guided me. Please ask if you don’t know what that

means. My personal scenario you could discuss is a AAA patient, developed high blood pressure, a declining drop in Hemoglobin and ended up going back to OR for rupture

as a result of my knowledge and wisdom. I am not sure about the terminologies listed above that need to be discussed. (hence why I having you write the paper.) : )

Please keep in contact with me in regards to more information needed about patient scenario or if you have one you have found.Uploading the rubric for grading. Please

email with questions

 

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1)    Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment? Category    Systolic BP mmHg (Clinic)    Diastolic BP mmHg (Clinic)    Systolic BP mmHg (Ambulatory)    Diastolic BP mmHg (Ambulatory) Normal High-normal Stage 1 Stage 2

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1)    Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment?

Category    Systolic BP mmHg (Clinic)    Diastolic BP mmHg (Clinic)    Systolic BP mmHg (Ambulatory)    Diastolic BP mmHg (Ambulatory)
Normal

High-normal

Stage 1

Stage 2

2)    What lifestyle measures would you advise Mr KK to help lower his blood pressure? Why are lifestyle measures important?

3)    About 1 week later Mr KK comes back into your pharmacy, he has now had 24 hour BP monitoring and his diagnosis of hypertension has been confirmed.

a.    How should an initial antihypertensive treatment be chosen for Mr KK?

b.    What antihypertensive therapy would you choose to start Mr KK on? What target blood pressure would you recommend for Mr KK and how often would you monitor his

blood pressure?

Fill this in on your care plan.
Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Hypertension

PART B: CARDIOVASCULAR RISK

4)    Mr KK has a cholesterol of 6.5mmol/L and his total cholesterol:HDL ratio is 6.5. Calculate his overall cardiovascular risk using the tables in the BNF.

Complete the table below with his modifiable and non-modifiable risk factors for CVD

Modifiable    Non-modifiable

5)    Mr KK’s doctor now wants to start other medicines for primary prevention. What do you understand by primary prevention? Suggest a drug and dosage regime if

appropriate. What counselling would you give Mr KK about any new medicines you recommend?

Fill this in on your care plan.

Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Cardiovascular Risk

PART C: OTHER CO-MORBIDITIES

Although you should refer to the NICE guidance for hypertension when choosing antihypertensive therapy consideration should also be given to co-morbid conditions

6)    In four groups, discuss, giving reasons, which antihypertensive(s)
would be a good choice or poor choice. What target BP would you aim for in these patients?

•    White male accountant, 34 years old, asthma and weighs 82kg

•    White male, 70 years old, diabetes and CKD (Creatinine 250micromol/L). He weighs 70kg and is 5 feet 9 inches tall.

•    28 year old African woman with CKD (Creatinine 290micrmol/L)

•    72 year old African American woman with chronic cardiac failure NYHA Stage 3.

PART D: ISCHAEMIC HEART DISEASE

7)    About 6 months later, Mr KK visits your pharmacy again. He tells you
his GP has diagnosed him as having angina. What is angina and what symptoms would you expect him to experience?

8)    What changes would you recommend to Mr KK’s prescription and why? What counselling and monitoring would he need?

9)    Mr KK comes back to your pharmacy 3 months later with a prescription for a GTN spray. You notice this will be his 4th repeat prescription for this in the last

3 months. What questions do you want to ask him before you dispense this and what changes could you suggest to his therapy?

Question        Response

10)    Mr KK collects a new prescription for his GTN spray and asks you when he should expect to need a new one. Each GTN spray contains 200sprays; Mr KK is now using

2 puffs 4 times a week. The spray you have dispensed for him expires in May 2015.

WORKSHOP THREE

MAJOR THEMES:
CHRONIC HEART FAILURE

LEARNING OBJECTIVES

Following the lecture, workshop, directed and background reading, students should be able to:

1)     Describe the aetiology and presentation of heart failure
2)     List the desired outcomes in care of patients with heart failure and how
pharmacists can help achieve these
3)     Discuss the pharmaceutical management of heart failure
4)     Outline how to initiate and titrate angiotensin converting enzyme inhibitor (ACEI) therapy and beta blocker therapy
5)    List the counselling required by patients commencing therapy on ACEIs and beta blockers for heart failure

DIRECTED READING

Karagkounis D. Heart Failure – clinical features and diagnosis. Clinical Pharmacist. 2014; 6: 119-122 2010

Williams H. Heart Failure – management. Clinical Pharmacist. 2014; 6:123-1282010

BNF sections 2.5.5

NICE Bites – Chronic Heart Failure (NW MI) September 2010

NICE Clinical Guideline No: 108 August 2010: Management of Chronic Heart Failure in adults in Primary and Secondary Care. NICE guideline Pages 15-20 Pharmacological

Treatment of Heart Failure and Appendix D – Practical Notes

BACKGROUND READING

Myocardial infarction; secondary prevention – NICE Guidelines 2007 – quick reference guide. May 2007

Chapter on Congestive Cardiac Failure) in Clinical Pharmacy and Therapeutics or similar textbook
PRE- WORKSHOP LEARNING – A HEART FAILURE FORMULARY

For each of the following group of drugs for heart failure indicate initiation and maximum dose and what stage of heart failure they should be used.

Beta-blockers (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Angiotensin Converting Enzyme Inhibitors
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Angiotensin II Receptor Antagonist (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Aldosterone Antagonists
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Loop diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Thiazide diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

WORKSHOP THREE: ANSWER ALL THESE QUESTIONS USING THE READING LIST IN THE PREVIOUS PAGE TO HELP YOU ANSWER THESE QUESTIONS PLEASE ANSWER THEM IN DETAIL

Mrs LL a 70 year old lady attended her GP practice as she had noticed that she had become increasingly tired and short of breath on carrying out her usual activities.

PC     Increased tiredness, SOB and swollen ankles

HPC   She noticed she needed to stop for breath when walking up the stairs.
Feeling tired and lethargic as not sleeping well at night for the last 2/52. Legs are feeling heavy and her shoes feel tight.

PMH    IHD, OA, MI 4 yrs ago
SHx    Lives alone in a house, usually independent, doesn’t drink any alcohol, ex-smoker, quit after her MI
RS    Basal creps in both lower bases, cough for past week producing watery sputum
CVS    BP 150/95mmHg    Pulse 90bpm reg
CNS     Grossly intact

O/E    Pitting oedema on both feet

Weight today = 67kg
Last recorded weight (4 months ago) in practice records = 60kg

Working diagnosis:    Heart failure/COPD/General deterioration

Current Rx:    Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Atenolol 50mg Mane
Ramipril 1.25mg Mane
GTN spray 400mcg 1-2 sprays when required for chest pain

1.    What do you understand by the term heart failure?

2. What medical conditions can lead to the development of heart failure?

3. What signs and symptoms does Mrs LL have that may be suggestive of
heart failure? How do these arise?

4. How would the diagnosis of heart failure in Mrs LL be confirmed?

5. What treatment option would you add to Mrs LL whilst she is awaiting her ECHO and specialist review? Include a suggested dose, preferred route of administration,

any monitoring required, and counselling you should offer Mrs LL.

Mrs LL is seen by a Cardiologist and her ECHO confirms that she has Left Ventricular Systolic Dysfunction (LVSD) with an Ejection Fraction of 30%. The aetiology of her

heart failure is due to ischaemia. The Cardiologist felt no further interventions or stents would be beneficial and optimisation of medical management was the plan.

Mrs LL was referred to the local Community heart failure nurses for optimisation.

On her first appointment the recommendation is to titrate ramipril to 2.5mg daily and switch atenolol to bisoprolol 2.5mg once daily.

6.   Why are angiotensin converting enzyme (ACE) inhibitors and beta-blockers recommended first line in the management of heart failure?

7.    a) How should ACE therapy be titrated and what monitoring is required?

b) What are the main side effects of ACE inhibitors? How should they be managed?

8.    a) How should beta-blockers be initiated in heart failure and what monitoring is required?

b) Why was Mrs LL switched from atenolol to bisoprolol?

c) In which situations are beta –blockers contra-indicated?

d) What are the main side effects of beta –blockers and how can they be managed?

9.    Mrs LL wants to know how many pints of water she can drink in a day? Calculate and advise Mrs LL. (1 pint = 568ml)

Mrs LL attends for a follow up appointment at the heart failure clinic she has noticed an increase in breathlessness since her last appointment and simple things like

brushing her teeth and getting dressed can make her extremely tired. Her osteoarthritis pain has worsened and her GP has given her a new prescription for her pain.

Current Treatment:
Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Bisoprolol 10mg Mane
Ramipril 10 mg Mane
Furosemide 40mg Mane
GTN spray 400mcg PRN
Naproxen 500mg TDS

Bloods: Creatinine 120micromol/L (60-120), urea 9mmol/L (2.5-7.5), potassium 4.5mmol/L (3.5-5)

BP 130/80mmHg, HR 65bpm. mild ankle swelling and lungs clear.

10.    Using the New York Heart Association (NYHA) functional classification,
how would you grade the severity of Mrs LL’s heart failure? Give reasons for your answer.

11.    Could any of Mrs LL’s drug treatments exacerbate her heart failure? If so,
how? Can you suggest alternative treatments that would not exacerbate her heart failure? Fill this in on your care plan.

12. Which other classes of drugs can precipitate or exacerbate heart failure?

13.    If Mrs LL’s heart failure were not controlled on her first-line agents, what second-line agents are available to add in?

14.    Two weeks later Mrs LL’s potassium is reported as 6.6 mmol/L. What is
likely to have caused this and what would you recommend?

Pharmaceutical care plan for Mrs LL (on review clinic at question 11)

Problem    Desired Outcome     Assessment    Actions
Options    Follow up / monitoring    Counselling

Worsening Heart Failure symptoms following titration of ACEi and BB.

Osteoarthritis

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After a further 6 months on pioglitazone 30mg daily and gliclazide 160mg BD, Miss HH’s HbA1c remains stubbornly high at 78mmol/mol in the diabetic clinic. The doctor decides to stop her pioglitazone and start subcutaneous insulin therapy whilst continuing gliclazide. Describe 3 different kinds of insulin regime – suggest preparations and doses. Which one would you recommend for Miss HH? Which regime best mimics the body’s natural insulin release?

/in /by

11)    After a further 6 months on pioglitazone 30mg daily and gliclazide 160mg BD, Miss HH’s HbA1c remains stubbornly high at 78mmol/mol in the diabetic clinic. The

doctor decides to stop her pioglitazone and start subcutaneous insulin therapy whilst continuing gliclazide. Describe 3 different kinds of insulin regime – suggest

preparations and doses. Which one would you recommend for Miss HH? Which regime best mimics the body’s natural insulin release?

12)    Should Miss HH be started on aspirin or a statin? (Refer to the NICE Guidance 2009).

At home, complete the care plan for Miss HH at the point of hospital admission in Q7.
Pharmaceutical care plan for Miss HH  DOB 1/6/1968 (on admission)
Problem    Desired outcome     Assessment    Actions
Options    Follow up/monitoring    Counselling
DM2

HBA1c to 6.5%
No hypos (see below)
HBA1c and glucose uncontrolled on metformin 1g BD
? Compliance
Cr= 250 micromol/L
BMs/HbA1c in longer term
Push dietary advice
How to manage hypos
Risk of hypoglycaemic attacks

Want none     None yet but risk if starts non-metformin based therapy

Cardiovascular risk

Reduce risk of CVD (CHD+stroke) plus PVD,CKD, retinopathy and nephropathy    DM2 (Uncontrolled)        BP, CBG (BM), lipids, HbA1c regularly
CKD    Stop further deterioration, avoid ESRF>> Check chronic/acute    Already lost 2/3 of GFR by age 65- bodes ill Needs tight BP (esp c ACE); tight sugar control

BP, Cr, urinary protein regularly,

VTE prophylaxis whilst in hospital

WORKSHOP TWO

MAJOR THEMES
HYPERTENSION
PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE
ISCHAEMIC HEART DISEASE

LEARNING OBJECTIVES

Following the workshop, directed and background reading, students should be able to describe/understand:
1)    Basic principles and problems in the management of hypertension
2)    The importance of considering concomitant illness in the selection of antihypertensive therapy
3)    The concept of cardiovascular risk including primary and secondary prevention of cardiovascular disease.
4)    Management of stable ischaemic heart disease

DIRECTED READING

BNF sections 2.5 Introductory pages
Stable angina. NICE Clinical Guideline CG126 2011- Quick reference guide

Management of hypertension in adults in primary care. NICE Clinical Guideline CG127 2011

MHRA and CHM. Aspirin: not licensed for primary prevention of thrombotic vascular disease. Drug Safety Update 2009;3(3):10-11.

NICE Bites – Hypertension, UKMI September 2011

NICE Bites – Management of stable angina, UKMI, September 2011

BACKGROUND READING

Stable angina – Clinical features and diagnosis. Clinical Pharmacist, January 2012

Stable angina – Management. Clinical Pharmacist, January 2012

WORKSHOP EXERCISE

Fill in the empty boxes in the diagram of the renin-angiotensin system below.

ANSWER ALL THESE QUESTIONS USE THE READING LIST IN PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS IN DETAIL

Mr KK, a 61 year old Caucasian secondary school teacher, has recently been diagnosed with hypertension. His recent blood pressure reading was 165/100mmHg.

He feels generally well but has been under a great deal of stress at work recently. He has no past medical history. His older brother has hypertension and type II

diabetes and his father died aged 52 following a myocardial infarction. He has no other medical problems. He smokes 15 cigarettes a day and weighs about 100kg.

He doesn’t think that he has hypertension as he has had only 2 high readings but he is to have 24 hour blood pressure (BP) monitoring next week. He has also had blood

tests to check his blood sugar, cholesterol, renal function and liver function. He has read about white coat hypertension in the newspaper but was not sure what this

means.

 

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What devices/forms are insulins commonly available in? What are the major types of insulin by onset/duration of action?

/in /by

MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.

MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.

LEARNING OBJECTIVES

Following the workshop, directed and background reading, students should be able to:
1)    Outline the dietary recommendations given to patients with diabetes
2)    Discuss the place in therapy of the different oral hypoglycaemic agents
3)    Describe the different insulins available
4)    List the factors influencing choice of insulins and insulin delivery devices in diabetic patients.

DIRECTED READING

BNF Section 6.1.1-6.1.4 Drugs used in diabetes (Introduction and section headings)

National Institute for Health and Clinical Excellence. Clinical Guideline 87 Management of type 2 diabetes. May 2009.

Jacques N. New NICE guidelines for type 2 diabetes treatment. Br J Clin Pharmacy 2009;1:167-8.

Questions:

What devices/forms are insulins commonly available in?

What are the major types of insulin by onset/duration of action?

BACKGROUND READING
National Institute for Health and Clinical Excellence. Clinical Guideline 15. The diagnosis and management of type 1 diabetes in adults. July 2004. (Look at pages 5-

10)

Hackett E, Jacques N, Gallagher A. Type 1 Diabetes: Pathophysiology and diagnosis. Clinical Pharmacist 2013;5:69-72.

Hackett E, Jacques N. Type 1 Diabetes: Insulin management. Clinical Pharmacist 2013;5:69-72.

WORKSHOP EXERCISE
Example of medicine    Typical starting and maximum dose    Class    How it works to lower blood glucose    Any other notes (place in therapy, common adverse

events, contra-indications etc.)
Insulin

Metformin

500mg od-max 2g OD

.
Gliclazide

40mg OD-max 320mg in divided doses

.
Pioglitazone

15mg OD- max 45mg OD

Nateglinide

60mg TDS to max 180mg TDS

Exenatide

5mcg BD top max 10mcg BD

Sitagliptin

100mg OD

Dapagliflozin     10mg OD

ANSWER ALL THESE QUESTIONS IN DETAIL AND USE THE READING LIST ON THE PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS

Miss HH is a 65 yr old lady weighing 83kg who presents to a community pharmacy, where you regularly do a locum, asking for “something stronger for thrush which keeps

coming back”. On further questioning she is feeling increasingly lethargic recently and is complaining of going to the toilet more often. You suspect she may have

diabetes mellitus and refer her to a G.P.

She has mild osteoarthritis and is only on ibuprofen and co-codamol.

1)    What signs and symptoms of diabetes mellitus does Miss HH have? What other initial symptoms may also be present?

2)    Miss HH has heard that in one type of diabetes she will need injections. She asks you how the G.P. will determine she has diabetes and which type she has?

What are the two types and is there a precise diagnosis for diabetes?

3)    What complications can arise in someone with diabetes mellitus?

4)    What are the aims of treating diabetes?

5) The G.P. diagnoses Miss HH with type 2 diabetes and gives her dietary advice. What type of diet is recommended in diabetic patients, and why?

6)    The GP also starts Miss HH on metformin 500mg TDS. In general, is this a reasonable initial therapy? What would make it not so?

7)    A year later Miss HH is seen in clinic and it is clear her diabetes is uncontrolled. She is admitted for review of her therapy. She is on metformin 1g bd for

her diabetes and usual painkillers. Blood tests came back as:
U&Es    FBCs
Glucose    22.3 mmol/L (3.6-8)    Hb     12.1 g/dl (11.5-16.5)
HbA1c     105mmol/mol
(<48mmol/mol/6.5%)     WBC 10.2×109/l (4-11)
Na            136 mmol/L (135-145)    Plts    293×109/l (150-450)
K               4.8 mmol/L (3.5-5.0)
Urea         11.7 mmol/L (2.5-7.5)
Creatinine 250micromol/l (60-120)

Wgt  80kg    Temp. 37.1 degrees
Hgt   5’6’’    BP 147/85mmHg

a)    Comment on Miss HH’s glucose and HbA1c in relation to NICE guidance.
You can use the 2112 rule to convert old HbA1c to new units and vice versa:
old to new:  -2 x 11 -2;
new to old: +2 divided by 11 +2.

b)    Work out Miss HH’s B.M.I. and ideal body weight. Are these relevant?
BMI = wt (kg)                IBW= 50kg (men)/45.5kg (women)
Ht2(m2).                 + 2.3kg for each inch > 5 feet.

c)    Comment on Miss HH’s creatinine and urea: use Cockcroft and Gault’s method to estimate her renal function.

8)    According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?

9)    A nursing student comes to you and tells you Miss HH’s “BMs are 2.3” (Random peripheral blood glucose is 2.3 mmol/L). What are the symptoms of a hypoglycaemic

attack and how would you would treat it? Why do some patients not exhibit any symptoms?

10)    Three months later, Miss HH is taking gliclazide 160mg BD but her blood sugar remains at least 11.5mmol/L most of the day. Three possible options exist other

than starting insulin. Which of the three possibilities below might or might not be suitable for Miss HH? Which would you support? Refer to the NICE algorithm.

a) Exenatide

b) sitagliptin

c) pioglitazone

 

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