Reply to discussion post

30Jan 2022 by

Respond to the posts and provide additional insight that might be useful and appropriate for the issue addressed. Use your learning resources and/or evidence from the literature to support your position

Post:
Summary of my chosen case study: 
The professor put up 2 interesting case scenarios and this nurse obviously got fascinated with one, Gloria Smart, a 55-year-old female who is interested in having a child. Gloria Smart has a history of cardiac stent, with mild hypertension also remarkable for surgical history for tonsils as a child and bunion. The interesting part of this is that Gloria smart still works full time job which she states makes her feel young. She is negative for tobacco and illicit drugs. She has never been married or pregnant before and she is interested in having a child. In this modern day technology, anything is possible. There are life stories of people older than 55 years old that have babies. However, with this patient, she has presenting issues that should not be overlooked. She has history of cardiac stent and taking some heart medications, which may pose a problem with pregnancy, that means the NP, should watch that very closely. Unfortunately as the case scenario narrated, she abrupted a male child who lived 20 minutes because of high blood pressure complications.
Differential diagnosis:
Gestational hypertension (GH) also known as transient hypertension is increased blood pressure during pregnancy without proteinuria, which is expected to return to normal by the 12th-week postpartum visit. PE is GH with proteinuria and /or other systemic manifestations (Yemane, A., et al. 2021) Women with gestational hypertension have high blood pressure that develops after 20 weeks of pregnancy. This very much lines up with patient’s presenting symptoms.
Chronic hypertension: Chronic Hypertension is the term for having high blood pressure and increases your risk for heart attack, stroke, heart failure, or kidney disease. Hypertension is a major public health problem and important area of research due to its high prevalence and being major risk factor for cardiovascular diseases and other complications. Raised blood pressure is a major risk factor for chronic heart disease, stroke, and coronary heart disease. Elevated BP is positively correlated to the risk of stroke and coronary heart disease. Other than coronary heart disease and stroke, its complications include heart failure, peripheral vascular disease, renal impairment, retinal hemorrhage, and visual impairment amongst others. Hypertension (or HTN) or high blood pressure is defined as abnormally high arterial blood pressure. According to the Joint National Committee 7 (JNC7), normal blood pressure is a systolic BP < 120 mmHg and diastolic BP < 80 mm Hg. Hypertension is defined as systolic BP level of ≥140 mmHg and/or diastolic BP level ≥ 90 mmHg (Singh, S., Shankar, R., & Singh, G. P. 2017)  Chronic hypertension with superimposed preeclampsia. Preeclampsia is considered superimposed when it complicates preexisting chronic hypertension. Up to 20–50% of women with chronic hypertension may develop superimposed preeclampsia, an incidence five times or more than that of pregnant women without hypertension  Preeclampsia: Preeclampsia is a pregnancy specific hypertensive disease with multi-system involvement. It usually occurs after 20 weeks of gestation and can be superimposed on another hypertensive disorder. Preeclampsia could also be defined as Gestational Hypertension Associated with New-Onset Maternal or Uteroplacental Dysfunction at or after 20 Weeks’ Gestation. Gestational hypertension is systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90. Blood pressure should be repeated to confirm true hypertension (Henderson JT, Thompson JH, Burda BU, et al. 2017)  Why I made this diagnosis decision:  The diagnosis made very much represents the presenting issues patient Smart presents with. Reading further along in the case scenario presented, it was noted that Patient Smart became pregnant via a donor and unfortunately abrupted after few months with a male child, which was pathetic. The major issue with this patient is not just the age but she presents with high blood pressure issue that eventually resulted in her loosing her baby. The main issue here is cardiological issue. Can a 55-year-old woman without any medical issue have a baby? Yes it’s possible. The man up stairs knows better than we can envision or anticipate.  What is my treatment plan:  My treatment plan is to monitor patient’s blood pressure at each visit. Also have patient monitor blood pressure at home and notify the office of any abnormal readings.  Assess the medications patient is on presently. Are these medications safe to be taken while pregnant?  Zocor and lisinopril are both category x drugs, and it is unknown whether Plavix is safe in pregnancy. The U.S. Food and Drug Administration (FDA) says that statins are not recommended for pregnant women. They are rated as “Pregnancy Category X” drugs, which signifies that studies have shown they may cause birth defects and that the risks clearly outweigh any benefit (Karalis DG, Hill AN, Clifton S, Wild RA. 2016) Clopidogrel can be used throughout pregnancy but it comes with a risk. The primary obstetric risk with the use of clopidogrel is potential increased risk for intrapartum and postpartum hemorrhage. Daily low-dose aspirin use in pregnancy is considered safe and is associated with a low likelihood of serious maternal, or fetal complications, or both, related to use. Order: OTC medication baby Aspirin 81 mg by mouth once a day.  Plan on providing quality education in lieu of patient’s presenting issues especially on eating the right kind of diet, encourage patient to continue exercising at own pace hence BMI is 26 and also resting very well. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend transitioning pregnant patients to methyldopa, nifedipine, or labetalol. Heart failure medications, including beta-blockers, furosemide, and digoxin, are relatively safe and can be used effectively (Kaye AB, et al., 2019) What evidence-based research can you provide to support your decision (choice for differential diagnosis and plan/intervention)? The evidence base research is already provided as stipulated above.  What resources did you use to meet your best practice guidelines? The resources used were the resources provided above with the resources provided by the professor.  Address the ethical dilemmas and/or other issues for your case study:  Ethical issues: The nurses face a lot of ethical issues on a daily basis as we deal with patients and the dilemmas that come with it.  In this case scenario for example, the patient is 55 years old and expresses the need to be pregnant. It is quite ethical for the nurse to adhere to patient’s rights even if a 55 years old woman should not be thinking of having a baby at this age knowing the possible complications, it is quite ethical to provide care to this patient without bias.  Psychological issues: This patient is cognitively intact, patient should be educated on some pregnancy behavioral issues that may arise which are normal with pregnancy most especially some post partum issues that develop after having a baby, slight irritations may occur, anger, crying, joyous and depression as well amongst others. Physical issues: Patient should be informed of Some physical issues or manifestations that may occur during pregnancy like swelling legs, faces, nausea and vomiting, high rise in blood pressure for some people, inability to eat certain food, weight gain etc.    Financial issues: Patient indicates working M-F, it is imperative we lay financial needs on the table for this patient. Procuring a donor is quite expensive, once a patient is pregnant; there is a chance that this patient may not work at all due to age and high blood pressure issues. When a lady is pregnant she is making plans on how to buy things for the baby. There are a lot of financial needs that crop up once a lady is pregnant. Patient should be informed of other help care agencies that help patients’ mostly low-income families. Women infant and children services (WIC0 help provide milk and certain foodstuffs for mum and baby. There are also help with delivery issues with free or minimal payments. Health insurance plays a tremendous role in easing financial worries most especially during pregnancy.  References:  Henderson JT, Thompson JH, Burda BU, et al. (2017) Screening for Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2017 Apr. (Evidence Synthesis, No. 148.) References. Available from: https://www.ncbi.nlm.nih.gov/books/NBK447469/ Karalis DG, Hill AN, Clifton S, Wild RA. (2016) The risks of statin use in pregnancy: A systematic review. J Clin Lipidol. 2016 Sep-Oct;10(5):1081-90. doi: 10.1016/j.jacl.2016.07.002. Epub 2016 Jul 20. PMID: 27678424.  Kaye AB, et al., (2019) Review of Cardiovascular Drugs in Pregnancy. J Womens Health (Larchmt). 2019 May;28(5):686-697. doi: 10.1089/jwh.2018.7145. Epub 2018 Nov 8. PMID: 30407107  Mendis S. World Health Organisation; 2010. Global status report on non communicable diseases 2010. http://www.who.int/nmh/publications/ncd_report2010/en/ [Google Scholar] [Ref list] Singh, S., Shankar, R., & Singh, G. P. (2017). Prevalence and Associated Risk Factors of Hypertension: A Cross-Sectional Study in Urban Varanasi. International journal of hypertension, 2017, 5491838. https://doi.org/10.1155/2017/5491838 Yemane, A., et al. (2021) Gestational hypertension and progression towards preeclampsia in Northern Ethiopia: prospective cohort study. BMC Pregnancy Childbirth 21, 261 (2021). https://doi.org/10.1186/s12884-021-03712-w      Original topic : Review the interactive case studies in this week’s Learning Resources. Select one of the cases to prepare your discussion post. Your post should address the following: Summary of your chosen case study What is your differential diagnosis?  Why did you make this diagnosis decision? What is your treatment plan? What evidence-based research can you provide to support your decision (choice for differential diagnosis and plan/intervention)? What resources did you use to meet your best practice guidelines? Address the ethical dilemmas and/or other issues for your case study: Ethical issues Psychological issues Physical issues Financial issues

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