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NRNP 6566 – Advanced Care of Adults in Acute Settings I Course Guide, Assignments & Examples

NRNP 6566 – Advanced Care of Adults in Acute Settings I (3 credits)

NRNP 6566 – Advanced Care of Adults in Acute Settings I Course Description

This course is the first of four clinical courses in the Adult-Gerontology Acute Care curriculum. Students will explore and integrate concepts of pathophysiology, pharmacology, assessment, and collaborative management of adolescents, adults, and older adults who are acutely/critically ill or experiencing an exacerbation of a chronic health problem. The clinical focus is on the role of the acute care nurse practitioner working with an interdisciplinary team across settings to facilitate the patient’s return to optimal health. Topics include cardiac, pulmonary, and renal issues as well as common diagnostic test and procedures.

Prerequisites

• NURS 6501
• NURS 6512
• NURS 6521
• NURS 6052

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Discussion: Pharmacokinetics and Pharmacodynamics

Impact of Pharmacokinetics on Medication Selection and Administration

As an advanced practice nurse, you will likely be responsible for selecting and prescribing pharmaceuticals to address your patients’ health needs and concerns. To what extent is understanding the pharmacokinetics of a certain medication important in your decision-making process when prescribing a medication for your patient?

Knowing the pharmacokinetic effects of medications—such as how long will the medication be absorbed and exert an effect on the body before it is eliminated—can have important implications for addressing your patient’s health needs.

Photo Credit: Getty Images/Ingram Publishing

For this Discussion, think about the types of decisions you might make, with an understanding of pharmacokinetics, when prescribing medications for your patients. Reflect on how having a working knowledge of pharmacokinetics of medications is important in your role as an advanced practice nurse.

To Prepare

• Review the Learning Resources on pharmacokinetics.
• Review the Discussion Prompt and Response Prompt assigned by your Instructor.

By Day 3 of Week 1

Post your response to the Discussion Prompt assigned by your Instructor. Be specific and provide examples.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Learning Resources

Required Readings (click to expand/reduce)

Doogue, M. P., & Polasek, T. M. (2013). The ABCD of clinical pharmacokinetics. Therapeutic Advances in Drug Safety, 4(1), 5–7. doi:10.1177/2042098612469335

Sakai, J. B. (2008). Practical pharmacology for the pharmacy technician. Philadelphia, PA: Jones & Bartlett Learning. • Chapter 3, “Pharmacokinetics: The Absorption, Distribution, and Excretion of Drugs” (pp. 27–40).

Required Media (click to expand/reduce)

Speed Pharmacology. (2015, April 7). Pharmacology – pharmacokinetics (made easy) [Video file]. Retrieved from https://www.youtube.com/watch?v=NKV5iaUVBUI

NRNP – 6566 Advanced Care of Adults in Acute Settings I Week one DB solved:

Hello, class!

In this first week you are asked to discuss a topic in pharmacotherapy. Your initial post must respond to the following initial post topic. For one of your response posts, you must address the response topic below.

Here are the required topics for the Week 1 Discussion:

Initial Post Topic

• Explain why administering warfarin and amiodarone cause increased levels of both medications. Describe the monitoring and dosage alterations necessary if both drugs are prescribed.

Response Post Topic- include this requirement into one of your responses. Remember you must post 2 replies, each on separate days.

• Explain another combination of medications that affects the pharmacokinetic processes in the body. Describe the monitoring and dose alterations needed to counter the combined effects.

**Remember that according to University policy, you must wait until day one of the course to post your initial discussion post.**

Branching Exercise: Cardiac Case 1: 63 Year Old Female

Branching Exercise: Cardiac Case 1: 63 Year Old Female

Week 2: 12-lead EKG Interpretation and Diagnostic Evaluation of Arrhythmias

Much like problems with a home’s heating and cooling system, arrhythmias begin with symptoms that often require expertise to diagnose. The symptoms of arrhythmias are routinely among the leading reasons for emergency room visits. Palpitations, racing hearts, anxiety, irregular heartbeats, and chest pain often alert sufferers to the potential for bigger problems. This puts cardiology squarely in the spotlight as the branch of medicine responsible for addressing not only arrythmias but the many cardiac and circulatory disorders that afflict so many each year.

As an advanced practice nurse, you must be prepared to effectively recognize, respond, diagnose, and treat these symptoms. Hence, it is important for nurses at every level of care to demonstrate expertise in heart arrhythmias as a component of cardiovascular care.

This week, you examine issues pertinent to arrhythmias. You examine diagnosis and management approaches to heart rhythm issues and the health problems that may trigger them. You also examine the tools used to help recognize and respond to these issues. 

Learning Objectives

Students will:

• Interpret 12-lead EKGs
• Discern arrhythmias within 12-lead EKGs
• Develop appropriate treatment plans, including diagnostics and laboratory orders for patients with identified arrhythmias

NRNP 6566 Branching Exercise: Cardiac Case 1 Assignment

Description

Assignment: Branching Exercise: Cardiac Case 1

For this Assignment, you will review the interactive media piece/branching exercise provided in the Learning Resources. As you examine the patient case, consider how you might assess and treat patients with the symptoms and conditions presented.

Photo Credit: [IMAGEMORE Co., Ltd.]/[none]/Getty Images

To prepare:

• Review the information provided in the case (patient presentation, vital signs, pmh, home meds, results of labs and diagnostics. With this information, critically think about what is happening with the patient.
• Use your critical thinking skills and current guidelines to develop orders. Include additional labs/diagnostics, what needs repeated and followed up on. Medications that need to be ordered or changed.

The Assignment:

• Using the required admission orders template found under the Learning Resources: Required Reading.
• Develop a set of orders as the admitting provider.
• Be sure to address each aspect of the order template
• Write the orders as you would in the patient’s chart. Be specific. Do not leave room for the nurse to interpret your orders.
• Do not assume anything has already been done/order. Use the information given. Example: If the case does not mention fluids were given, the patient did not receive fluids. You may have to start from scratch as if you are working in the ER. And you must provide orders if the patient needs to be admitted.
• Make sure the order is complete and applicable to the patient.
• Make sure you provide rationales for your labs and diagnostics and anything else you feel the need to explain. This should be done at the end of the order set – not included with the order.
• Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is the appropriate standard of care for this patient.
• A minimum of three current (within the last 5 years), evidenced based references are required

By Day 7 of Week 2

Submit your completed Assignment by Day 7 of Week 2 in Module 2.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “MD2Assgn1+last name+first initial.(extension)” as the name.
• Click the Module 2 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
• Click the Module 2 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “MD2Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

CASE STUDY INFORMATION:

BACKGROUND

Scenario #1 63 year old female (Branching Exercise: Cardiac Case 1: 63 Year Old Female)

• • 63-year-old female presents to the Emergency Department complaining of dizziness and shortness of breath.

VITAL SIGNS

• • PMH: HTN, Diabetes, TIA
  • Home Meds: Lisinopril, Metformin
  • Allergies: Penicillin
  • HR: 180, O2 Sat 94%, BP: 107/78, RR: 21
  • The patient is a full code

• • Atrial Fibrillation with Rapid Ventricular Response
  • 12 lead EKG, TSH, CBC,CMP, INR
  • Metoprolol tartrate 2.5mg IV bolus over 2 minutes (Rate control in this patient is the first priority in order to enable ventricular filling and cardiac output. Anticoagulation is indicated unless there is a contraindication. Rate control and anticoagulation are the priority then Cardiology will advise on TEE/Cardioversion.)

Learning Resources – Branching Exercise: Cardiac Case 1: 63 Year Old Female

Required Readings (click to expand/reduce)

Barkley, T. W., Jr., & Myers, C. M. (2020). Practice considerations for the adult-gerontology acute care nurse practitioner (3rd ed.). Barkley & Associates.

• Chapter 21, “Arrhythmias” (pp. 263–290)

Fuller, V. J., & McCauley, P. S. (2023). Textbook for the adult-gerontology acute care nurse practitioner: Evidence-based standards of practice. Springer Publishing Company.

Tachycardia’s, pp. 106-109

Harris, C. (2023). Adult-gerontology acute care practice guidelines (2nd ed.). Springer Publishing Company.

Arrhythmias, pp. 54-58

Document: Admission Orders Template (Word document)Download Admission Orders Template (Word document)

Document: Admission Orders Template (Word document)

Required Media (click to expand/reduce)

MedCram. (2019, June 9). ECG interpretation explained clearly and succinctly – arrhythmias, blocks, hypertrophy [Video file]. Retrieved from https://www.youtube.com/watch?v=Rv6l0ViRJDQ

MedCram. (2018, July 15). ST elevation – EKG/ECG interpretation case 12 (STEMI, MI, ACS) [Video file]. Retrieved from https://www.youtube.com/watch?v=8ajWCLqz3VQ

MedCram. (2017, July 23). EKG/ECG practice strip interpretation explained clearly – case 10 [Video file]. Retrieved from https://www.youtube.com/watch?v=zA1Dpwnzrxg

Walden University (Producer). (2019a). Branching exercise: Cardiac case 1 [Interactive media file]. Minneapolis, MN: Author.

Walden University (Producer). (2019a). Branching exercise: Cardiac case 1.[Interactive media file]. Minneapolis, MN: Author.

Antiarrhythmic Drugs for the AGACNP

Dr. Tony Anno, core faculty for the AGACNP program at Walden University reviews that cardiac cycle and arrythmia pathophysiology. A review and discussion on the use of antiarrhythmic drugs that the AGACNP may encounter in practice is also provided. (18m)

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript

ECG Review for the AGACNP

Dr. Tony Anno reviews important concepts and skills needed in understanding and interpreting ECGs for the AGACNP in practice. This review will also build upon you previous knowledge and expertise in diagnosing and treating cardiac disorders. (14m)

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript

LEARNING RESOURCES

Required Media

The assignment this week is the branching exercise.  You can go through the exercise as much as you want, until it is submitted.  You can only submit the assignment one time for grading.   Your assignment at the end of the exercise is to write orders that reflect your treatment plan for this patient.  The template for your order set is located in the required reading. Please be sure that you are writing specific orders exactly as you would in a patient’s chart.    The assignment is due by Sunday. 

Admission Orders Template

Primary Diagnosis:

Status/Condition (Critical, Guarded, Stable, etc.):

Code Status:

Allergies:

Admit to Unit:

Activity Level:

Diet:

IV Fluids:

 Critical Drips (If ordered, include type and rate. Do not defer to ICU protocol.):

Respiratory: Oxygen (If ordered, include type and rate.), pulmonary toilet needs, ventilator settings:

Medications (include ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc., dose and route):

Nursing Orders (vital signs, skin care, toileting, ambulation, etc.):

Follow-Up Lab Tests:

 Diagnostic testing (CXR, US, 2D Echo, etc.):

Consults:

NOTE: (Do not defer management to a specialist. As an ACNP, you must manage the patient’s acute needs for at least a 24-hour period]. Include indication for consult. For example: “Cardiology consult for evaluation of new-onset atrial fibrillation,” or “Nutrition consult for TPN recommendations.”

Patient Education and Health Promotion (address age-appropriate patient education. if applicable):

Discharge Planning and Required Follow-Up Care:

References (minimum of three timely references that prove this plan follows current standards of care):

NRNP 6566 Branching Exercise: Cardiac Case 2

Description

• Review the interactive media under Required Media: Branching exercise. This is provided in the Learning Resources.
• Review the information provided in the case (patient presentation, vital signs, pmh, home meds, results of labs and diagnostics. With this information, critically think about what is happening with the patient.
• Use your critical thinking skills and current guidelines to develop orders. Include additional labs/diagnostics, what needs repeated and followed up on. Medications that need to be ordered or changed.

The Assignment:

• Using the required admission orders template found under the Learning Resources: Required Reading.
• Develop a set of orders as the admitting provider.
• Be sure to address each aspect of the order template
• Write the orders as you would in the patient’s chart. Be specific. Do not leave room for the nurse to interpret your orders.
• Do not assume anything has already been done/order. Use the information given. Example: If the case does not mention fluids were given, the patient did not receive fluids. You may have to start from scratch as if you are working in the ER. And you must provide orders if the patient needs to be admitted.
• Make sure the order is complete and applicable to the patient.
• Make sure you provide rationales for your labs and diagnostics and anything else you feel the need to explain. This should be done at the end of the order set – not included with the order.
• Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is the appropriate standard of care for this patient.
• A minimum of three current (within the last 5 years), evidenced based references are required.

INFORMATION NEEDED:

• An 84-year-old female is brought in by family with complaints of increased confusion and lethargy.
• Patient usually lives alone and is fully functional.
• Son reports that she has been increasingly confused and sleeping a lot at home.
• Son denies any fever.
• Patient complains of pain “all over” and responds to repeated questions with “I think I’m sick”
• She has a DNR status but wants full treatment at this time.

EXAM

• • BP 105/64, HR 115, RR 24, T 96॰ F, SpO2 92% on room air
  • Patient is alert and oriented to person, however, thinks the year is 1990
  • PMH: HTN and Diabetes
  • Home Med: Metoprolol, Insulin, Lantus 10mg at bedtime, Calcium
  • NKDA
  • Initial 12-Lead EKG to assess myocardial function
  • CBC to assess for leukocytosis (increased WBC) and potential anemia
  • CMP to assess electrolyte disturbances, liver and renal function. And potential for DKA
  • Urinalysis to assess for potential UTI
  • Chest X-ray to assess for infiltrates (pneumonia)

RESULTS OF INDICATED TESTS

Complete Blood Count (CBC)

WBC 3.4 k/UL
Hgb 9.3 g/dL
Hct 28%
Platelets 250 k/UL
Differential
Neutrolphil 90%
Bands 10%
Eosinophil 0%
Basophil 0%
Lymphocyte 2%
Monocyte 3%

Complete Metabolic Panel (CMP)

NA+ 132 mEq/L
K+ 3.7 mEq/L
HCO# 27 mEq/L
Cl- 101 mEq/L
Glucose 1766
BUN 55 mg/dL
Creatinine 2.0 mg/dL
Albumin 3.2g/dL
Alkaline Phosphatase 99 IU/L
ALT 38 IU/L
AST 30 IU/L
Total Bilirubin 2.1 mg/DL

Urinalysis (U/A)

Color: Yellow
Clarity: Dark/Cloudy
Sp gravity 1.042
pH 6.2
Total Protein: Negative
Glucose: Positive
Ketones: Negative
Bilirubin: Negative
RBCS: 10
WBC: 12
Leukocyte Esterase: 3+
Nitrite: Positive

Because the patient has circulatory compromise (hypotension, altered mental status) she is in septic shock.

Septic Shock is a subset of sepsis with circulatory and/or cellular or metabolic dysfunction. Patients will have hypotension, decreased urine output, altered mental status-signs of organ damage

Associated with a higher risk of mortality

Aggressive resuscitation and early initiation of septic protocols are a must

Admission Orders Template

Primary Diagnosis:

Status/Condition (Critical, Guarded, Stable, etc.):

Code Status:

Allergies:

Admit to Unit:

Activity Level:

Diet:

IV Fluids:

 Critical Drips (If ordered, include type and rate. Do not defer to ICU protocol.):

Respiratory: Oxygen (If ordered, include type and rate.), pulmonary toilet needs, ventilator settings:

Medications (include ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc., dose and route):

Nursing Orders (vital signs, skin care, toileting, ambulation, etc.):

Follow-Up Lab Tests:

 Diagnostic testing (CXR, US, 2D Echo, etc.):

Consults:

NOTE: (Do not defer management to a specialist. As an ACNP, you must manage the patient’s acute needs for at least a 24-hour period]. Include indication for consult. For example: “Cardiology consult for evaluation of new-onset atrial fibrillation,” or “Nutrition consult for TPN recommendations.”

Patient Education and Health Promotion (address age-appropriate patient education. if applicable):

Discharge Planning and Required Follow-Up Care:

References (minimum of three timely references that prove this plan follows current standards of care):

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