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Integrated Nursing Practice 4

1. Review Patients Background and History. Ms Ruby Pascal Has Multiple Comorbidities Including Diabetes Mellitus Type 2.

a. Identify and discuss (2) signs and symptoms that support a diagnosis of diabetes melitus type 2. 

b. Using evidence, compare and contrast the pathophysiology of type 1, type 2 and gestational diabeties melitus.

ANSWER 1(a) : According to the simulation we can see that the

(1) In Ruby’s medical history she is described as a patient of Diabates Type 2 .she is diagnosing herself with the Metformin SR 2000 mgs nocte. she is facing difficulty in controlling her diabetes with old medications. She is also taking paracetamol and antacids to counter the consequences of increasing diabetes level.

(2) In Ruby’s medical history we also found that her anxiety level is rising which may also a cause of higher diabetes. She herself tripled the dose what she was taking before the higher anxiety level.

b. Using evidence, compare and contrast the pathophysiology of type 1, type 2 and gestational diabeties melitus.


Type 1 Diabates

Another form of insulin, which accounted for just 4-11% of others with insulin, historically characterized by the terms insulin-dependent diabetes, form high cholesterol, or adolescent-onset diabetes, resulted from cell-mediated autoimmune destruction of the β-cell pancreatic. (Norman A, Henry H, 2015 pp: 136-137) Markers of β-cell receptor disruption involve

allogeneic autoimmune reactions, insulin autoimmune reactions, ornithine glutamic acid antibody titers (GAD65), and antibody titers for amino acid phosphatases.

Type 2 Diabates

This form of disease, which provides for around Ninety and 98 percent of the population with diabetic, usually referred to as pseudo-insulin-dependent diabetes (Norman A, Henry H, 2015 pp: 136-137) with type II insulin, or individual-onset diabetes, includes persons with insulin resistance and who usually have a significant (rather than an absolute) insulin deficit. This form of diabetes may have multiple causes.

Gestational Diabates Melitus

Gestational diabetes mellitus (GDM) is a severe childbirth condition in which individuals, given proven diabetes, suffer chronic hyperglycemia at birth. (Norman A, Henry H, 2015 pp: 136-137) In certain instances, this lactic acidosis is the product of impaired insulin production in the context of chronic insulin tolerance owing to β-cell pancreatic dysfunction. Obesity and hypertension, old premature birth and certain form of diabetes family history are reasons for GDM.

2 .Obesity Is a Significant Risk Factor for Diabetes Melitus Type 2. Discuss how Obesity Is Diagnosed and Describe (2) Physiological Effects It Can Have on The Body


(1) Fatness is regarded as the causal factor for certain anti-communicable disorders such as cardiac disease, type 2 diabetes, cholesterol, lung failure, or certain predisposing factors. This causes in turn different neurological conditions or physiological disabilities as well. According to the WHO, fat and obese blame for 44% of diabetic incidents, 23% of clinicians with atherosclerosis and only about 7–41% of other tumors.

(2) Style 2 diabetic is most strongly associated with depression, as well as the prevalence of cardiovascular disease-related diabetes is expected to rise towards 300 millions by 2030. This strong relation has led to the overtone of 'diabesity,' illustrating the reality that too many insulin sufferers are overweight or overweight. Around each other, these raise risk of death by fivefold for people. According to the World Health Organization (WHO), obesity is now the greatest public health problem in this world, and it is rising as a threat for public health greater extreme than deprivation.

3. Ms Pascal’s Acute Deterioration in The First Simulation Scenario Is Due to A Pulmonary Embolism.R

A. Identify and Discuss (1) Risk Factor Ms Pascal Has for Developing a Pulmonary Embolism.


In simulation we found that Ruby is facing the chest pain and has been admitted before due to the anxiety attack.she is facing chest pain with nausea and vomiting. she is also facing anxiety disorder for a long time. For pulmonary embolism if we see its symptomps we will find that Ms. Pascal is having some of the symptomps included in her medical condition like chest pain , vomiting and nausea for a long time. The risk factors for pulmonary embolism for Ms. Ruby are

Extended bed rest or lack of activity, like lengthy rides in a vehicle or a plane.

using hormonal contraceptives (birth control pills).


maternity procedure – heart attack operation before, before and after childbirth.

b. Discuss how you would educate Ms Pascal about the diagnosis and treatment of a pulmonary embolism, including information you would give and how you would deliver this information

Answer: we will first get the full information about Ms. Pascal’s current health and pulmonary embolism as well. We then tell Ruby about the what is pulmonary embolism , what are its consequences and risk factors. We will also let her know about how she is prevailing the symtomps of pulmonary embolism in her medical conditions.after making her educated about pulmonary embolism’s diagnosis we will deliver the procedures accepted and suitable for her to counter pulmonary embolism like anticoagulant drugs heparin, warfarin and enoxaparin etc.

4. Using your understanding of the clinical reasoning cycle:

a. Identify one priority clinical nursing problem that Ms Pascal is experiencing related to her pulmonary embolism

Answer: Ms. Pascal is having chest pain and the nausea and vomiting as well. So, on the basis of these symptoms we can say that she is vulnerable to pulmonary embolism. For priority we will start to give her anticoagulant drugs for reducing its risk.

b. From the identified clinical priority nursing problem, state one (1) short term goal for Ms Pascal’s management using the SMART framework.

Answer: one short term goal is to keep patient happy so , she can counter the GAD and her risk of pulmonary embolism as well. We can also help her by giving her anticoagulant drugs like heparin and can also give her proper medication suitable for GAD.

c. Based on the short-term goal, state and justify (2) interventions (nursing, collaborative or pharmacological) which would assist to achieve Ms Pascal’s short-term goal. 

Answer: For achieving short term goals defined for Ms. Pascal , there are some steps to be taken

(1) provide proper care to her and keep regularly check of her health.

(2) Provide happy atmosphere to her to counter the risk of GAD.

(3) Provide her anticoagulant drugs with suitable doses for her.

(4) provide her medications related to GAD as GAD can also trigger the risk of pulmonary embolism.

d. Provide and justify two (2) ways you would evaluate the outcomes of your interventions (one for each intervention)

Answer: we can evaluate of the effectiveness of the intervention through their outcomes. We can evaluate them as (D. John Reynolds; Jamie Coleman; Jeffrey Aronson , 2018 pp: 432)

(1) By observational study in this we will examine the daily routine habits of her as her eating habits , working habits and other habits as well compare her habit effectiveness before and after medications.

(2) By regular health checkup in this we will examine her health improvement by dong various health checks of her and will compare trends before and after medication . on the basis of it we will decide whether medication is effective or not.

5. Review Standard 8 of the NSQHS. Identify and discuss two (2) strategies to ensure that patient deterioration is identified early and managed appropriately by nurses in the acute care setting. Justify each with evidence.


(1) Performing a thorough skin examination in timescales set out in good practice guidance for individuals with a significant risk of experiencing stress injuries at present, periodically as clinically recommended during treatment and before departure there are many patients which are benefitted by this assessment. This assessment give early risk signs to clinical staff regarding health issue.

(2) Recognizing health conditions for stress accidents use an established diagnostic method for all clinicians participating in the good practice guidance. This is an effective method as we find that Ms. Ruby has been admitted in hospital before now. So she is more vulnerable to health issues. So, this strategy will help more to clinical staff to serve her in a better way.

6. During the second simulation scenario, Ms Pascal requires anticoagulation therapy. In relation to Ms Pascal’s clinical scenario:

a. Discuss the pharmacokenetics of heparin and warfarin and compare and contrast their use in the management of a pulmonary embolism.

Answer: Heparin (O'Sullivan, Susan , 2017 pp: 60)is a potent anticoagulant (blood thinner), which works rapidly. It is typically provided by IV (a thin needle implanted in a vein) in the hospital, although it may also be delivered by an injection under the arm. IV heparin works fast; many patients have superb anticoagulation within minutes of acquiring it, which should avoid further coagulation.

Warfarin (Coumadin) is a mouth-taking, anticoagulant drug. Patients are prescribed warfarin for various reasons. Some people will take warfarin for a few weeks; some will continue to take warfarin for the rest of their life. The period of therapy depends on the cause a patient requires anticoagulants.

Warfarin acts by delaying the cycle in the kidney that produces some substances (coagulation variables) that induce coagulation utilizing vitamin K.

b.Identify two (2) medications that may interact with warfarin.

Answer: Metformin.


c. Review Standard 4 of the NSQHS. Using the standard and other relevant literature, identify and justify two (2) nursing considerations when administering anticoagulant therapy.


Ensure the relevant and reliable knowledge and decision support resources for medicinal goods are freely accessible to the healthcare community in making medicinal decisions.

Identifying and ensuring that high-risk drugs are processed, prepared, dispensed and delivered appropriately throughout the organization.

7. Ruby also has General Anxiety Disorder, therefore good communication is an integral in making sure she receives person centred care.

a. Discuss the difference between Anxiety and General Anxiety Disorder (GAD)



One natural aspect of life is feeling mild anxiety. However, individuals with anxiety problems also have serious, constant and recurrent thoughts regarding daily circumstances and fears. Distress disorders also include frequent periods with extreme feelings with severe anxiety and fear or paranoia hitting a high in a matter of minutes (panic attack).


Generalized anxiety disorder (GAD) (Rif S. El-Mallakh; S. Nassir Ghaemi ,2 April 2017 pp. 158-159) is an anxiety condition marked by intense, uncontrollable and sometimes unfounded anxiety regarding events or activities .This extreme anxiety frequently interferes with day-to-day life, and patients become excessively worried with daily concerns such as safety, income, mortality, family issues, issues of relationships, human relationship issues, or job related issue.

b.Identify and explain the assessment tool used to screen for GAD

The K-ANX displayed outstanding internal stability (α=0.97) and item-total coefficients (0.92–0.97), which implied a single-factor structure.( Barrett ML, Smith MW, Elizhauser A, Honigman LS, Pines JM ,December 2014 pp: 653 ) Both elements were closely associated with the BAI, GAD-7, and Rutgers Concern Survey overall ratings. The IRT study showed that the K-ANX was the most useful method for evaluating anxiety conditions varying from 0.8 to 1.6 (i.e., maximum 21.2 to 5.5 quintiles). Higher responsiveness (0.795) and specificity (0.937) for anxiety condition detection were observed in K-ANX relative to BAI and GAD-7.

C .The first step in undertaking any nursing assessment of a person with an anxiety disorder is to develop raport and a working therapeutic alliance. Discuss what is meant by this and justify why it is important.


A medical alliance's critical essence isn't a novel concept. Carl Rogers published an essay in the Field of Clinical Psychology in 1957 describing the reasons he considered necessary to promote a positive shift in behavior by counseling. ("The top 10 causes of death Fact sheet N°310". World Health Organization., 2018 pp : 154 ) Four of the six topics discussed the connection between client and therapist explicitly. Rogers believed that the therapist must be sincerely interested in the counseling process Provide absolute constructive regard for the client Feel empathy for the client.

Many practitioners have a common philosophy, approach or school of thinking that they follow, be it cognitive behavioral counseling, solution-focused counseling, strength-based, mental treatment, person-centered, Adlerian or other. And both of these Therapeutic-alliance branding strategies and methods share at least one aspect in common — their future efficacy is likely to be squelched until the psychologist succeeds in establishing a solid therapeutic relationship with the person.

d. Anxiety levels range from mild, moderate, severe and panic. Identify and justify two (2) physiological characteristics of a severe anxiety levels


Unreasonable fear is the maximum degree, where you may avoid thought objectively and feel extreme distress. You can feel afraid and frustrated, upset, disconnected and that you can find it very difficult to think straight, too. The breathe can get quicker and you can tend to swell as your limbs seem really tight.

e. Ruby is experiencing a severe anxiety episode. Identify two (2) nursing interventions (excluding pharmaceutical) and provide a rational

Answer: We saw that Ruby is facing the severe anxiety disorder. For this there are two interventions that will help her to counter the risk of anxiety disorder.


The major neurotransmitter routes derive (Torio CM, Andrews RM. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011 pp: 160-162) from the hypothalamus in the dorsal tegmental region and substantia nigra, with amygdala, amygdala, brain's nuclei, and infundibulum predictions. The function of dopamine in normal and neurological dysfunction states of anxiety is complicated, and serotonergic receptors may influence levels of distress in many ways.

Gamma-aminobutyric acids

GABA is the spinal cord (CNS)'s primary excitatory neurotransmitter. Rises in GABA synaptic plasticity mediate the analgesic activity of barbiturates and benzodiazepines.49 Drugs in such groups may not specifically bind to the GABA receptor; rather, they facilitate an open chloride channel structure.

8.Ms Pascal has multiple comorbidies requiring complex interdisciplinary care both in hospital and on discharge.

a. Define interdisciplinary care and discuss why it is important in achieving patient centred care.

Answer: An interdisciplinary strategy (D. John Reynolds; Jamie Coleman; Jeffrey Aronson (10 November 201 1 pp:765-768 ).includes team leaders from diverse backgrounds working together, for a shared intent, to set objectives, make choices and exchange expertise and obligations.

It is important because an interdisciplinary strategy will strengthen medical safety, healthcare systems and engagement rates. It will also reduce the duration of stay to prevent repetition of appraisals resulting in more detailed to balanced treatment documentation

b. Identfy two healthcare professionals in the community that Ruby should be referred to on discharge to assist and justify why they are essential in Ruby’s ongoing care.

Answer: Dr. Alex Clark

Dr. Saphrine George.

C.Identify and justify two (2) nursing responsibilities to help prepare Ruby for discharge.


Hospital departure defines the stage when medical service ceases, with continuing treatment being moved to many other primary, group, or domestic settings. (Gonçalves-Bradley, Daniela C.; Lannin, Natasha A; Clemson, Lindy M; Cameron, Ian D; Shepperd, Sasha ,2016 pp: 142 )In this sense, hospital discharge is not an end stage, but instead one of the steps within the treatment process of the person.

• Ensure that directives, debriefings and examinations are performed in a timely manner.

• Communicate patients and their family referral outlets as needed.

References for Integrated Nursing Practice 4

Rif S. El-Mallakh; S. Nassir Ghaemi (2 April 2017). Bipolar Depression: A Comprehensive Guide. American Psychiatric Pub. p. 158. ISBN 978-1-58562-651-9. Stephen M. Stahl; Bret A. Moore (13 February 2013). Anxiety Disorders: A Guide for Integrating Psychopharmacology and Psychotherapy. Routledge. p. 65. ISBN 978-1-136-44588-0. Ø D. John Reynolds; Jamie Coleman; Jeffrey Aronson (10 November 2018). Oxford Handbook of Practical Drug Therapy. Oxford University Press. p. 432. ISBN 978-0-19-956285-5..

Torio CM, Andrews RM. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. HCUP Statistical Brief #160. Agency for Healthcare Research and Quality, Rockville, MD. August 2013. [1]

Barrett ML, Smith MW, Elizhauser A, Honigman LS, Pines JM (December 2014). "Utilization of Intensive Care Services, 2011". HCUP Statistical Brief #653. Rockville, MD: Agency for Healthcare Research and Quality. Ø Norman A, Henry H (2015). Hormones. Elsevier. pp. 136–137. ISBN 9780123694447. Ø "The top 10 causes of death Fact sheet N°310". World Health Organization. October 2018. Archived from the original on 30 May 2017.

O'Sullivan, Susan (2017). "Physical Rehabilitation", p.60, 512, 720. F.A. Davis, Philadelphia. ISBN 0-8036-1247-8

Gonçalves-Bradley, Daniela C.; Lannin, Natasha A; Clemson, Lindy M; Cameron, Ian D; Shepperd, Sasha (2016-01-27). "Discharge planning from hospital". Cochrane Database of Systematic Reviews (1): CD000313. doi:10.1002/14651858.cd000313.pub5. PMC 7073416. PMID 26816297.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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