Assignment: Clinical Practice DNP 805
Assignment: Clinical Practice DNP 805
Assignment: Clinical Practice DNP 805
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Hypertension Clinical Practice Guidelines
Hypertension is defined as high systolic blood pressure (SBP) above140 mm Hg and diastolic blood pressure (DBP) above 90 mm Hg, in two or more measurements taken in two or more interactions after the initial recording. In this essay, the author will discuss Hypertension, including its prevalence in the US, the pathophysiology, and its presentation. They will also review the clinical practice guidelines that are used in the management of Hypertension and discuss how they are applicable in the primary care setting. Lastly, the author will provide a clinical practice encounter and compare the treatment offered to the patient with the recommendations from the guidelines.
Prevalence of Hypertension in the United States
Hypertension is the most common condition in the United States (US) and globally too. A report by Centers for Disease Control and Prevention (CDC) revealed that in 2017, approximately 75 million American adults have high BP, which accounts for one in every three adults (Zhou et al., 2018). One-third of adults have pre-hypertension and only 54% of Americans with hypertension have their blood pressure under control. Hypertension has predisposed Americans to conditions such as stroke, vascular diseases, myocardial infarction, and chronic kidney disease (Zhou et al., 2018). Furthermore, hypertension has contributed to maternal mortality, and it accounts for about 7.4% of pregnancy-related deaths annually (Ananth et al., 2018). It is also associated with pregnancy complications such as eclampsia, placental abruption, renal failure, and disseminated intravascular coagulation.
Pathophysiology
Blood pressure is the product of cardiac output and peripheral resistance, and an elevation of one or both results in elevated blood pressure. In high blood pressure, there is usually a dysfunction of the control systems that monitor and regulate blood pressure (Delacroix, Chokka & Worthley, 2014). Hypertension is caused by various factors including increased sympathetic nervous system activity caused by a dysfunction in the autonomic nervous system (Garcia & Marin-Castaño, 2014). Further, increased reabsorption of water, sodium, and chloride ions in the kidneys also lead to the condition (Delacroix, Chokka & Worthley, 2014). Another causative factor includes increased renin-angiotensin-aldosterone system activity that results in an increased extracellular fluid volume and systemic vascular resistance resulting in an increased BP (Garcia & Marin-Castaño, 2014). In addition, increased arterial vasoconstriction caused by dysfunction of the vascular endothelium results in an elevated vascular resistance causing an elevated BP.
Clinical Presentation of Hypertension
Hypertension is often referred to as the ‘silent killer’ since most patients are asymptomatic, and it is mostly diagnosed during a routine checkup. The most common symptom is headache in the occipital region (Garcia & Marin-Castaño, 2014). The specific sign of hypertension includes an elevated systolic BP of above 140 mm Hg or diastolic BP ab 90 mm Hg (Delacroix, Chokka & Worthley, 2014). Other signs of high BP are mostly a result of vascular damage and include retinal hemorrhage.
Application of Clinical Practice Guidelines in Primary Care
A panel of members appointed to the Eighth Joint National Committee (JNC 8) developed the clinical practice guidelines for the management of hypertension. James and Oparil headed the panel and had full access to the data used in the study (James et al., 2014). The original guidelines, JNC 1, were published in 1977, and the guidelines have been revised over the years (Kotchen, 2014). The 2nd to 8th publications were released in the years 1980, 1984, 1988, 1993, 1997, 2003, and 2014 respectively (Kotchen, 2014). The seven guidelines reports released between1977 to 2003 were published by the National Institutes of Health (NIH), under the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.
The JNC 8 guidelines are applicable in the primary care setting since it guides health care providers on the pharmacological regimen and steps to use in the management of hypertension. It also recommends the approach in initiating treatment in individuals older or younger than 60 years, and black and non-black populations. Besides, it guides the pharmacological approach to use on patients with hypertension and diabetes or chronic kidney disease.
Key Action Statements & Body of Evidence
The JNC 8 recommendation 1 for individuals above 60 years is to initiate pharmacological management to lower BP of more 150/90 mmHg to a target of below 150/90 mm Hg (James et al., 2014). It is based on substantial evidence from a randomized controlled trial (RCT), which revealed that in individuals aged above 60 years, managing BP to a target of below 150/90 mm Hg lowers the rate of CVA, cardiac disease, and heart failure.
Recommendation 2 states that in individuals below the age of 60 years, initiate medication to lower DBP of 90 and above to below 90 mm Hg (James et al., 2014). This is a strong recommendation for age 30 to 59 years but an expert opinion for age 18-29 years. Recommendation 2 is based on strong evidence from five trials that showed an improved health outcome among individuals aged 30 to 59 years with an elevated BP by reducing the rate of stroke, heart failure, and mortality.
Recommendation 4 is an expert opinion and states that in patients above18 years with CKD, commence treatment to lower SBP of above 140 or DBP of above 90 to an SBP less than 140 and DBP below 90 mm Hg (James et al., 2014). The recommendation also applies to patients below 70 years with a GFR below 60 mL/min/1.73 m2 and any individual with albuminuria (James et al., 2014). Moderate evidence demonstrates that there is no value in slowing the progression of kidney disease from management with antihypertensive medication to a target BP of less than 130/80 compared to a goal of less than 140/90.
Recommendation 5 is an expert opinion and states that in individuals above 18 years with Diabetes, begin treatment to lower BP higher than 140/90 to a goal of less than 140/90 mmHg(James et al., 2014). There is moderate evidence from three trials that shows that lowering SBP to a goal of below 150 mm Hg improves cerebrovascular and cardiovascular health outcomes and decreases mortality.
Recommendation 6 proposes that in the non- black population, the initial treatment should include a thiazide diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) (James et al., 2014). The evidence is based on RCTs that proved that each of the four drugs produced similar effects on mortality, cardiovascular, kidney, and cerebrovascular outcomes but not in heart failure. Thiazide diuretic had better outcomes than CCB or ACEI, while ACEI was better than CCB in improving heart failure outcomes.
The guidelines provide a medication titration strategy with three options. The first strategy is to maximize the first drug before adding a second drug, and the second option is to add a second drug before reaching the maximum dose of the first medication (James et al., 2014). The third option is, to begin with, two medications separately or in combination as a fixed-dose.
Application in Clinical Practice
A 65-year-old Hispanic female patient with controlled hypertension came in the E.D with complaints of chest pain, heart palpitations, and dyspnea on exertion and at rest. The BP was 146/94 mm Hg, and the pulse was weak and rapid. Physical exam findings and diagnostic tests pointed to a diagnosis of congestive heart failure secondary to hypertension, and she was initiated on HCTZ 25 mg OD. Health education on lifestyle modification was reinforced. After two weeks, the BP was at 144/96 mm Hg, and the HCTZ dose was increased to 50 mg BD and started on Nifedipine 30 mg OD.
Initiating treatment with HCTZ and provision of health education on lifestyle modification was right as per JNC 8 guidelines. Modifying the dosage when the targeted BP was not achieved was as per guidelines which indicate that the first medication should be increased to improve the outcome. However, to improve the health outcome, the HCTZ dose should have first been maximized before adding Nifedipine. Alternatively, the HCTZ dose should have remained unchanged, and an ACEI added to the regimen instead of Nifedipine, which is a CCB, to improve the outcome of heart failure.
Conclusion
Hypertension is an elevated blood pressure of more than 140/90 mm Hg recorded at two or more interactions after an initial measurement. JNC 8 recommends initiating pharmacological interventions to lower BP of 140/90 and above to a goal of below 140/90 mm Hg to reduce the risk of CVA, coronary heart diseases, and heart failure and improve overall outcome. Medication should include a thiazide diuretic, CCB, ACEI, or ARB, but Thiazide diuretics are more effective. Health education on lifestyle modification is the first-line management and should be reinforced in every patient encounter.
References
Ananth, C. V., Duzyj, C. M., Yadava, S., Schwebel, M., Tita, A. T., & Joseph, K. S. (2019). Changes in the Prevalence of Chronic Hypertension in Pregnancy, United States, 1970 to 2010. Hypertension, HYPERTENSIONAHA-119.
Delacroix, S., Chokka, R. G., & Worthley, S. G. (2014). Hypertension: Pathophysiology and treatment. J Neurol Neurophysiol, 5(250), 3.
Garcia, P. J. M., & Marin-Castaño, M. E. (2014). Angiotensin II-related hypertension and eye diseases. World journal of cardiology, 6(9), 968.
James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D.T., LeFevre, M.L., MacKenzie, T.D., Ogedegbe, O. & Smith, S. C. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Jama, 311(5), 507-520.
Kotchen, T. A. (2014). Developing hypertension guidelines: an evolving process. American journal of hypertension, 27(6), 765-772.
Zhou, D., Xi, B., Zhao, M., Wang, L., & Veeranki, S. P. (2018). Uncontrolled hypertension increases risk of all-cause and cardiovascular disease mortality in US adults: the NHANES III Linked Mortality Study. Scientific reports, 8(1), 9418. DOI:10.1038/s41598-018-27377-2
Details:
For this assignment, select one clinical practice issue that involves a specific medication. Using a Computerized Provider Order Entry (CPOE) system, design a Clinical Decision Support System (CDSS) that would be embedded in the EHR at your site of practice. Your CDSS must connect with CPOE to include a medication. You must link these two applications within the design.
General Guidelines:
Use the following information to ensure successful completion of the assignment:
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.
Use primary sources published within the last 5 years. Provide citations and references for all sources used.
You are required to submit this assignment to Turnitin. Refer to the directions in the Student Success Center.
Directions:
Write a 1,000-1,250 word paper that provides the following:
Specific details of the clinical issue involving a specific medication
The rationale behind your design development.
A description of how this CDSS will be implemented and adopted by fellow clinicians.
An assessment of challenges and proposed solutions which might apply to this scenario (e.g., information loss, communication breakdown).
Portfolio Practice Hours:
It may be possible to earn portfolio practice hours for this case report. Enter the following after the references section of your paper:
Practice Hours Completion Statement DNP-805
I, (INSERT NAME), verify that I have completed (NUMBER OF) clock hours in association with the goals and objectives for this assignment. I have also tracked said practice hours in the Typhon Student Tracking System for verification purposes and will be sure that all approvals are in place from my faculty and practice mentor
DNP 805 Week 4 Assignment EHR Database and Data Management
Details
As a DNP-prepared nurse, you may be called upon to assist in the design of a clinical database for your organization. This assignment requires you to integrate a clinical problem with data technologies to better understand the components as well as how those components can lead to better clinical outcomes.
General Guidelines:
Use the following information to ensure successful completion of the assignment:
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.
This assignment requires that at least two additional scholarly research sources related to this topic, and at least one in-text citation from each source be included.
You are required to submit this assignment to Turnitin. Refer to the directions in the Student Success Center.
Directions:
For this assignment, write a 1,000-1,250 word paper in which you:
Click here to ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment: Clinical Practice DNP 805
Select a clinically-based patient problem in which using a database management approach provides clear benefit potential.
Identify the data needed to manage this patient problem using information from the electronic health record (EHR).
Include a brief description of the patient problem which incorporates information needed to manage the specific problem.
Identifies whether the EHR-supplied data is structured or unstructured with an explanation as to why.
Provide a complete description of the structured and unstructured data from the EHR that are needed to organize a hypothetical database.
Provide a complete description of data relationships that apply to the hypothetical database.
Portfolio Practice Hours:
It may be possible to earn portfolio practice hours for this case report. Enter the following after the references section of your paper:
Practice Hours Completion Statement DNP-805
I, (INSERT NAME), verify that I have completed (NUMBER OF) clock hours in association with the goals and objectives for this assignment. I have also tracked said practice hours in the Typhon Student Tracking System for verification purposes and will be sure that all approvals are in place from my faculty and practice mentor.
DNP 805 Topic 6 Assignment Telehealth
Details:
Telehealth encompasses a wide range of basic to complex health care delivery options, with an equally expansive array of technologies that may be employed. For this assignment, you will locate a scholarly article published within the last 3 years in a peer-reviewed journal on telehealth. This assignment consists of two parts; Part One requires you to develop and present a two-paragraph assessment comprising a précis and critical evaluation of a scholarly article focusing on a telehealth technology, and the second part requires you to construct a Mind Map to generate ideas about how the telehealth technology you identified can be used in your current practice.
General Guidelines:
Use the following information to ensure successful completion of the assignment:
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.
This assignment requires that at least two additional scholarly research sources related to this topic, and at least one in-text citation from each source be included.
You are required to submit this assignment to Turnitin. Refer to the directions in the Student Success Center.
Directions:
PART I: Précis and Critical Evaluation.
Donald Davidson, in his book, American Composition and Rhetoric, discusses the précis as follows:
“A précis is not an outline, but a summary or digest. It is useful as an exercise in grasping the essential ideas of an already completed composition and in stating these ideas in concentrated form. The précis shears away all elaborations of the thought and gives only what is left, in such a way as to make the summary a complete composition. It does not, therefore, skeletonize the original composition so much as it reduces its scale. Many of the articles in The Reader’s Digest are only précis, so skillfully done that the average reader does not know that he is reading a summary. Since the précis says a great deal within a brief space, it is of great service in taking notes on library assignments and general reading.”
The précis should be an organization of ideas, include logical sequencing of points, contain clear and meaningful expression, and use language suitable to the situation. When finished, the précis should clearly state:
A statement of what was studied (i.e., argued, discussed, deliberated).
A statement of focus of the scholarly article you selected, (i.e., how it was organized and completed).
A statement of what information was identified or learned from the scholarly article.
A statement of why the information in the article is important to your field of study.
PART II: Mind Map.
Brainstorm to generate ideas about how the telehealth technology you identified can be used in your current practice using a mind map. Submit the final map along with the précis to the Topic drop box.
How to do it:
Take a sheet(s) of paper and write an identifiable main idea in the center of the page, using a one-three words. (You may also achieve this via an electronic sheet of “paper”).
Draw a branch off your main idea; on the branch write or draw a main topic related to your main idea.
Continue to branch off from your main idea with main topics as needed.
Assignment:Clinical Practice DNP 805
From your main topics, branch off with subtopics.
From your subtopics, branch off with supporting details (write and/or draw). Continue to add more details. You are free to add more topics, subtopics, or any other items.
When you stand back and survey your work, you should see a map: hence the name for this activity. At this point you can start to form conclusions about how to approach a potential area of practice change. At the end of the day, what you do with the particular “map” or “cluster set” or “web” that you produce depends on what you need.
Submit both the précis and the final mind map in fulfillment of this assignment.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.