Category: Nursing

NURS-6521 Week 9 Assignment

Week 9 Assignment: Case Studies/Scenarios

Case Studies

Scenario 1

In the first case, there are multiple discrepancies in medications that need to be addressed for appropriate medication therapy to be accomplished. The medication for Lupron 3.75 mg incorrectly identifies the mode of administration by administering it subcutaneously, since Lupron Depot is administered intramuscularly as a single injection monthly. In that case, the correct medication order is thus Lupron Depot 3.75 mg IM monthly for six months, dispense one vial with five refills. The medication is for treating endometriosis using a gonadotropin-releasing hormone (GnRH) agonist, which is done using continuous stimulation of the receptors (Kim et al., 2021). Such mechanisms lead to down-regulation of gonadotropin secretion and subsequent suppression of estrogen secretion, providing symptomatic relief from endometriosis.

Also, the medication for the finasteride treatment incorrectly identifies 1 mg daily for benign prostatic hyperplasia (BPH), but it is supposed to be 5 mg daily for BPH. The correct medication order is therefore: Finasteride 5 mg PO daily, dispense thirty tablets with three refills, and it is important to acknowledge that finasteride is an inhibitor of 5-alpha-reductase (Pompili et al., 2021). The medication reduces the conversion rate from testosterone to dihydrotestosterone, hence regenerating prostate volume with improvement in urinary obstructs.

The erythromycin medication order is also inaccurate because it identifies “otic,” which is for ophthalmic medication only. The correct medication order should thus read “Erythromycin 0.5% ophthalmic ointment; apply ½-inch ribbon to the affected eye (s) every four hours for five days; dispense one 3.5-gram tube with no refills. According to Mahfouz et al. (2023), erythromycin is a macrolide antibiotic that is an inhibitor that binds specifically to the 50S ribosomal subunit in bacterial treatment.

There is also an inaccuracy in the medication order for Augmentin, since there is an ingredient amount reversal written as 125 mg amoxicillin and 875 mg clavulanate. The correct administration should be 875 mg amoxicillin with 125 mg clavulanate acid administered every twelve hours for ten days, dispense 20 tablets, no refills (Gregory et al., 2021).

There is also an inaccuracy in the spelling of the last medication order rivoraxaban 20 mg PO daily. The correct medication order is thus: Rivaroxaban 20 mg tablet daily with evening meal; dispense thirty tablets with no refills. The medication is an oral direct anticoagulant, an inhibitor with action on factor Xa; it prevents the formation of thrombosis (Genis‐Najera et al., 2022).

Scenario Two

JL is a 65-year-old female presenting with fatigue, sore throat, and mild fever, who has tested positive for COVID-19, where her stable oxygen saturation and standard chest X-ray indicate mild disease. Given her age and concurrent therapy with Atorvastatin, antiviral treatment is needed to reduce the risk of disease progression. The recommended regimen is Nirmatrelvir 300 mg, which involves two 150 mg tablets with the ritonavir 100 mg medication where just one tablet is taken orally every twelve hours for five days, known commercially as Paxlovid (Hammond et al., 2022). Atorvastatin on the other hand should be stopped for three days during and after the course due to significant CYP3A4 inhibition by ritonavir and the potential increase of statin serum levels and myopathy risk. In addition, acetaminophen 500 mg every six hours may be used as an alternative for fever or sore throat, adequate fluid intake, and rest (Krohmer et al., 2023).

Additionally, JL should be educated about potential side effects such as altered taste, diarrhea, and possible drug interactions and instructed to complete the entire five-day antiviral regimen even if symptoms improve and to seek medical attention once respiratory symptoms worsen or oxygen saturation falls below 94 percent. Also, the effectiveness of the therapy must be monitored by assessing the symptoms and ensuring that follow-up happens within three days. On the same note, Nirmatrelvir inhibits the SARS-CoV-2 main protease (Mpro), preventing viral replication. In contrast, ritonavir is a pharmacokinetic enhancer that inhibits CYP3A-mediated metabolism, thus maintaining therapeutic drug levels (Hammond et al., 2022). Such a combination, illustrated by Hammond et al. (202), has significantly reduced hospitalization and mortality rates in high-risk, nonhospitalized adults with mild-to-moderate COVID-19 infection.

Scenario 3

JS, aged 23 years, is presenting with weakness, poor concentration, and excessive menstrual bleeding. After carrying out a series of tests on the patient, JS was found to have high levels of TSH measured at 20 µIU/mL with low levels of MCV, MCHC, and ferritin, hence confirming the diagnosis for the case of primary hypothyroidism together with iron deficiency anemia (Davis & Phillippi, 2022). The treatment procedure follows a strategy for simultaneously handling these two situations in relation to medications on an ongoing basis.

In addition, the appropriate treatment for the condition is using Levothyroxine 75 mcg orally daily before eating anything, 30-60 minutes before breakfast, with vitamin C 500mg for improved bioavailability. Levothyroxine is proposed since it is a pure formulation acting on the hormone T4, which is metabolized in the body with a new hormone named T3, thus restoring body metabolism (Eghtedari & Correa, 2023). Ferrous sulfate 325 mg (65mg elemental iron) would also be effective in enhancing iron deficiency, even if the patient must be advised to separate levothyroxine and iron by at least four hours to avoid absorption interference.

However, there is an appropriate need for withholding the kelp vitamin completely since it contains high levels of iodine, making it potentially dangerous for body functions for all individuals with hypothyroidism (Eghtedari & Correa, 2023). Also, chromium, turmeric, and other tea formulations would warrant consideration for potential interactions, even though they would also be safe for unidirectional usage with high caution (Garber et al., 2021). Overall, the outcome of the treatment would depend on enhanced iron deficiency and hypothyroidism, hematologic stability, and metabolic equilibrium.

Scenario 4

In a 60-kg patient, the appropriate dosage would be 300 mg IV daily; since the pharmacy gives the dosage in 2 mL vials with 80 mg medication, 7.5 mL would have to be obtained for each treatment session. Moreover, since the infusion rate is 10 mg/min, it would take 30 minutes to administer the medication wholly. When trough levels were down to 3 mcg/mL, it is clear it is too high since it would need to be under two mcg/mL for once-daily dosing in order to avoid renal nephrotoxicity and ototoxicity where either the dose would need to be reduced for 4 mg/kg (IV 240 mg daily) or the dosing interval would need to be extended to 36 hours(Chaves & Tadi, 2023). Hence, the reordered medication would be: Gentamicin 240 mg IV q24h; infused IV over 30 min, and there is a need to monitor renal function and trough levels before the fourth treatment cycle is administered.

As an aminoglycoside antibiotic, gentamicin binds to the 30S ribosomal subunit irreversibly in bacterial cells, thus preventing protein synthesis and causing cell death in a concentration-dependent way with bactericidal rates. In that regard, when gentamicin is administered intravenously, gentamicin bioavailability is so low due to its high polarity, projecting its inability to pass equally well throughout the gastrointestinal tract, thus requiring parenteral therapy for systemic infections only (Gamaan et al., 2023). The two significant toxicities associated with the aminoglycosides belong to their nephrotoxicity in the renal tubular cell concentration, which affects receptor function in the vestibular system, aside from their toxic function within inner ear cells (Chaves & Tadi, 2023). As such, monitoring creatinine levels and any audiological toxicities, in addition to blood urea nitrogen levels, is required to avoid its toxic effects and to maintain gentamicin efficacy in its usage.

 

References

Chaves, B. J., & Tadi, P. (2023, April 10). Gentamicin. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557550/

Davis, M. G., & Phillippi, J. C. (2022). Hypothyroidism: Diagnosis and Evidence‐Based Treatment. Journal of Midwifery & Women’s Health, 67(3), 394–397. https://doi.org/10.1111/jmwh.13358

Eghtedari, B., & Correa, R. (2023, August 28). Levothyroxine. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539808/

Gamaan, M., Zaky, H., & Ahmed, H. (2023). Gentamicin-induced nephrotoxicity: A mechanistic approach. Azhar International Journal of Pharmaceutical and Medical Sciences, 0(0). https://doi.org/10.21608/aijpms.2023.161755.1167

Genis‐Najera, L., Sañudo‐Maury, M. E., & Moquete, T. (2022). A Single‐blind, Randomized, Single‐dose, Two‐sequence, Two‐period, Crossover Study to Assess the Bioequivalence between Two Oral Tablet Formulations of Rivaroxaban 20 mg in Healthy Mexican Volunteers. Clinical Pharmacology in Drug Development, 11(7), 826–831. https://doi.org/10.1002/cpdd.1092

Gregory, J., Huynh, B., Tayler, B., Korgaonkar-Cherala, C., Garrison, G., Ata, A., & Sorum, P. (2021). High-Dose vs Standard-Dose Amoxicillin Plus Clavulanate for Adults With Acute Sinusitis: A Randomized Clinical Trial. JAMA Network Open, 4(3), e212713. https://doi.org/10.1001/jamanetworkopen.2021.2713

Hammond, J., Leister-Tebbe, H., Gardner, A., Abreu, P., Bao, W., Wisemandle, W., Baniecki, M., Hendrick, V. M., Damle, B., Simón-Campos, A., Pypstra, R., & Rusnak, J. M. (2022). Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with Covid-19. New England Journal of Medicine, 386(15). https://doi.org/10.1056/nejmoa2118542

Kim, G.-Y., Kim, J.-H., Lee, T., Bae, B.-C., Baik, H., Kim, T., Kim, J., Kang, D. W., Kim, J. H., Kim, D., Cho, H.-Y., & Kim, D.-D. (2021). In vitro and in vivo evaluations of a 3-month sustained-release microsphere depot formulation of leuprolide acetate. Journal of Pharmaceutical Investigation, 52(1), 129–138. https://doi.org/10.1007/s40005-021-00551-x

Krohmer, E., Rohr, B. S., Stoll, F., Gümüs, K. S., Bergamino, M., Mikus, G., Sauter, M., Jürgen Burhenne, Weiss, J., Meid, A. D., Czock, D., Blank, A., & Haefeli, W. E. (2023). Influence of a Short Course of Ritonavir Used as a Booster in Antiviral Therapies Against SARS-CoV-2 on the Exposure of Atorvastatin and Rosuvastatin. Cardiovascular Drugs and Therapy. https://doi.org/10.1007/s10557-023-07538-w

Mahfouz, A. A., Said, H. S., Elfeky, S. M., & Shaaban, M. I. (2023). Inhibition of Erythromycin and Erythromycin-Induced Resistance among Staphylococcus aureus Clinical Isolates. Antibiotics, 12(3), 503. https://doi.org/10.3390/antibiotics12030503

Pompili, M., Magistri, C., Maddalena, S., Mellini, C., Persechino, S., & Baldessarini, R. J. (2021). Risk of Depression Associated With Finasteride Treatment. Journal of Clinical Psychopharmacology, 41(3), 304–309. https://doi.org/10.1097/jcp.0000000000001379

 

NURS-6521 Week 9 Assignment

Case studies are a useful way for you to apply your knowledge of pharmacokinetic and pharmacodynamic aspects of pharmacology to specific patient cases and health histories.

For your week 9 assignment, evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.

Directions:
 
For each of the scenarios below, answer the questions using your required learning resources, Medscape, and clinical practice guidelines (ie AHA, ACC, ADA). When recommending medications, write out a 
complete prescription
 for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills etc. Also state if you would continue, discontinue or taper the patient’s current medications (if applicable). Use 
at least 3 sources
 for 
each scenario
 and cite sources using APA format.

Week 9 Cases

SCENARIO 1

What are the errors in the following prescriptions (5 total)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?

Lupron 3.75 mg Inject SC monthly for endometriosis up to 6 months #1 5RF

finasteride 1 mg PO daily for BPH #30 3RF (
Note: women should not handle crushed/broken tablets- teratogenic to male fetus
)

erythromycin 0.5% otic ointment Apply a ½ inch ribbon to the affected eye(s
) every 4 hours x 5 days #1 tube (3.5g) 0RF

Augmentin (875 mg 
clavulanate/125 mg amoxicillin) PO every 12 hours x 10 days #20 0RF

rivoraxaban 20 mg PO daily with evening meal #30 0RF

 

SCENARIO 2

JL is a 65-year-old female seen in the clinic today. She presents with fatigue, brain fog, sore throat and temperature of 99.1. She reports that symptoms began three days ago with a sore throat and have progressively worsened. She also mentions loss of appetite. Oxygen sat 97%, respiratory rate 17, bp 122/73. Her rapid COVID-19 antigen test is positive. Chest x-ray is clear, no signs of pneumonia. Current medication includes atorvastatin 40 mg po daily. What treatment plan would you implement for JL (include complete medication order)? What patient education and monitoring would you provide?

 

SCENARIO 3

JS is a 23-year-old woman that presents with fatigue, poor concentration and heavy menstrual periods. Her labs today show TSH 20, MCV 76, MCHC 27, ferritin 11, TIBC 421, Hgb 11.8. Current medications include sumatriptan prn for migraine with aura and drospirenone 4mg one tablet po daily prescribed by her pharmacist, as well as kelp, chromium picolinate, turmeric and green tea supplements daily. What treatment plan would you implement for JS? What medication changes would you make? Include complete medication order(s). How would you monitor the effectiveness of this plan, and what patient education would you provide?

 

SCENARIO 4

A patient is prescribed 
gentamicin 5 mg/kg IV once daily
 for a 
60 kg
 patient. The pharmacy stocks gentamicin in 
80 mg/2 mL vials
.

How much gentamicin (mg) should be administered per dose?

How many milliliters of gentamicin solution should be drawn up for each dose?

If the infusion rate is 10 mg/min, how long will it take to administer one dose?

A trough level is drawn 30 minutes before the next dose, and the result is 3 mcg/mL. Is the current dosing regimen appropriate based on the trough level? Would you increase, decrease, or leave the dose the same?
 Please include a complete medication order. What are risks associated with aminoglycoside therapy?

Why is gentamicin typically administered intravenously rather than orally? How does this relate to bioavailability?

 

Assignment: Case Studies

Case studies are a useful way for you to apply your knowledge of pharmacokinetics and pharmacodynamic aspects of pharmacology to specific patient cases and health histories.

For this Assignment, you evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.

Resources

 

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare:

Review the case study posted in “Announcements” by your Instructor for this Assignment

Review the information provided and answer questions posed in the case study

When recommending a medication, write out a complete prescription for the medication

Whenever possible, use clinical practice guidelines in developing your answers when possible

Include at least three references to support your answer and cite them in APA format.

By Day 7 of Week 9

Submit the Assignment.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the 
Turnitin Drafts
 from the 
Start Here
 area.

To submit your completed assignment, save your Assignment as 
WK9Assgn_LastName_Firstinitial

Then, click on 
Start Assignment
 near the top of the page.

Next, click on 
Upload File
 and select 
Submit Assignment
 for review.

Rubric

NURS_6521_Week9_Assignment_Rubric

NURS_6521_Week9_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome
Scenario 1: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 1: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 1: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 1: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 2: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. NURS-6521 Week 9 Assignment 

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 3: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 4: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

NURS-6521 Week 9 Assignment

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

Total Points: 
100

Pharmacologic Management of Musculoskeletal and Related Disorders – NURS-6521 Week 7 Assignment: Case Studies

Pharmacologic Management of Musculoskeletal and Related Disorders

Pharmacologic management of musculoskeletal and related disorders, such as arthritis, rheumatoid arthritis (RA), gout, and chronic pain, requires an understanding of pharmacokinetics, pharmacodynamics, and individual patient factors. Factors such as genetics, age, comorbidities, diet, and concurrent medication use significantly influence drug metabolism and therapeutic response (Cox et al., 2025). The following scenarios evaluate drug therapy plans, identify prescription errors, and propose evidence-based treatment options following current clinical practice guidelines.

Scenario 1: Prescription Errors, Classifications, and Mechanisms of Action

Allopurinol 2 mg PO initially, followed by 0.6 mg one hour later for acute gout flare #3 0 RF

Error:
Incorrect dose and indication. Allopurinol is not used for acute gout attacks but for chronic urate-lowering therapy (Qurie et al., 2023).

Correct Prescription:

Allopurinol 100 mg PO daily; increase gradually every 2–4 weeks to achieve serum uric acid <6 mg/dL. Dispense #30, 1 refill . Mechanism of Action (MOA): Inhibits xanthine oxidase, decreasing uric acid synthesis (Aziz & Jamil, 2023). Classification: Xanthine oxidase inhibitor (urate-lowering therapy). Rationale : Initiated for chronic gout prevention per 2020 ACR Gout Guidelines (American College of Rheumatology, 2020). GET ASSIGNMENT HELP HERE Dextromethorphan/bupropion (Vraylar) 45 mg/105 mg ER tablet. Take 1 tablet PO QAM for 3 days, then 1 tablet PO BID #60 0 RF Error: Incorrect brand name; Vraylar is cariprazine, not dextromethorphan/bupropion. Correct Prescription: Dextromethorphan/bupropion (Auvelity) 45 mg/105 mg ER tablet; take 1 tablet PO twice daily. Dispense #60, 0 refills. MOA : Dextromethorphan/bupropion acts by combining NMDA receptor antagonism and sigma-1 receptor agonism from dextromethorphan with dopamine and norepinephrine reuptake inhibition from bupropion, resulting in enhanced monoaminergic and glutamatergic neurotransmission that improves mood regulation (McCarthy et al., 2023). Classification: Combination of an uncompetitive NMDA receptor antagonist and sigma-1 receptor agonist (dextromethorphan) with a norepinephrine-dopamine reuptake inhibitor (bupropion). In combination, used as an antidepressant. Rationale: Dextromethorphan/bupropion is used for acute major depressive disorder (MDD) following FDA-approved labeling. Trazadone 50 mg PO qhs #30 1 RF Error: Spelling error. Trazodone has been misspelled as “Trazadone”. Correct Prescription: Trazodone 50 mg PO at bedtime for sleep. Dispense #30, 1 refill. MOA: Trazodone primarily blocks 5-HT₂A receptors and inhibits the serotonin transporter (SERT), which increases serotonergic signaling in a way that improves mood and alleviates anxiety (Shin & Saadabadi, 2022). It also antagonizes α₁-adrenergic and H₁-histamine receptors, which contribute to its sedating and orthostatic-hypotension effects. Classification: Serotonin antagonist and reuptake inhibitor (SARI) antidepressant (Shin & Saadabadi, 2022). Lithium carbonate 300 mg PO TID #90 for the goal therapeutic range of 1–2 mEq/L Error: Toxic target range; therapeutic serum level should be 0.6–1.2 mEq/L. Correct Prescription: Lithium carbonate 300 mg PO TID; monitor serum lithium and renal function every 3 months. Dispense #90, 0 refills. MOA: Lithium carbonate modulates neurotransmitter signaling via inositol monophosphatase inhibition (Sakrajda & Rybakowski, 2025). Classification: Mood stabilizer. Fentanyl transdermal patch 25 mcg/hr Apply 1 patch topically every 72 hours. Rotate application site. #10 patches 1RF Error: Strength appropriate, but must specify opioid-naïve status (contraindicated). Should be reserved for opioid-tolerant patients. Correct Prescription: Fentanyl transdermal patch 25 mcg/hr; apply 1 patch topically every 72 hours. Rotate sites. For opioid-tolerant patients only. Dispense #10 patches, 1 refill. MOA: Fentanyl is a μ-opioid receptor agonist providing central analgesia (Rullo et al., 2024). Classification: Opioid analgesic (Schedule II controlled substance). Pharmacologic Management of Musculoskeletal and Related Disorders – NURS-6521 Week 7 Assignment: Case Studies Scenario 2: Buspirone Half-Life and Anxiolytic Prescriptions Buspirone has a half-life of 3 hours. If a patient takes 15 mg at 20:00, by 08:00 (12 hours later), four half-lives have passed (12 ÷ 3 = 4). The remaining amount = 15 × (½)^4 = 0.94 mg. Thus, the plasma concentration is approximately 0.94 mg. Three Commonly Prescribed Medications for Anxiety Buspirone (Buspar) Order: Buspirone 10 mg PO twice daily. Dispense #60, 1 refill. MOA: Partial agonist at serotonin 5-HT1A receptors (Wilson & Tripp, 2023). Side Effects: Dizziness, nausea, headache. Rationale: Non-benzodiazepine anxiolytic suitable for generalized anxiety disorder (GAD). Escitalopram (Lexapro) Order: Escitalopram 10 mg PO daily. Dispense #30, 1 refill. MOA: Selective serotonin reuptake inhibitor (SSRI) (Landy & Estevez, 2023). Side Effects: Nausea, sexual dysfunction, and insomnia. Rationale: First-line SSRI for GAD and panic disorder (DeGeorge et al., 2022). Sertraline (Zoloft) Order: Sertraline 50 mg PO daily. Dispense #30, 1 refill. MOA: SSRI that increases synaptic serotonin (Moncrieff et al., 2022). Side Effects: Gastrointestinal upset, insomnia, fatigue. Scenario 3: Pediatric ADHD Diagnosis and Management Diagnosis: Based on DSM-5-TR criteria, LB exhibits symptoms of inattention and hyperactivity consistent with Attention-Deficit/Hyperactivity Disorder (ADHD), combined type. First-Line Medication: Methylphenidate ER (Concerta) Order: Methylphenidate ER 18 mg PO every morning. Dispense #30, 0 refills. MOA: Inhibits dopamine and norepinephrine reuptake in the CNS, enhancing attention and focus (Verghese & Abdijadid, 2024). Monitoring: Weight, appetite, BP, HR, sleep, and behavioral changes (Wolraich et al., 2020). Rationale: Stimulants like methylphenidate are first-line per AAP and NICE guidelines, with 70–80% efficacy in school-aged children (American Academy of Pediatrics, 2020). Scenario 4: Polypharmacy, Assessment, and Medication Optimization Current Medications: Metformin, Jentadueto (linagliptin/metformin), fluoxetine, amitriptyline, valacyclovir, gabapentin. Assessment: Duplication: Metformin and Jentadueto both contain metformin, which is a risk for lactic acidosis (Dyatlova et al., 2022). CNS depressants (amitriptyline + gabapentin + fluoxetine) raise fall and sedation risk (van Poelgeest et al., 2021). Unknown labs (A1c, renal, hepatic function) impede safe refills. Plan: Discontinue standalone metformin (duplicate therapy). Continue Jentadueto 2.5/1000 mg PO BID for diabetes. Reassess amitriptyline use; it may contribute to fatigue. Consider taper and switch to duloxetine if needed for neuropathic pain (Catalisano et al., 2024). Order labs: CBC, CMP, A1c, eGFR, LFTs, BP, and EKG. Possible disease states: Diabetes, depression, neuropathic pain, viral infection (Herpes Simplex Virus), and anxiety/insomnia. Conclusion Safe pharmacologic management requires attention to dosage accuracy, therapeutic duplication, pharmacodynamics, and individualized factors such as comorbidities and concurrent medications. Clinical decision-making should align with updated guidelines to ensure safety and efficacy across age groups and disease states. References American Academy of Pediatrics. (2020). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics , 144 (4), 1–25. https://doi.org/10.1542/peds.2019-2528 American College of Rheumatology. (2020). Gout clinical practice guidelines . Rheumatology.org. https://rheumatology.org/gout-guideline Aziz, N., & Jamil, R. T. (2023, July 25). Biochemistry, xanthine oxidase . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545245/ Catalisano, G., Campione, G. M., Spurio, G., Galvano, A. N., di Villalba, C. P., Giarratano, A., Alongi, A., Ippolito, M., & Cortegiani, A. (2024). Neuropathic pain, antidepressant drugs, and inflammation: A narrative review. Journal of Anesthesia, Analgesia and Critical Care , 4 (1). https://doi.org/10.1186/s44158-024-00204-z Cox, N., Mallen, C. D., & Scott, I. C. (2025). Pharmacological pain management in patients with rheumatoid arthritis: A narrative literature review. BMC Medicine , 23 (1). https://doi.org/10.1186/s12916-025-03870-0 DeGeorge, K. C., Grover, M., & Streeter, G. S. (2022). Generalized anxiety disorder and panic disorder in adults. American Family Physician , 106 (2), 157–164. https://www.aafp.org/pubs/afp/issues/2022/0800/generalized-anxiety-disorder-panic-disorder.html Dyatlova, N., Tobarran, N. V., Kannan, L., North, R., & Wills, B. K. (2022). Metformin-associated lactic acidosis (MALA) . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK580485/ Landy, K., & Estevez, R. (2023). Escitalopram . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557734/ McCarthy, B., Bunn, H., Santalucia, M., Wilmouth, C., Muzyk, A., & Smith, C. M. (2023). Dextromethorphan-bupropion (Auvelity) for the treatment of major depressive disorder. Clinical Psychopharmacology and Neuroscience , 21 (4), 609–616. https://doi.org/10.9758/cpn.23.1081 Moncrieff, J., Cooper, R. E., Stockmann, T., Amendola, S., Hengartner, M. P., & Horowitz, M. A. (2022). The serotonin theory of depression: A systematic umbrella review of the evidence. Molecular Psychiatry , 28 (3243–3256), 1–14. https://doi.org/10.1038/s41380-022-01661-0 Qurie, A., Bansal, P., Goyal, A., & Musa, R. (2023, December 26). Allopurinol . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499942/ Rullo, L., Morosini, C., Lacorte, A., Cristani, M., Coluzzi, F., Candeletti, S., & Romualdi, P. (2024). Opioid system and related ligands: From the past to future perspectives. Journal of Anesthesia, Analgesia and Critical Care , 4 (1). https://doi.org/10.1186/s44158-024-00201-2 Sakrajda, K., & Rybakowski, J. K. (2025). The mechanisms of Lithium action: The old and new findings. Pharmaceuticals , 18 (4), 467. https://doi.org/10.3390/ph18040467 Shin, J. J., & Saadabadi, A. (2022). Trazodone . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470560/ van Poelgeest, E. P., Pronk, A. C., Rhebergen, D., & van der Velde, N. (2021). Depression, antidepressants, and fall risk: Therapeutic dilemmas—A clinical review. European Geriatric Medicine , 12 (3), 585–596. https://doi.org/10.1007/s41999-021-00475-7 Verghese, C., & Abdijadid, S. (2024, October 29). Methylphenidate . Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482451/ Wilson, T. K., & Tripp, J. (2023). Buspirone . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK531477/ Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., & Zurhellen, W. (2020). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics , 144 (4), 1–25. https://doi.org/10.1542/peds.2019-2528   Pharmacologic Management of Musculoskeletal and Related Disorders – NURS-6521 Week 7 Assignment: Case Studies Case studies are a useful way for you to apply your knowledge of pharmacokinetics and pharmacodynamic aspects of pharmacology to specific patient cases and health histories. For this Assignment, you evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis. Resources   Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources. WEEKLY RESOURCES To Prepare: Review the case study posted in “Announcements” by your Instructor for this Assignment Review the information provided and answer questions posed in the case study When recommending a medication, write out a complete prescription for the medication Whenever possible, use clinical practice guidelines in developing your answers when possible Include at least three references to support your answer and cite them in APA format. By Day 7 of Week 7 Submit the Assignment. submission information Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the  Turnitin Drafts  from the  Start Here  area. To submit your completed assignment, save your Assignment as  WK7Assgn_LastName_Firstinitial Then, click on  Start Assignment  near the top of the page. Next, click on  Upload File  and select  Submit Assignment  for review. Rubric NURS_6521_Week7_Assignment_Rubric NURS_6521_Week7_Assignment_Rubric Criteria Ratings Pts This criterion is linked to a Learning Outcome Scenario 1: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection. 15   to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 1: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 1: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Pharmacologic Management of Musculoskeletal and Related Disorders – NURS-6521 Week 7 Assignment: Case Studies

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 1: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 2: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 3: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate. Pharmacologic Management of Musculoskeletal and Related Disorders – NURS-6521 Week 7 Assignment: Case Studies

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 4: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

Total Points: 
100

Pharmacologic Management of Musculoskeletal and Related Disorders – NURS-6521 Week 7 Assignment: Case Studies

Case studies are a useful way for you to apply your knowledge of pharmacokinetic and pharmacodynamic aspects of pharmacology to specific patient cases and health histories.

For your week 7 assignment, evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.

Directions:
 
For each of the scenarios below, answer the questions using your required learning resources, Medscape, and clinical practice guidelines (ie AHA, ACC, ADA). When recommending medications, write out a 
complete prescription
 for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills etc. Also state if you would continue, discontinue or taper the patient’s current medications (if applicable). Use 
at least 3 sources
 for 
each scenario
 and cite sources using APA format.

WEEK 7 ASSIGNMENT (covers weeks 7-8)

SCENARIO 1

What are the errors in the following prescriptions (5 total)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?

allopurinol 2 mg PO initially, followed by 0.6 mg one hour later for acute gout flare #3 0 RF

dextromethorphan/bupropion (Vraylar) 45 mg/105 mg extended-release tablet Take 1 tablet PO QAM for 3 days, then 1 tablet PO BID #60 0RF

trazadone 50 mg po qhs #30 1 RF

lithium carbonate 300 mg po TID #90 for goal therapeutic range of 1-2 mEq/L

fentanyl transdermal patch 25 mcg/hr Apply 1 patch topically every 72 hours. Rotate application site. #10 patches 1RF

 

SCENARIO 2

Buspirone has a 
half-life
 of 3 hours. If a patient takes 15 mg at 20:00, what will the blood level (mg) be at 8 am? Name 
3 medications
 you might prescribe for a patient with 
anxiety
. Include complete medication orders, MOA and common side effects for each of the 3 medications.

 

SCENARIO 3

LB is an 8-year-old male brought in by his mother due to concerns about behavior and school performance. His teacher reports that LB is frequently out of his seat, talks excessively, blurts out answers, and has difficulty completing tasks or following multi-step directions. At home, he often loses toys and homework, seems forgetful, and struggles to stay focused on activities like reading. He has no significant medical history. Growth and development are age-appropriate. He sleeps about 9 hours per night but still wakes up feeling tired. His diet is average for a child his age. There are no signs of anxiety, depression, or other mood disorders. What is the 
most likely 
diagnosis
? What is an appropriate 
first-line medication
 (include complete medication order)? What 
monitoring parameters
 should be considered during treatment?

 

SCENARIO 4

ST is a 51-year-old male presenting for medication refills. He has no recent lab work, but reports fatigue and occasional dizziness. Current meds: metformin 1000 mg PO daily, Jentadueto 2.5 mg/1000 mg PO BID, fluoxetine 20 mg po daily, amitriptyline 50 mg PO qhs, valacyclovir 1 gram PO TID x 7 days, gabapentin 300 mg PO TID. He is unsure of his A1c or blood pressure. How would you assess and 
improve his regimen
? What monitoring is needed? List 
5 possible disease states
based on his medications. Pharmacologic Management of Musculoskeletal and Related Disorders – NURS-6521 Week 7 Assignment: Case Studies

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

To Prepare:

Review the case study posted in “Announcements” by your Instructor for this Assignment

Review the information provided and answer questions posed in the case study

When recommending a medication, write out a complete prescription for the medication

Whenever possible, use clinical practice guidelines in developing your answers when possible

Include at least three references to support your answer and cite them in APA format.

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

SCENARIO 1

What are the errors in the following prescriptions (5 total)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?

fluticasone/salmeterol (Advair) 115/21 mcg 1 inhalation BID #1 Diskus 3 RF

albuterol 4 mg po 15-30 min before exercise #30 2 RF

budesonide/fluticasone (Symbicort) 160/4.5 mcg, 2 puffs inhaled BID and 1-2 puffs prn asthma symptoms (max 12 inhalations in 24 hours) #1 inhaler 2 RF

tiatropium (Spiriva Respimat) 2.5 mcg/actuation inhaler; inhale 2 actuations po once daily for COPD #1 inhaler/60 actuations 1 RF

lamotrigine (Keppra) 500 mg po BID #60 2 RF

 

SCENARIO 2

AB is a 34-year-old female presenting to the clinic with ongoing migraine headaches. “I’m still getting migraines once a week, even though I take Ubrelvy when they start.” She reports experiencing 3 to 4 migraine attacks per month, typically associated with throbbing pain on one side, light sensitivity, and nausea. Migraines can last from 6-24 hours. AB has been taking Ubrelvy 50 mg po as needed at migraine onset for the past 3 months. She says it helps sometimes, but not consistently, and the pain often returns in a few hours. PMH: migraine without aura (diagnosed at age 27) Current medications: Ubrelvy 501mg po PRN at onset of migraine, ondansetron 4 mg ODT dissolve on tongue PRN nausea, may repeat in 8 hours if needed. Vitals: BP 118/74, HR 78. What treatment plan would you implement for AB? What medication changes would you make? How would you monitor the effectiveness of this plan, and what patient education would you provide? Is a patient with migraines more likely to start on an acute or preventive agent? What are examples of each?

 

SCENARIO 3

RC is a 58-year-old female that presents to the clinic today with early-onset Alzheimer’s Disease. What would you prescribe? Consider her labs and provide a drug therapy plan. Include complete medication orders. How would you monitor therapy? Labs: TSH 3.4 mU/L, vitamin D 22 ng/mL, B12 501 pg/mL, Hgb 12.8 g/dL, BG 96 mg/dL, A1C 5.9%, BP 115/72, HR 76. Medications include: Tresiba 15 units SC once daily QHS, Novolog 5 units SC before each meal TID (adjusting based on carbohydrate intake and glucose monitoring), and lisinopril 10 mg po daily

 

SCENARIO 4

PL is a 63-year-old male with poorly controlled type 2 diabetes presenting for follow-up and treatment optimization. Current medications include dicyclomine 10 mg po QID prn abdominal pain, pantoprazole 40 mg po daily 30 minutes before breakfast, losartan 50 mg po daily, and probiotics daily. His lab work today includes: BG 196 mg/dL, A1C  8.6%, K⁺ 4.2,  Cr 1.8, eGRF 27, BP 127/74. What treatment plan would you implement for PL (include complete medication order)? What is the classification and MOA of the drug you selected; why is it the best treatment option for PL? What education would you provide and how would you monitor the effectiveness of the treatment plan? What is his goal A1C?

 

 

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

WEEK 4: Gastrointestinal and Hepatobiliary System

Scenario 1: Medication Errors

Question:
What are the errors in the prescriptions (5 total)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?

fluticasone/salmeterol (Advair) 115/21 mcg 1 inhalation BID #1 Diskus 3 RF

Error:
Incorrect dosage strength. Advair Diskus is available as 100/50, 250/50, or 500/50 mcg; 115/21 is the HFA inhaler formulation. The wrong device is specified.

Correct Prescription:

fluticasone/salmeterol (Advair Diskus) 250/50 mcg; inhale 1 puff by mouth twice daily. Dispense: 1 Diskus (60 doses). Refills: 3.

Classification:
Inhaled corticosteroid (ICS) + long-acting beta-2 agonist (LABA).

MOA:
Fluticasone decreases airway inflammation via glucocorticoid receptor activity (Remien & Bowman, 2024); salmeterol stimulates β2-adrenergic receptors, causing bronchodilation (Hsu & Bajaj, 2023).

GET ASSIGNMENT HELP HERE

albuterol 4 mg po 15-30 min before exercise #30 2 RF

Error:
Oral albuterol is rarely used; inhalation is standard for exercise-induced bronchospasm.

Correct Prescription:

Albuterol sulfate HFA inhaler 90 mcg/actuation; inhale 2 puffs by mouth 15 minutes before exercise. Dispense: 1 inhaler (200 actuations). Refills: 2.

Classification:
Short-acting beta-2 agonist (SABA).

MOA:
Stimulates β2-adrenergic receptors in bronchial smooth muscle, leading to relaxation and rapid bronchodilation (Johnson & Bounds, 2024).

budesonide/fluticasone

(Symbicort) 160/4.5 mcg, 2 puffs inhaled BID and 1-2 puffs prn asthma symptoms (max 12 inhalations in 24 hours) 1 inhaler 2 RF

Error:
Medication incorrectly written as “budesonide/fluticasone.” Should be budesonide/formoterol. PRN dosing is only indicated in SMART (single maintenance and reliever therapy) but requires clarification.

Correct Prescription:

Budesonide/formoterol (Symbicort) 160/4.5 mcg; inhale 2 puffs by mouth twice daily and 1 puff as needed for asthma symptoms, maximum 12 inhalations per 24 hours. Dispense: 1 inhaler (120 actuations). Refills: 2.

Classification:
ICS + LABA.

MOA:
Budesonide reduces airway inflammation; formoterol is a rapid-acting LABA that provides bronchodilation (Lipworth et al., 2024).

tiotropium (Spiriva Respimat) 2.5 mcg/actuation inhaler; inhale 2 actuations po once daily for COPD #1 inhaler/60 actuations 1 RF

Error:
Route written incorrectly as “po” (oral); should be “by inhalation.”

Correct Prescription:

Tiotropium (Spiriva Respimat) 2.5 mcg/actuation; inhale 2 actuations (5 mcg total) by mouth once daily. Dispense: 1 inhaler (60 actuations). Refills: 1.

Classification:
Long-acting muscarinic antagonist (LAMA).

MOA:
Blocks M3 muscarinic receptors in airway smooth muscle, preventing acetylcholine-mediated bronchoconstriction (Delgado & Bajaj, 2022).

lamotrigine (Keppra) 500 mg po BID #60 2 RF

Error:
Wrong drug name. Lamotrigine (Lamictal) and levetiracetam (Keppra) are two different drugs. Incorrect combination written.

Correct Prescription (assuming levetiracetam intended):

Levetiracetam (Keppra) 500 mg; take 1 tablet by mouth twice daily. Dispense: 60 tablets. Refills: 2.

Classification:
Antiepileptic (broad-spectrum).

MOA:
Modulates synaptic neurotransmitter release by binding to synaptic vesicle protein SV2A, stabilizing neuronal activity (Contreras-García et al., 2022).

Scenario 2: Migraine (AB, 34 years old)

Treatment Plan & Medication Changes

AB continues to experience migraines 3–4 times per month despite acute therapy with Ubrelvy. Since migraines are frequent and disruptive, preventive therapy is warranted per AHS guidelines (American Headache Society, 2024). For this case, I will optimize acute therapy (Ubrelvy) and continue an antiemetic.

Prescriptions

Preventive
– Propranolol LA 60 mg PO once daily.

Sig: Take 1 capsule by mouth daily.

Disp: 30 capsules. Refills: 2.

Acute
– Ubrogepant (Ubrelvy) 50 mg PO PRN.

Sig: Take 1 tablet by mouth at onset of migraine; may repeat in 2 hours if needed (max 200 mg/24 hrs).

Disp: 16 tablets. Refills: 2.

Antiemetic
– Ondansetron ODT 4 mg.

Sig: Dissolve 1 tablet under the tongue PRN for nausea; may repeat in 8 hours.

Disp: 20 tablets. Refills: 1.

Classification & MOA

Propranolol
: Non-selective β-blocker; reduces frequency of migraines by stabilizing vascular tone and decreasing excitability (Jeong et al., 2024).

Ubrogepant
: CGRP receptor antagonist; blocks neuropeptide-mediated vasodilation and pain signaling (Boinpally et al., 2024).

Ondansetron
: 5-HT3 receptor antagonist; blocks serotonin-mediated nausea pathways (Theriot & Ashurst, 2019).

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

Monitoring & Education

Maintain headache diary (frequency, triggers, severity).

Monitor Blood pressure and heart rate for propranolol side effects.

Education: Avoid migraine triggers (caffeine, skipped meals, poor sleep, stress).

Follow-up in 6–8 weeks to assess frequency reduction (goal ≥50% reduction in migraine days).

Scenario 3: Early-Onset Alzheimer’s (RC, 58 years old)

RC is a 58-year-old woman with early-onset Alzheimer’s disease. Her labs are stable, except for a vitamin D deficiency. She has a history of diabetes (on insulin therapy) and hypertension (on lisinopril). Management should address cognitive decline and vitamin D deficiency while ensuring safety with her current regimen.

Prescription & Drug Therapy Plan

Cognitive Symptoms – Alzheimer’s Disease

Donepezil 5 mg PO once daily at bedtime

Mechanism: Acetylcholinesterase inhibitor increases acetylcholine in the brain, slowing cognitive decline (Marucci et al., 2020).

Prescription

Medication:
Donepezil 5 mg tablets (Aricept or generic)

Sig:
Take one (1) tablet by mouth once daily at bedtime
.

Quantity
: 30 tablets (30-day supply)

Refills:
2

Special Instructions:
Take at bedtime. May be taken with or without food. Monitor for nausea, diarrhea, insomnia, dizziness, or slow heart rate. Contact the clinic if fainting, palpitations, or severe GI upset occur.

Titrate to 10 mg PO once daily after 4–6 weeks if tolerated.

Vitamin D Deficiency

Cholecalciferol (Vitamin D3) 2000 IU PO once daily

Mechanism: Restores vitamin D levels, improves bone health, and may support cognition (Al-Hashimi & Abraham, 2024).

Prescription

Medication:
Cholecalciferol (Vitamin D3) 2000 IU capsules/tablets

Sig:
Take one (1) capsule by mouth once daily.

Quantity:
30 capsules (30-day supply)

Refills:
2

Special Instructions:
Take with food to improve absorption. Recheck vitamin D level in 3 months.

Continue current medications

Tresiba 15 units SC QHS.

Novolog 5 units SC TID before meals (with carbohydrate adjustments).

Lisinopril 10 mg PO once daily.

Monitoring Plan

Cognition & function:
Use MMSE or MoCA every 6–12 months.

Adverse effects of donepezil:
Monitor for nausea, diarrhea, bradycardia, and insomnia. Check HR regularly (Kumar et al., 2023).

Labs:

Vitamin D level in 3 months.

Continue routine diabetes labs (A1C every 3–6 months, BG logs).

Renal function (BMP) annually with lisinopril and insulin use.

Blood pressure & HR:
Monitor for hypotension or bradycardia.

Family/caregiver input:
Monitor changes in memory, ADLs, and mood.

Scenario 4: Poorly Controlled Type 2 Diabetes (PL, 63 years old)

Because PL has type 2 diabetes with CKD (eGFR 27), metformin is contraindicated (risk of lactic acidosis), and SGLT2 inhibitors are not recommended at this level of kidney function. The best choice is a GLP-1 receptor agonist, which lowers A1C, reduces CV risk, and is safe in reduced renal function (Adamczak et al., 2024).

Prescription:

Medication:
Dulaglutide (Trulicity) 0.75 mg/0.5 mL prefilled pen

Sig (Directions):
Inject 0.75 mg subcutaneously once weekly.

Quantity:
4 pens (28-day supply)

Refills:
2

Special Instructions:
Administer on the same day each week, with or without meals. Rotate injection sites (abdomen, thigh, upper arm). Do not share pens.

Drug Classification & Mechanism of Action (MOA)

Class:
GLP-1 receptor agonist

MOA:
Mimics incretin hormone GLP-1, enhances glucose-dependent insulin secretion, suppresses glucagon secretion, slows gastric emptying, and increases satiety, which lowers A1C and promotes weight loss (Ayesh et al., 2024).

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

Education for PL

Common side effects: nausea, vomiting, diarrhea (usually improve after the first week).

Eat smaller, more frequent meals to reduce GI upset.

Monitor blood sugar regularly; keep a log.

Report symptoms of pancreatitis (severe abdominal pain, persistent nausea/vomiting).

Continuing lifestyle modifications (low-carb diet, exercise as tolerated).

Monitoring Plan

Blood glucose logs
: monitor fasting and postprandial BG.

A1C:
repeat in 3 months (goal:
<7% , individualized; with CKD and age, <7.5–8% may be reasonable). Renal function: monitor serum creatinine/eGFR every 3–6 months. BP: continue losartan for renal protection. Weight and GI tolerance: track during follow-up visits. Goal A1C: <7% (per ADA), but <7.5–8% may be safer given CKD, age, and comorbidities (ElSayed et al., 2024).   References Adamczak, M., Kurnatowska, I., Naumnik, B., Stompór, T., Tylicki, L., & Krajewska, M. (2024). Pharmacological nephroprotection in chronic kidney disease patients with type 2 diabetes mellitus—Clinical practice position statement of the Polish Society of Nephrology. International Journal of Molecular Sciences , 25 (23), 12941–12941. https://doi.org/10.3390/ijms252312941 Al-Hashimi, N., & Abraham, S. (2024, January 10). Cholecalciferol . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549768/ American Headache Society. (2024). Preventative migraine treatment . American Headache Society. https://americanheadachesociety.org/resources/primary-care/preventative-migraine-treatment Ayesh, H., Suhail, S., Ayesh, S., & Niswender, K. (2024). Comparative efficacy and safety of weekly Dulaglutide versus weekly insulin in type 2 Diabetes: A network meta-analysis of randomized clinical trials. Metabolism Open , 100284–100284. https://doi.org/10.1016/j.metop.2024.100284 Boinpally, R., Shebley, M., & Trugman, J. (2024). Ubrogepant: Mechanism of action, clinical and translational science. Clinical and Translational Science , 17 (1), e13675. https://doi.org/10.1111/cts.13675 Contreras-García, I. J., Cárdenas-Rodríguez, N., Romo-Mancillas, A., Bandala, C., Zamudio, S. R., Gómez-Manzo, S., Hernández-Ochoa, B., Mendoza-Torreblanca, J. G., & Pichardo-Macías, L. A. (2022). Levetiracetam mechanisms of action: From molecules to systems. Pharmaceuticals , 15 (4), 475. https://doi.org/10.3390/ph15040475 Delgado, B. J., & Bajaj, T. (2022). Tiotropium . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541127/ ElSayed, N. A., McCoy, R. G., Aleppo, G., Balapattabi, K., Beverly, E. A., Early, K. B., Bruemmer, D., Echouffo-Tcheugui, J. B., Ekhlaspour, L., Garg, R., Khunti, K., Lal, R., Lingvay, I., Matfin, G., Napoli, N., Pandya, N., Pekas, E. J., Pilla, S. J., Polsky, S., & Segal, A. R. (2024). Older adults: Standards of care in diabetes—2025. Diabetes Care , 48 (Supplement_1), S266–S282. https://doi.org/10.2337/dc25-s013 Hsu, E., & Bajaj, T. (2023, June 20). Beta 2 Agonists . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542249/ Jeong, E., Mogos, M. F., & Chen, Y. (2024). Stroke risk reduction in migraine patients using propranolol: Evidence from two large-scale real-world data analyses. MedRxiv (Cold Spring Harbor Laboratory) . https://doi.org/10.1101/2024.06.11.24308801 Johnson, D. B., & Bounds, C. G. (2024, January 10). Albuterol . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482272/ Kumar, A., Sharma, S., & Gupta, V. (2023). Donepezil . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513257/ Lipworth, B., Kuo, C. R., Stewart, K., & Chan, R. (2024). Budesonide/formoterol or budesonide/albuterol as an anti-inflammatory reliever therapy for asthma. The Journal of Allergy and Clinical Immunology: In Practice . https://doi.org/10.1016/j.jaip.2024.02.003 Marucci, G., Buccioni, M., Ben, D. D., Lambertucci, C., Volpini, R., & Amenta, F. (2020). Efficacy of Acetylcholinesterase Inhibitors in Alzheimer’s Disease. Neuropharmacology , 190 (1), 108352. https://doi.org/10.1016/j.neuropharm.2020.108352 Remien, K., & Bowman, A. (2024). Fluticasone . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542161/ Theriot, J., & Ashurst, J. V. (2019). Antiemetic serotonin-5-HT3 receptor blockers . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513318/ NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

Comparison of APRN Board of Nursing Regulations: California vs. Washington State

Introduction

Boards of Nursing (BONs) ensure public safety by regulating nursing practices (Halm, 2018). California and Washington have APRNs with regulatory frameworks in each state, governing through specific rules regarding licensure and scope of practice. The comparison will be made according to two dimensions considered very important: they allow APRNs to practice independently based on their education and experience, independent practice authority, and continuing education requirements California vs Washington Comparison of APRN Board of Nursing Regulations.

Independent Practice Authority

One of the significant differences between California and Washington state pertains to the autonomy granted to APRNs. Historically, APRNs have been much more restricted in California and must practice under standardized procedures with physician supervision (Bosse et al., 2017). This has recently changed through legislation changes that allow qualified APRNs with a threshold requirement, such as three years of full-time practice, to apply for independent practice authority. This gives APRNs more autonomy, but a transitional process still regulates the pathway to complete independence.

By contrast, APRNs are granted full practice authority in Washington State from licensure forward. In effect, APRNs in Washington can diagnose and treat patients independently and prescribe medications, including and excluding controlled substances, from the beginning of their careers without requiring physician collaboration. Based on these measures, Washington emerges as one of the more APRN-friendly states, where advanced practice nurses, from the very outset, can utilize their fullest scope in improving healthcare access for underserved populations California vs Washington Comparison of APRN Board of Nursing Regulations.

Continuing Education Requirements

Continuing education is inherent in APRNs for competency. APRNs in California require 30 hours of CE for license renewal every two years. Continuing education requirements include courses in pharmacology, especially the courses with prescriptive authority to keep up with the best practices in the medication management process.

APRNs in the State of Washington must also have completed 45 hours of continuing education related to their scope of practice, including current issues in patient safety and updates to clinical practice. The CE requirements in Washington have a degree of flexibility that could allow the APRNs to meet specific interests or clinical needs and, therefore, may lead to more specialized expertise.

Implications for APRN Practice

These differences in independent practice authority and continuing education represent varying professional freedom that APRNs experience in states like California and Washington. APRNs in California need to undergo a more articulated process before they begin independent practice, thus postponing the full use of their training (Bosse et al., 2017). Contrarily, the entire practice authority of Washington immediately allows APRNs, upon licensure, to integrate into advanced roles that might help alleviate such healthcare shortages in rural areas. Continuing education requirements similarly keep APRNs in Oregon and Washington updated in their knowledge, but the flexibility offered by Washington allows perhaps more tailored learning and skill development.

Adherence to Regulations

APRNs, therefore, in these states practice their profession within their legal authority through strict adherence to their regulating law. For example, APRNs seeking practice authority independence in California will have to meticulously record their years of practice before seeking independence (Halm, 2018). In Washington state, on the other hand, an APRN may practice independently at the point of licensure, with ongoing continuing education during licensure to provide safe, evidence-based care California vs Washington Comparison of APRN Board of Nursing Regulations

Conclusion

This comparison of APRN regulations, side by side, between California and Washington state underlines how often similar rules emanate from a specific state, thus setting the professional environment for APRNs. Both states similarly wish to protect public safety and maintain high nursing practice standards. Yet, the immediate full practice authority available in Washington is in contrast to that of California, which provided a more incremental approach, thus influencing the speed and manner in which APRNs could fully employ their training and experience. As these state regulations continue to evolve, APRNs must also seek knowledge on effective navigation across changing state lines.

 

References:

Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017). Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care. 
Nursing Outlook
, 65(6), 761–765.

Halm, M. A. (2018). Evaluating the impact of EBP education: Development of a modified Fresno test for acute care nursing. 
Worldviews on Evidence-Based Nursing
, 15(4), 272–280. doi:10.1111/wvn.12291 California vs Washington Comparison of APRN Board of Nursing Regulations

NURS-6521 Week 2: Assignment Case Studies 

WEEK 2: Cardiovascular System scenario Assignment

Scenario 1

Errors, Correct Prescriptions, Classifications, and MOA

Metoprolol succinate ER 50 mg PO daily #30 1 RF

Error:
Missing clear instructions (e.g., “once daily”). “ER” should be stated as “extended-release.”

Correct Prescription:

Metoprolol succinate ER 50 mg PO once daily. Dispense 30 tablets. Refills: 1.

Class:
Beta-1 selective blocker.

MOA:
Decreases heart rate and contractility by blocking beta-1 adrenergic receptors, lowering myocardial oxygen demand (Morris & Dunham, 2024).

Amiodarone 75 mg PO daily #30 1 RF

Error:
Incorrect strength (not commercially available in 75 mg tablets). Standard doses are 100, 200, or 400 mg.

Correct Prescription:

Amiodarone 200 mg PO once daily. Dispense 30 tablets. Refills: 1.

Class:
Class III antiarrhythmic.

MOA:
Blocks potassium channels, prolonging repolarization and action potential duration (Gelman et al., 2024).

Amlodipine/hydrochlorothiazide (Lotrel) 5 mg/12.5 mg PO daily #30 3 RF

Error:
Lotrel combines amlodipine and benazepril, not hydrochlorothiazide.

Correct Prescription:

Amlodipine/benazepril (Lotrel) 5/20 mg PO once daily. Dispense 30 capsules. Refills: 3.

Class:
Calcium channel blocker + ACE inhibitor.

MOA:
Amlodipine blocks calcium influx into vascular smooth muscle (Bulsara & Cassagnol, 2024); benazepril inhibits angiotensin-converting enzyme, reducing vasoconstriction and aldosterone effects (Dahal & Gupta, 2020).

Hydralazine/isosorbide mononitrate (BiDil) 37.5 mg/20 mg PO every 8 hours #90 1 RF

Error:
Frequency incomplete. BiDil is dosed TID (every 8 hrs). #90 covers only one month.

Correct Prescription:

Hydralazine/isosorbide dinitrate (BiDil) 37.5/20 mg PO three times daily. Dispense 90 tablets. Refills: 1.

Class:
Direct vasodilator + nitrate.

MOA:
Hydralazine relaxes arterioles via smooth muscle relaxation; isosorbide dinitrate donates nitric oxide, causing venous dilation (Mavrakanas et al., 2022).

Clonidine patch (Catapres-TTS-1) 0.1 mg/day apply one patch to skin and replace every 3 days #10 patches 0 RF

Error:
Patch is replaced every 7 days, not every 3 days.

Correct Prescription:

Clonidine patch (Catapres-TTS-1) 0.1 mg/day. Apply one patch weekly. Dispense 4 patches. Refills: 0.

Class:
Central alpha-2 adrenergic agonist.

MOA:
Reduces sympathetic outflow from the CNS, lowering blood pressure (Yasaei & Saadabadi, 2023).

Scenario 2

Verapamil and First-Pass Effect

Verapamil undergoes high first-pass metabolism, meaning a significant portion is metabolized by the liver before reaching systemic circulation. This is important to know because it will determine the route of administration. Oral bioavailability is low, approximately 20–35% because much of the absorbed dose is metabolized in the gut wall and liver before reaching systemic circulation (Herman & Santos, 2023). Since verapamil undergoes substantial first-pass metabolism, oral doses produce variable systemic levels. Clinicians must be cautious about interactions that affect CYP3A / hepatic blood flow or gut metabolism (grapefruit, CYP3A inhibitors), as these can raise verapamil concentrations and risk toxicity (excess bradycardia or hypotension).

First-pass effect:
The process by which the liver metabolizes drugs taken orally, reducing systemic bioavailability.

Bioavailability:
The proportion of a drug that reaches systemic circulation unchanged.

100% Bioavailability Route:
Intravenous (IV).

To avoid first-pass metabolism:
Verapamil can also be administered sublingually or intravenously.

Prescription Example:

Verapamil 80 mg PO three times daily. Dispense 90 tablets. Refills: 1.

Scenario 3

CYP Enzyme & Drug Identification

1) Where are the majority of cytochrome P450 (CYP) enzymes located?

CYP enzymes are predominantly expressed in the liver (hepatocytes, smooth endoplasmic reticulum) and are also significantly present in the small intestinal mucosa (enterocytes), where they contribute to first-pass metabolism. Other tissues (kidney, lung, brain) express lower amounts. The highest total CYP mass is in the liver, making it the primary site of drug metabolism.

2) Pill identification (imprint ATO 40, oval white)

Using the Medscape pill identifier (Medscape, 2024), imprint ATO 40 corresponds to Atorvastatin 40 mg (white oval tablet).

3) What CYP enzyme metabolizes this medication?

Atorvastatin is primarily metabolized by CYP3A4 (hepatic CYP3A4 pathway) (McIver & Siddique, 2020). This matters because drugs that inhibit or induce CYP3A4 will significantly change atorvastatin plasma concentrations.

4) How can this information be applied to medication-therapy management (MTM)?

Screen for interacting drugs
: Avoid co-prescription with potent CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, some HIV protease inhibitors) or adjust dose/switch statin (consider pravastatin or rosuvastatin, which have less CYP3A4 dependence) to reduce the risk of statin-associated myopathy or rhabdomyolysis (Sizar et al., 2024).

Counsel patients
about grapefruit/grapefruit juice (inhibits intestinal CYP3A4 and can raise atorvastatin levels) (McIver & Siddique, 2020).

Monitoring
: check baseline lipid panel, then recheck LDL-C 4–12 weeks after initiation or dose change to assess response; monitor for muscle symptoms and check CK if symptomatic; monitor LFTs as clinically indicated. (Follow ACC/AHA lipid monitoring recommendations.) (Grundy, 2019).

5) Sample prescription (complete order):

Atorvastatin 40 mg (ATO 40) — Take one (1) tablet by mouth once daily at bedtime. Dispense #30 (30-day supply). Refills: 2. Special instructions: Baseline fasting lipid panel prior to initiation; repeat LDL-C 4–12 weeks after start or dose change and then every 3–12 months; avoid grapefruit juice; notify provider for unexplained muscle pain/weakness.

6) What are the goal cholesterol levels and CAD risk factors?

For patients with clinical ASCVD or very high risk, aim for LDL-C < 70 mg/dL and consider high-intensity statin or nonstatin therapy if the threshold is not met. For secondary prevention and many high-risk primary prevention patients, LDL percent reduction goals and clinician-patient discussion guide intensity (Grundy, 2019). Other lipid targets: HDL desirable >40 mg/dL (men) / >50 mg/dL (women); triglycerides <150 mg/dL (desirable) (Grundy, 2019). Common CAD risk factors: Hypertension, diabetes mellitus, dyslipidemia (elevated LDL), cigarette smoking, age (men ≥45 y; women ≥55 y), family history of premature CAD, obesity, physical inactivity, chronic kidney disease, chronic inflammatory conditions, and specific biomarkers (e.g., elevated hsCRP), all used in ASCVD risk assessment (Grundy, 2019). Scenario 4 Case Analysis (RT, 54 years old) Current BP: 135/90, consistent with Stage 1 Hypertension (Whelton et al., 2018). Goal BP: <130/80 mmHg for patients with diabetes (ElSayed et al., 2023). Current meds: Metformin, ibuprofen, duloxetine. Concern: Long-term NSAID use (ibuprofen) can elevate BP and increase cardiovascular risk (Buciuman et al., 2025). Recommend discontinuing or limiting. Treatment Plan: Start an ACE inhibitor for BP control and renal protection in diabetes. Recommend stopping ibuprofen; suggest acetaminophen as safer for chronic pain. Start lisinopril (ACE inhibitor): Lisinopril 10 mg: Take one (1) tablet by mouth once daily. Dispense #30 (30-day supply). Refills: 2. Special instructions: Check serum creatinine and potassium 1–2 weeks after initiation or dose change; hold and notify provider for lightheadedness, angioedema, cough, or significant rise in creatinine (>30% increase). Take at the same time daily (bedtime may reduce first-dose dizziness).

Stop/modify current meds:

Ibuprofen 600 mg PO TID
: Discontinue for chronic use; recommend acetaminophen prescription as below: Acetaminophen (Tylenol) 500 mg PO (by mouth) Every 6 hours as needed for pain. Do not exceed 3,000 mg per 24 hours (to avoid hepatotoxicity). Dispense #60 tablets (10-day supply). Refills
:
1

Metformin 500 mg PO BID:
continue (for glycemic control). Monitor renal function per usual practice, but metformin generally continued unless eGFR falls below guideline cutoffs (Corcoran & Jacobs, 2023).

Duloxetine 60 mg PO daily: Continue
if clinically indicated (e.g., neuropathic pain), but
advise BP monitoring
because duloxetine can increase blood pressure in some patients. If BP remains uncontrolled or if duloxetine is judged contributory, consider alternative analgesic strategies in coordination with the patient.

Monitoring & Education:

Monitor BP at home 2–3 times per week.

Labs: Serum creatinine and potassium in 1–2 weeks.

Educate the patient on a low-sodium DASH diet, weight management, smoking cessation, and physical activity.

References

Buciuman, C. A., Dobrea, C. M., Butuca, A., Frum, A., Gligor, F. G., Gligor, O., Vicaș, L. G., & Morgovan, C. (2025). Exploring the cardiovascular safety profile of ibuprofen: Insights from EudraVigilance database.
Pharmaceuticals
,
18
(7), 1045.
https://doi.org/10.3390/ph18071045

Bulsara, K. G., & Cassagnol, M. (2024, April 21).
Amlodipine
. National Library of Medicine.
https://www.ncbi.nlm.nih.gov/books/NBK519508/

Corcoran, C., & Jacobs, T. F. (2023, August 17).
Metformin
. National Library of Medicine; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK518983/

Dahal, S. S., & Gupta, M. (2020).
Benazepril
. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK549885/

ElSayed, N. A., Aleppo, G., Bannuru, R. R., Bruemmer, D., Collins, B., Das, S. R., Ekhlaspour, L., Hilliard, M. E., Johnson, E. L., Khunti, K., Kosiborod, M., Lingvay, I., Matfin, G., McCoy, R. G., Mary Lou Perry, Pilla, S. J., Polsky, S., Prahalad, P., Pratley, R. E., & Segal, A. R. (2023). 10. Cardiovascular disease and risk management: Standards of care in diabetes—2024.
Diabetes Care
,
47
(Supplement_1), S179–S218.
https://doi.org/10.2337/dc24-s010

Gelman, I., Sharma, N., Mckeeman, O., Lee, P., Campagna, N., Tomei, N., Baranchuk, A., Zhang, S., & El-Diasty, M. (2024). The ion channel basis of pharmacological effects of amiodarone on myocardial electrophysiological properties, a comprehensive review.
Biomedicine & Pharmacotherapy = Biomedecine & Pharmacotherapie
,
174
, 116513.
https://doi.org/10.1016/j.biopha.2024.116513

Grundy, S. M. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol.
Circulation
,
139
(25).
https://doi.org/10.1161/cir.0000000000000625

Herman, T. F., & Santos, C. (2023, November 3).
First pass effect
. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK551679/

Mavrakanas, T. A., Soomro, Q. H., & Charytan, D. M. (2022). Hydralazine–Isosorbide dinitrate use in patients with end-stage kidney disease on dialysis.
Kidney International Reports
,
7
(6), 1332–1340.
https://doi.org/10.1016/j.ekir.2022.03.032

McIver, L. A., & Siddique, M. S. (2020, September 25).
Atorvastatin
. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK430779/

Medscape. (2024).
Pill identifier (drug & pill finder) – Medscape reference
. Reference.medscape.com.
https://reference.medscape.com/pill-identifier

Morris, J., & Dunham, A. (2024).
Metoprolol
. Nih; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK532923/

Sizar, O., Khare, S., Jamil, R. T., & Talati, R. (2024).
Statin medications
. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK430940/

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., & Williamson, J. D. (2018). 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the american college of cardiology/american heart association task force on clinical practice guidelines.
Hypertension
,
71
(6).
https://doi.org/10.1161/hyp.0000000000000065

Yasaei, R., & Saadabadi, A. (2023, July 17).
Clonidine
. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK459124/

 

NURS-6521 Week 2: Assignment Case Studies

Scenario 1

What are the 
errors
 in the following prescriptions (1 per prescription)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?

metaprolol succinate ER 50 mg PO daily #30 1 RF

amiodarone 75 mg PO daily #30 1 RF

amlodipine/hydrochlorothiazide (Lotrel) 5 mg/12.5 mg PO daily #30 3RF

hydralazine/isosorbide mononitrate (BiDil) 37.5 mg/20 mg PO every 8 hours #90 1 RF

clonidine patch (Catapres-TTS-1) 0.1 mg/day apply one patch to skin and replace every 3 days #10 patches 0 RF

 

SCENARIO 2

Does verapamil have a high or low 
first pass effect
? Please discuss why this is important to know and how it relates to 
bioavailability
. Define these two terms. What route has 100% bioavailability? In addition to parenterally, how can verapamil be given to counter the first pass effect? Write a sample prescription for this medication.

 

SCENARIO 3

Where are the majority of cytochrome P450 (CYP) enzymes 
located
? Using the Medscape pill identifier, enter the following characteristics to identify the medication AND strength. What 
CYP enzyme
 metabolizes this medication? How can this information be applied to 
medication therapy management
? Write a sample prescription for the identified medication and strength. What are 
goal cholesterol levels
 and (Coronary Artery Disease) 
CAD risk factors
?

Imprint (ATO 40)  Shape (Oval)  Color (White)  Form (Tablet)  Scoring (None)

 

SCENARIO 4

RT is a 54-year-old female presenting with blood pressure today of 135/90 HR 80 RR 15. Her last visit to the clinic 3 months ago shows a BP of 134/88. She is currently taking metformin 500 mg PO BID with meals, ibuprofen 600 mg PO TID for back pain, and duloxetine 60 mg PO daily. What is her goal blood pressure? What medication would you prescribe and how would you improve her treatment (include complete medication order)? What patient monitoring and education would you provide?

 

Assignment: Case Studies

Case studies are a useful way for you to apply your knowledge of pharmacokinetics and pharmacodynamic aspects of pharmacology to specific patient cases and health histories.

For this Assignment, you evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.

Resources

 

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare:

Review the case study posted in “Announcements” by your Instructor for this Assignment

Review the information provided and answer questions posed in the case study

When recommending a medication, write out a complete prescription for the medication

Whenever possible, use clinical practice guidelines in developing your answers when possible

Include at least three references to support your answer and cite them in APA format.

NURS-6521 Week 2: Assignment Case Studies

By Day 7 of Week 1

Submit the Assignment.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the 
Turnitin Drafts
 from the 
Start Here
 area.

To submit your completed assignment, save your Assignment as 
WK1Assgn1_LastName_Firstinitial

Then, click on 
Start Assignment
 near the top of the page.

Next, click on 
Upload File
 and select 
Submit Assignment
 for review.

Rubric

NURS_6521_Week2_Assignment_Rubric

NURS_6521_Week2_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome
Scenario 1: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 1: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 1: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 1: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 2: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 2: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 3: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 3: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

NURS-6521 Week 2: Assignment Case Studies

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

15
 
to >
11.0
 pts
Excellent
Medication selected is appropriate and considers all of the unique patient characteristics. Rationale for selection is clear, complete, and appropriate.

11
 
to >
7.0
 pts
Good
Medication selected might be appropriate but conflicts with the unique patient characteristics. Rationale for selection is clear but lacks discussion about potential prescribing issues.

7
 
to >
3.0
 pts
Fair
Medication selected is not appropriate for this patient unique characteristics. Rationale provided is not correct or is flawed in applying the medication to this patient.

3
 
to >
0
 pts
Poor
Medication selected is inappropriate or would not be provided based on patient unique characteristics.

15
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

3
 pts
Complete
Written medication orders includes all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

0
 pts
Poor
The prescription is incomplete. Aspects of a complete order are missing. The order is either incomplete, inaccurate, or inappropriate.

3
 pts

This criterion is linked to a Learning Outcome
Scenario 4: References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

4
 pts
Excellent
References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable. Correct APA format is used.

3
 pts
Good
References for the scenario are within past 5 years but do not include the appropriate clinical practice guideline if applicable. Contains a few (1 or 2) APA format errors.

2
 pts
Fair
References for the scenario are not from within the past 5 years or do not reflect the content of this scenario and do not include the appropriate clinical practice guideline if applicable. Contains several (3 or 4) APA format errors.

0
 pts
Poor
No references are included. References do not reflect the content of this scenario. Appropriate clinical practice guideline is not include. Contains many (≥ 5) APA format errors.

4
 pts

This criterion is linked to a Learning Outcome
Scenario 4: Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

3
 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.

2
 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

1
 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

0
 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. NURS-6521 Week 2: Assignment Case Studies

3
 pts

Total Points: 
100

Comparison of APRN Board of Nursing Regulations: Michigan vs. Ohio

Application to Advanced Practice Registered Nurses

Advanced Practice Registered Nurses (APRNs) are highly skilled and educated professionals integral to the healthcare system. Their licensure, postgraduate education, and training in nursing, which can be at the master’s, post-master, or doctoral level, along with national board certification, are all essential for their entry-level practice (Clarke, 2023). Each state has its regulations that must be followed.

My practicing state is Michigan. I’ve considered obtaining a license in Ohio since I’m so close to the border. Michigan and Ohio are both considered to be restricted practice states, which means APRNs have a significant level of autonomy, empowering them to make independent decisions in their practice. However, they must have a collaborative agreement with a physician to practice. The Standard Care Arrangement, applicable in both states, is a written agreement that defines the scope of practice, including guidelines for diagnosing and treating patients between the APRN and collaborating physician APRN Board of Nursing Regulations Michigan vs Ohio.

The Standard Care Arrangement will also outline prescriptive authority. In both states, APRNs can prescribe scheduled II-V substances; however, guidelines differ with Schedule II medications. In Ohio, Schedule II medications are regulated by the Board of Nursing and can only be given in specific settings (Ohio Board of Nursing, 2022). An APRN is permitted to prescribe Schedule II controlled substances if the patient has a terminal condition or if the supervising physician initially prescribed the medication, and the prescription is restricted to the amount needed for the patient’s use within a single 24-hour period (Ohio Board of Nursing, 2022). In Michigan, only a Standard Care Arrangement is needed with a physician to prescribe Schedule II medications, which are not as strict as Ohio guidelines. Understanding these differences will ensure that you are knowledgeable and aware of the regulations in each state.

Examples of How APRNs Adhere to Regulations

APRNs must adhere to regulations. This ensures not only compliance but also professionalism in your practice. Understanding and following the regulations in each state is vital to the APRN’s role. After reviewing the regulations, it was found that license renewal requirements for each state have some slight differences. These differences are significant, and it is important for APRNs to be aware of them. Both states require the APRN to obtain continuing education credits. In Michigan, two of those hours are focused on pain and symptom management, and one hour on medication management of controlled substances. One of the differences in Ohio is that if the APRN has prescriptive authority, they must have 12 hours of advanced pharmacology credits and one hour focused on laws and regulations.

 

References

Clarke, E. (2023, November 10). 
Nurse practitioner practice authority: A State-by-state guide
. NurseJournal. https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/

Michigan Board Of Nursing. (2019). 
Nursing Policy
. Michigan.gov. https://www.michigan.gov/mdhhs/doing-business/providers/nursing/nursing-policy

Ohio Board of Nursing. (2022). 
Nursing Practice and Scopes of Practice
. Ohio.gov. https://nursing.ohio.gov/resources-for-practice-and-prescribing/resources/01-nursing-practice-and-scopes-of-practice APRN Board of Nursing Regulations Michigan vs Ohio

NURS-6521 Week 1: Assignment Practimum Manual Quiz

Question 1

0.33 
/ 0.33
 pts

I have read the entire syllabus and I will abide by the requirements described in order to successfully complete this course.

Yes

 

No

 

Question 2

0.33 
/ 0.33
 pts

I acknowledge reading the syllabus and understand the course requirements to successfully pass the class.

Yes

 

No

 

Question 3

0.34 
/ 0.34
 pts

 

I have downloaded and read the entire MSN Nurse Practitioner Practicum Manual. I will abide by the requirements described in order to successfully complete the NP program.

Yes

 

No

NURS-6521 Week 1: Assignment Practimum Manual Quiz

Comparison of APRN Board of Nursing Regulations

In my state of Delaware, the Board of Nursing serves as an APRN through strict rules concerning scope and license issues, among other things. Drawing a parallel with California on these issues, it emerges that there are a number of differences between states with regard to APRNs’ autonomy and prescriptive authorities (Margo et al., 2022). These differences have influenced how APRNs have been allowed to conduct practice within the concerned states.

Independent Practice Authority

APRNs in the state of Delaware are accorded full practice authority where, upon licensure and certification, APRNs can practice independently without any collaboration or supervision by physicians. This includes independent diagnosis, treatment, and prescription of medications upon meeting the licensure and certification requirements. On the other hand, California recently implemented APRN-independent practice in primary care settings, although such APRN-independent practice in California should be accorded to APRNs who have completed the transition-to-practice requirements. In California, physician oversight is still required for other areas of care.

Example: Once fully licensed, the APRN in Delaware practices independently without physician oversight, as compared with California, where this is really a more autonomous role (Nguyen et al., 2021). In California, under AB-890, APRNs practice independently in primary care, though transition requirements remain; other specialties continue to maintain physician oversight. Several years into their clinical experience, APRNs still need to be independent in all cases within California.

Prescriptive Authority

APRNs in Delaware have prescribing authority for controlled substances in Schedule II through Schedule V without needing a written agreement with a collaborating physician. This, in turn, means greater independence in care provided and prescribing practices. APRNs from California also have prescriptive authority, but their practice should be conducted under standardized procedures agreed upon by the supervising physician.

Example: APRNs in Delaware, with the appropriate licensure, can independently prescribe opioids or other controlled substances. However, APRNs in California are required to follow very strict protocols set by the overseeing physician when prescribing these controlled substances (Sheer B., 2023). This ultimately means fewer independent decisions in prescription settings compared to Delaware.

Application to APRN Practice

These regulations explain, to a great degree, the scope of practice of APRNs within their jurisdictions (Zhong et al., 2024). For example, Delaware permits an APRN to increase his independence in primary care and specialty practices. On the other hand, APRNs in California remain under more restrictive supervision for patient care decisions and prescriptive undertakings. Delaware APRN State-Level Regulations

 

 

References

Margo Brooks Carthon, Brom, H., Nikpour, J., Todd, B., Aiken, L., & Lusine Poghosyan. (2022). Supportive Practice Environments Are Associated With Higher Quality Ratings Among Nurse Practitioners Working in Underserved Areas. Journal of Nursing Regulation, 13(1), 5–12. 
https://doi.org/10.1016/s2155-8256(22)00028-x
Links to an external site.

Nguyen, T., Muench, U., Andraka-Christou, B., Simon, K., W. David Bradford, & Spetz, J. (2021). The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill. Medical Care Research and Review, 79(2), 290–298. 
https://doi.org/10.1177/10775587211004311
Links to an external site.

Sheer, B. (2023). Evolution in Healthcare: The Journey from a U.S. Demonstration Project to an International Concept. Advanced Practice in Nursing, pp. 3–39. 
https://doi.org/10.1007/978-3-031-20762-4_1
Links to an external site.

Zhong, E. H., Martin, B., O’Hara, C., Kaminski-Ozturk, N., Buck, M., Livanos, N., & Alexander, M. (2024). Advanced Practice Registered Nurses’ Views of the APRN Compact: Survey Findings From Five U.S. States. Journal of Nursing Regulation, 14(4), 5–12. 
https://doi.org/10.1016/s2155-8256(23)00154-
Links to an external site.
  Delaware APRN State-Level Regulations

Evaluation and management (E/M) documentation for a patient and a crosswalk of codes from DSM-5-TR to ICD-10

Evaluation and Management (E/M)

Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.

For this Assignment, you will review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes from 
DSM-5-TR
 to ICD-10.

Resources

 

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare

Review this week’s Learning Resources on coding, billing, reimbursement.

Review the E/M patient case scenario provided.

The Assignment

Assign 
DSM-5-TR
 and ICD-10 codes to services based upon the patient case scenario.

Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.

Explain what pertinent information, generally, is required in documentation to support 
DSM-5-TR
 and ICD-10 coding.

Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

By Day 7 of Week 2

Submit
 your Assignment.

 

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the 
Turnitin Drafts
 from the 
Start Here
 area.

To submit your completed assignment, save your Assignment as 
WK2Assgn1_LastName_Firstinitial

Then, click on 
Start Assignment
 near the top of the page.

Next, click on 
Upload File
 and select 
Submit Assignment
 for review.

Rubric

NRNP_6675_Week2_Assignment1_Rubric

NRNP_6675_Week2_Assignment1_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome
In the E/M patient case scenario provided:• Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.

20
 
to >
17.0
 pts
Excellent 90%–100%
DSM-5 and ICD-10 codes assigned to the scenario are correct, with no more than a minor error.

17
 
to >
15.0
 pts
Good 80%–89%
DSM-5 and ICD-10 codes assigned to the scenario are mostly correct, with a few minor errors.

15
 
to >
13.0
 pts
Fair 70%–79%
DSM-5 and ICD-10 codes assigned to the scenario contain several errors.

13
 
to >
0
 pts
Poor 0%–69%
DSM-5 and ICD-10 codes assigned to the scenario contain significant errors, or response is missing.

20
 pts

This criterion is linked to a Learning Outcome
In 1–2 pages, address the following: • Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.

25
 
to >
22.0
 pts
Excellent 90%–100%
The response accurately and concisely explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

22
 
to >
19.0
 pts
Good 80%–89%
The response accurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

19
 
to >
17.0
 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

17
 
to >
0
 pts
Poor 0%–69%
The response vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding, or the explanation is incomplete or missing.

25
 pts

This criterion is linked to a Learning Outcome
• Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

25
 
to >
22.0
 pts
Excellent 90%–100%
The response accurately and concisely identifies the pertinent misssing information from the case scenario and clearly identifies what additional information would narrow coding and billing options.

22
 
to >
19.0
 pts
Good 80%–89%
The response accurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options.

19
 
to >
17.0
 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options.

17
 
to >
0
 pts
Poor 0%–69%
The response vaguely or inaccurately identifies the pertinent misssing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing.

25
 pts

This criterion is linked to a Learning Outcome
• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

15
 
to >
13.0
 pts
Excellent 90%–100%
The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement.

13
 
to >
11.0
 pts
Good 80%–89%
The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement.

11
 
to >
10.0
 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement.

10
 
to >
0
 pts
Poor 0%–69%
The response vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement, or response may be incomplete or missing.

15
 pts

This criterion is linked to a Learning Outcome
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5
 
to >
4.0
 pts
Excellent 90%–100%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4
 
to >
3.5
 pts
Good 80%–89%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time…. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3.5
 
to >
3.0
 pts
Fair 70%–79%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment are vague or off topic.

3
 
to >
0
 pts
Poor 0%–69%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time…. Purpose statement, introduction, and conclusion were not provided. 5  pts This criterion is linked to a Learning Outcome Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation 5   to >
4.0
 pts
Excellent 90%–100%
Uses correct grammar, spelling, and punctuation with no errors

4
 
to >
3.5
 pts
Good 80%–89%
Contains 1-2 grammar, spelling, and punctuation errors

3.5
 
to >
3.0
 pts
Fair 70%–79%
Contains 3-4 grammar, spelling, and punctuation errors

3
 
to >
0
 pts
Poor 0%–69%
Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

5
 pts

This criterion is linked to a Learning Outcome
Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.

5
 
to >
4.0
 pts
Excellent 90%–100%
Uses correct APA format with no errors

4
 
to >
3.5
 pts
Good 80%–89%
Contains 1-2 APA format errors

3.5
 
to >
3.0
 pts
Fair 70%–79%
Contains 3-4 APA format errors

3
 
to >
0
 pts
Poor 0%–69%
Contains five or more APA format errors

5
 pts

Total Points: 
100

Evaluation and management (E/M) documentation for a patient and a crosswalk of codes from DSM-5-TR to ICD-10

Psychiatric Patient Evaluation

Instructions

 

Use the following case template to complete Week 2 Assignment 1. On page 5, assign 
DSM-5-TR
and Updated ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document.

Identifying Information

 

Identification was verified by stating of their name and date of birth.

Time spent for evaluation: 0900am-0957am

Chief Complaint

 

“My other provider retired. I don’t think I’m doing so well.”

HPI

 

25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.

Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking.  Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors.

Diagnostic Screening Results

 

Screen of symptoms in the past 2 weeks:

PHQ 9 = 0 with symptoms rated as no difficulty in functioning

Interpretation of Total Score

Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

GAD 7 = 2 with symptoms rated as no difficulty in functioning

Interpreting the Total Score:

Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety

MDQ screen negative

PCL-5 Screen 32

Past Psychiatric and Substance Use Treatment

 

·        Entered mental health system when she was age 19 after raped by a stranger during a house burglary.

·        Previous Psychiatric Hospitalizations:  denied

·        Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015

·        Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing)

·        Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records

Substance Use History

 

Have you used/abused any of the following (include frequency/amt/last use):

Substance

Y/N

Frequency/Last Use

Tobacco products

Y

½

ETOH

Y

last drink 2 weeks ago, reports drinks 1-2 times monthly one drink socially

Cannabis

N

 

Cocaine

Y

last use 2015

Prescription stimulants

Y

last use 2015

Methamphetamine

N

 

Inhalants

N

 

Sedative/sleeping pills

N

 

Hallucinogens

N

 

Street Opioids

N

 

Prescription opioids

N

 

Other: specify (spice, K2, bath salts, etc.)

Y

reports one-time ecstasy use in 2015

 

Any history of substance related:

·        Blackouts:  +

·        Tremors:   –

·        DUI: –

·        D/T’s: –

·        Seizures: –

Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings

Psychosocial History

 

Client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children.

Employed at local tanning bed salon

Education: High School Diploma

Denied current legal issues.

Suicide / HOmicide Risk Assessment

 

RISK FACTORS FOR SUICIDE:

·        Suicidal Ideas or plans – no

·        Suicide gestures in past – no

·        Psychiatric diagnosis – yes

·        Physical Illness (chronic, medical) – no

·        Childhood trauma – yes

·        Cognition not intact – no

·        Support system – yes

·        Unemployment – no

·        Stressful life events – yes

·        Physical abuse – yes

·        Sexual abuse – yes

·        Family history of suicide – unknown

·        Family history of mental illness – unknown

·        Hopelessness – no

·        Gender – female

·        Marital status – single

·        White race

·        Access to means

·        Substance abuse – in remission

 

PROTECTIVE FACTORS FOR SUICIDE:

·        Absence of psychosis – yes

·        Access to adequate health care – yes

·        Advice & help seeking – yes

·        Resourcefulness/Survival skills – yes

·        Children – no

·        Sense of responsibility – yes

·        Pregnancy – no; last menses one week ago, has Norplant

·        Spirituality – yes

·        Life satisfaction – “fair amount”

·        Positive coping skills – yes

·        Positive social support – yes

·        Positive therapeutic relationship – yes

·        Future oriented – yes

 

Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors

 

Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence, however, risk of lethality increased under context of drugs/alcohol.

 

No required SAFETY PLAN related to low risk

Mental Status Examination

 

She is a 25 yo Russian female who looks her stated age. She is cooperative with examiner. She is neatly groomed and clean, dressed appropriately. There is mild psychomotor restlessness. Her speech is clear, coherent, normal in volume and tone, has strong cultural accent. Her thought process is ruminative. There is no evidence of looseness of association or flight of ideas. Her mood is anxious, mildly irritable, and her affect appropriate to her mood. She was smiling at times in an appropriate manner. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her insight is good.

Clinical Impression

 

Client is a 25 yo Russian female who presents with history of treatment for PTSD, ADHD, Stimulant use Disorder, in remission.

Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal symptoms, has somatic concerns of GI upset and headaches.

At the time of disposition, the client adamantly denies SI/HI ideations, plans or intent and has the ability to determine right from wrong, and can anticipate the potential consequences of behaviors and actions. She is a low risk for self-harm based on her current clinical presentation and her risk and protective factors.

Diagnostic: Impression:

 

 The act of rendering care to the patients by the provider can be consultation, examination, or counseling (Wiggins et al., 2019). Patient care services can occur in an acute care setting, emergency room, outpatient, rehabilitation, long-term care, hospice, and home care. When services are rendered, reimbursement is expected from the payers. Clinicians use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a tool to primarily assess and diagnose patients with mental health disorders (Wiggins et al., 2019). It is important to note that the guidelines contained in DSM-5 are not for treating patients, and the codes are not for billing patients after rendering services. The International Classification of Diseases, Tenth Revision, and Clinical Modification (ICD-10) are tools the provider uses as a guide to bill the payer. Billing and service reimbursement is sent to the payer in a coded format. A delay, denial, or partial payment can result if services are improperly coded. The DSM-5 helps clinicians to assess and diagnose patients, while the ICD-10 guides clinicians with the correct coding of care and services given to the patient. The provider uses reimbursement codes from ICD-10 to add value to the services rendered to patients based on the level and quality of services. A reimbursement claim must be appropriately coded, as codes convey the level of care given. Analyzing the scenario in this assignment, correctly coding the services given and the time spent with the patient is vital to proper reimbursement. A unique code like 90837 is used for any time the clinician spends with the patient above 53 minutes. The time spent with the patient in this scenario was 57 minutes; therefore, the code 90792 applies, while F41.1 is the code for medical services of the diagnosis of generalized anxiety post-PTSD (Khera et al., 2018)

 

 

.

 

Treatment Plan

 

1)      Medication:

·        Increase fluoxetine 40mg po daily for PTSD #30 1 RF

·        Continue with atomoxetine 80mg po daily for ADHD.  #30 1 RF

Instructed to call and report any adverse reactions.

Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful

 

2)      Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained.

Not to drive or operate dangerous machinery if feeling sedated.

Not to stop medication abruptly without discussing with providers.

Discussed risks of mixing  medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings.

Discussed how drugs/ETOH affects mental health, physical health, sleep architecture.

 

3)      Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.

 

4)      Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

 

5)      Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation.

 

6)      RTC in 30 days

 

7)      Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results

Patient is amenable with this plan and agrees to follow treatment regimen as discussed.

 

 

Narrative Answers

Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options.

When patient care is given, attention to detail and linking all the pieces is crucial. This is vital because maximum reimbursement depends on connecting the dots when filing claims. (Nguyen et al., 2018). Often, the insurance companies or payer may demand extra proof to buttress the claims or show that the level of care reimbursement filed met the level coded/billed. When pertinent information is missing during coding, reimbursement can be delayed, denied, or result in low reimbursement (Nguyen et al., 2018). Patient assessment, including physical examinations, medical decision-making, counseling, care coordination, presenting condition, and time, are essential in DSM-5 and ICD-10 coding for proper billing (Nguyen et al., 2018). Translating all these services into a billable format is essential in coding. The clinician should pay attention to a primary complaint (cc) and current illness history (HPI), a thorough review of systems (ROS), and any pertinent previous, family, social history, patient’s medical history, drug abuse histories, suicide risk assessments, mental health examinations, proposed treatment plans and amount of time spent doing an assessment (Nguyen et al., 2018). In this scenario involving assessing a 25-year-old Russian female patient, pertinent information was captured, but a detailed review of the patient’s health records to authenticate the diagnosis is recommended. The vital information to aid proper coding, billing, and reimbursement and assist with DSM-5 diagnosis. Documentation in this scenario can be summarized as physicians’ descriptions, patients’ presenting symptoms, and other tips for diagnosing mental illness (Nguyen et al., 2018).

 

Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

The use of technology in healthcare practice has transformed documentation to support coding and billing. Using electronic medical records (EMR), billing and coding is faster and more accurate. The transformation of coding and billing through technology has improved how coders streamline claims to meet the company’s mission and vision. Identification of accounting, updating, uploading, and extracting data is simple, faster, and less stressful. It enables good work ethics and co-ordinations among coders and documentation specialists due to enhancement in technology. Investing in personnel to champion and support the employees is another strategy to improve documentation. Clinical managers fall under this category as they will train and re-train employees in advancing technology at all levels. Integrating coding roles in surveys to monitor compliance will also help keep the consciousness of coders on doing the right thing to avoid being tagged.

 

References

American Psychiatric Association. (2022).  
ICD-10-CM Codes Update Links to an external site.
. 
https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm/updates-to-dsm-5-tr-criteria-text

American Psychiatric Association. (2020). 
Updates to DSM–5 criteria, text and ICD-10 codes
 Links to an external site.
. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5

Khera, R., Dorsey, K. B., & Krumholz, H. M. (2018). Transition to the ICD-10 in the United States: an emerging data chasm. Jama, 320(2), 133-134. https://jamanetwork.com/journals/jama/article-abstract/2683806

Nguyen, A. N., Truran, D., Kemp, M., Koopman, B., Conlan, D., O’Dwyer, J., … & Green, D. (2018). Computer-assisted diagnostic coding: effectiveness of an NLP-based approach using SNOMED CT to ICD-10 mappings. In AMIA Annual Symposium Proceedings (Vol. 2018, p. 807). American Medical Informatics Association.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371260/

Clarke DE, Narrow WE, Regier DA, et al. DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches. Am J Psychiatry. 2013;170:43-58.

World Health Organization. ICD-10 Classification of mental and behavioral disorders. Diagnostic criteria for research. Geneva: World Health Organization; 1993

Wiggins, L. D., Rice, C. E., Barger, B., Soke, G. N., Lee, L. C., Moody, E., Edmondson-Pretzel, R., & Levy, S. E. (2019, March 8). DSM-5 criteria for autism spectrum disorder maximizes diagnostic sensitivity and specificity in preschool children.
Social Psychiatry and Psychiatric Epidemiology
,
54
(6), 693–701. https://doi.org/10.1007/s00127-019-

01674-1 Evaluation and management (E/M) documentation for a patient and a crosswalk of codes from DSM-5-TR to ICD-10

Maryland and Georgia APRN State-Level Regulations

Boards of nursing (BON) are present in all states to oversee nursing practice licensure. They evaluate license applications to either approve or decline (National Council of State Boards of Nursing, n.d.). According to Neff et al. (2018), BON approves registered nursing (RN) education programs to ensure that they comprehensively cover the skills and knowledge required to operate as a licensed RN (Neff et al., 2018). Despite the overall functions of BONs, each state has its set of regulations for licensing advanced practice registered nurses (APRNs). The laws determine the scope of APRNs in the states (Milstead & Short, 2019).

APRN board of nursing regulations in Maryland

The Advanced Practice Registered Nurse regulations in the state of Maryland stipulate various elements of practice, including certification, renewal of certification, education, practice before certification, and other nursing administration elements. The APRN regulations in Maryland stipulate that nurses can independently perform a wide range of clinical functions, including comprehensive physical assessment of patients (Maryland Board of Nursing, 2020). Nurses are also empowered to establish a medical diagnosis for short-term and chronic health problems as well as order, perform, and interpret laboratory results and diagnostic tests for patients.

Nurse practitioners in Maryland are also equipped to perform advanced therapeutic measures, such as performing diagnostic, therapeutic, and corrective measures on patients, including prescribing drugs and providing emergency care (Rubenfire, n.d.). However, the performance of these nursing responsibilities is defined and coordinated under various regulatory foundations, including the General Health Article §4-212 (Maryland Board of Nursing, 2020). Nurses may also refer patients to appropriate licensed physicians for purposes of coordinating the acquisition of advanced or specified clinical procedures or actions. Psychiatric nurse practitioners may also coordinate with other physicians to administer treatment on mental disorders on a voluntary basis as well as when the clinical intervention is warranted Maryland and Georgia APRN State-Level Regulations.

However, practicing nurses in the state of Maryland are only mandated to specialize the practice to their specific area of professional training for which they were certified. Nurses are also offered the leeway to refuse delegated tasks in cases where their individual judgement or assessment of the delegated task shows some element of professional doubt, gaps, ethical concerns or lack of observation of safety procedures or standards. Lastly, all practicing APRNs in the state of Maryland are subject to additional relevant regulatory measures, including disciplinary action in accordance with the Health Occupations Article §8-316 (Maryland Board of Nursing, 2020).

APRN board of nursing regulations in Georgia

In the state of Georgia, regulations of Advanced Practice Registered Nurses are quite strict and restrictive in terms of what nurses are allowed to do in practice. The scope of practice of APRN nurses in Georgia limits the nurses from offering prescription drug orders, especially for schedule I or II controlled substances. APRN nurses are also limited from offering any drug refills if the date of the initial drug prescription order was more than 12 months before. Nurses are, however, allowed to carry out drug refills for oral contraceptive drugs, hormone replacement therapy drugs, and prenatal vitamins for a duration of up to 24 months after the initial drug order (Advanced Practice Legal Issues, n.d.).

When it comes to actual practice, APRN nurses in the state of Georgia are restricted from providing advanced patient care unless a physician supervises the APRN nurse and proper stipulations of responsibility delegation are explained. This includes diagnosing patients, ordering tests, or even writing prescriptions. The practice limitation for APRN nurses in Georgia also extends into the issue of supervision of licensed APRN nurses by a licensed physician (“Practitioner Scope of Practice,” n.d.). To stipulate the terms of working, the two parties are required to establish a protocol agreement, which is a written document that allows licensed physicians to delegate responsibilities to APRN nurses. The state requirements regarding delegation of responsibilities define that if a physician delegates prescriptive authority to an APRN, then the nurse involved in the delegation cannot exercise protocol agreement with more than four other APRN nurses. In general, the strict restrictive practice regulations in the state of Georgia has limited the number of nurses willing to practice in the state (Rules and Regulations of the State of Georgia, n.d.) Maryland and Georgia APRN State-Level Regulations.

Practicing as an APRN nurse in Maryland and Georgia is significantly different. In Maryland, for example, APRN nurses can exercise the full scope of authority, including prescribing drugs and ordering tests on patients. This makes it substantially easy for APRN nurses to consider private practice. In the state of Georgia, however, APRN nurses are very limited in terms of their authority, and it is virtually impossible for them to focus on private practice, especially since they do not have the authority to attend to patients individually without physician supervision (Clement, 2018).

Reference

Advanced Practice Legal Issues. (n.d.). 
Nurse practitioner scope of practice: Georgia
. ThriveAP. 
https://thriveap.com/blog/nurse-practitioner-scope-practice-georgia
Links to an external site.
.

Clement, D. M. (2018). Factors Influencing Georgia Legislators’ Decision-Making on Nurse Practitioner Scope of Practice. 
Policy, Politics, & Nursing Practice
, 
19
(3-4), 91-99. 
http://dx.doi.org/10.1177/1527154418817036
Links to an external site.
.

Maryland Board of Nursing. (2020). 
Advanced practice registered nursing: Nurse practitioners
. Home. 
https://mbon.maryland.gov/Pages/adv-prac-nurse-practitioner-index.aspx
Links to an external site.
.

Milstead, J. A., & Short, N. M. (2019). 
Health policy and politics: A nurse’s guide
 (6th ed.). Jones & Bartlett Learning.

National Council of State Boards of Nursing (NCSBN). (n.d.). 
Nurse Licensure Guidance. 
https://www.ncsbn.org/index.htm
Links to an external site.
.

Neff, D. F., Yoon, S. H., Steiner, R. L., Bumbach, M. D., Everhart, D., & Harman J. S. (2018). The impact of nurse practitioner regulations on population access to care. 
Nursing Outlook
, 66(4), 379–385.

Practitioner Scope of Practice
. (n.d.). Scope of Practice Policy. 
https://scopeofpracticepolicy.org/states/ga/
Links to an external site.
.

Rubenfire, A. (n.d.). 
Maryland allows nurse practitioners to practice independently of a physician
. Modern Healthcare. 
https://www.modernhealthcare.com/article/20150514/NEWS/150519928/maryland-allows-nurse-practitioners-to-practice-independently-of-a-physician
Links to an external site.
.

Rules and Regulations of the State of Georgia. (n.d.). 
Chapter 410-11 Regulation of Advanced Practice Registered Nurses
. rules.sos.state.ga.us/nllxml/georgiacodesGetcv.aspx?urlRedirected=yes&data=admin&lookingfor=410-11.  Maryland and Georgia APRN State-Level Regulations