HCA 699, NR 509 and NURS 6670 Bank

HCA 699, NR 509 and NURS 6670 Bank

HCA 699, NR 509 and NURS 6670 Bank

HCA 699: Evidence Based Research Project

Write a paper of 500-750 words (not including the title page and reference page) on your proposed problem description for your EBP project. The paper should address the following:

  1. Describe the background of the problem. Tell the story of the issue and why it deserves attention.
  2. Identify the stakeholders/change agents. Who or what organizations are concerned about, may benefit from, or are affected by this proposal. List the interested parties, patients, students, agencies, Joint Commission, etc.
  3. Provide the PICOT question. (PICOT: Population-Intervention-Comparison-Outcome-Timeframe). Make sure that the question fits with your graduate degree specialization. HCA 699: Evidence Based Research Project 
  4. State the purpose and project objectives in specific, realistic, and measurable terms. The objective should address what is to be gained. This is a restatement of the question, providing focus. Measurements need to be taken before and after the evidence-based practice is introduced to identify the expected changes.
  5. Provide supportive rationale that the problem or issue is an important one for nursing to resolve using relevant professional literature sources.

Develop an initial reference list to ensure that there is adequate literature to support your evidence-based practice project. Follow the “Steps to an Efficient Search to Answer a Clinical Question” box in chapter 3 of the textbook. Refer to the “Search Method Example” as the format in which to compile this data.

  1. The majority of references should be research articles. However, national sources such as Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Department of Health and Human Resources (HHS), or the Agency for Healthcare Research and Quality (AHRQ) and others may be used when you are gathering statistics to provide the rationale for the problem.
  2. Once you get into the literature, you may find there is very little research to support your topic and you will have to start all over again. Remember, in order for this to be an evidence-based project, you must have enough evidence to introduce this as a practice change. If you find that you do not have enough supporting evidence to change a practice, then further research would need to be conducted. HCA 699: Evidence Based Research Project

Prepare this HCA 699: Evidence Based Research Project assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required for the individual sections, but is required for the final paper.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

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Upon receiving feedback from the instructor, refine Section A for your final paper submission.

HCA699.R.SearchMethod_student.docx. HCA 699: Evidence Based Research Project

HCA 699 Topic 1 DQ 1

  • What is the difference between research and evidence-based practice (EBP) projects? Provide an example of each one and the reason for the difference. Why should health care workers be interested in learning about EBP?

HCA 699 Topic 1 DQ 2

  • Many businesses/organizations have performance problems that can be reevaluated to improve performance. Explain Research Problem and Problem Statement. HCA 699: Evidence Based Research Project

HCA 699 Topic 3 Section B Literature Support

Details:
To begin, work through the reference list that was created in the Problem Description Assignment in Topic 2. Appraise each resource using the “Rapid Critical Appraisal Checklists” available in the textbook appendix. The specific checklist you use will be determined by the type of evidence within the resource.Develop a research table to organize and summarize the research studies. Using a summary table allows you to be more concise in your narrative description. Only research studies used to support your intervention are summarized in this table. Refer to the “Evaluation Table Template” available in the textbook appendix or use the “Evaluation Table Template” resource as an adaptable template.Write a narrative of 750-1,000 words (not including the title page and references) that presents the research support for the project’s problem and proposed solution. Make sure to include: HCA 699: Evidence Based Research Project

  1. Description of the search method (i.e., databases, keywords, criteria for inclusion and exclusion, and number of studies that fit your criteria).
  2. Summarization of all of the research studies used as evidence. The essential components of each study need to be described so that readers can evaluate its scientific merit, including study strengths and limitations.
  3. Description of the validity of the internal and external research.

It is essential to make sure that the research support for the proposed solution is sufficient, compelling, relevant and from peer-reviewed professional journal articles.

Although you will not be submitting the checklist information or the evaluation table you design in Topic 3 with the narrative, the checklist information and evaluation table should be placed in the appendices for the final paper.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required for the individual sections, but is required for the final paper. HCA 699: Evidence Based Research Project

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Upon receiving feedback from the instructor, refine Section B for your final submission.

HCA699.R.EvaluationTable_student.docx

HCA 699 Topic 2 DQ 1

What strategies will you use in your new role in health care to review and critique literature pertinent to your practice?

HCA 699 Topic 2 DQ 2

“Nobody likes change” is a frequent comment, but creating a culture that allows for new ways of knowing takes a unique set of leadership skills. As a leader, how would you create a culture of change?

HCA 699 Topic 3 DQ 1

What levels of evidence are present in relation to research and practice and why are they important regardless of the method you use?

HCA 699 Topic 3 DQ 2

What factors must be assessed when critically appraising quantitative studies (i.e., validity, reliability, and applicability)? Which is the most important? Why? HCA 699: Evidence Based Research Project

HCA 699 Topic 4 Section C Solution Description

Details:

Write a paper of 500-750 words (not including the title page and reference page) paper for your proposed evidence-based practice project solution. Address the following criteria:

Proposed Solution

Describe the proposed solution (or intervention) for the problem and the way(s) in which it is consistent with current evidence. Heavily reference and provide substantial evidence for your solution or intervention.

Consider if the intervention may be unrealistic in your setting, too costly, or there is a lack of appropriate training available to deliver the intervention. If it is, you may need to go back and make changes to your PICOT before continuing. HCA 699: Evidence Based Research Project

Organization Culture

Explain the way(s) in which the proposed solution is consistent with the organization or community culture and resources.

Expected Outcomes

Explain the expected outcomes of the project. The outcomes should flow from the PICOT.

Method to Achieve Outcomes

Develop an outline of how the outcomes will be achieved. List any specific barriers that will need to be assessed and eliminated. Make sure to mention any assumptions or limitations which may need to be addressed.

Outcome Impact

Describe the impact the outcomes will have on one or all of the following indicators: quality care improvement, patient-centered quality care, efficiency of processes, environmental changes, and/or professional expertise.

Paper Guidelines

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required for the individual sections, but is required for the final paper. HCA 699: Evidence Based Research Project

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Upon receiving feedback from the instructor, refine Section C for your final submission.

HCA 699 Topic 4 DQ 1

Define “methodology” and explain how your research problem can be studied. Share your methodology.

HCA 699 Topic 4 DQ 2

What are some of the obstacles or barriers to implementing EBP in the health care field? Provide a rationale for your answer. Since there are numerous topics on the issue, it is not appropriate to repeat one that has already been mentioned unless you are providing new information.

HCA 699 Topic 5 DQ 1

Reliability and validity are related qualities but independent. They are similar to the terms “precision” and “accuracy,” respectively. A wind-up clock that does not work is accurate (valid) twice a day. But it lacks precision (reliability). A digital clock that is always 5 minutes slow is never accurate (valid) but is very precise (reliable). Elaborate on the assessment instrument used in your project to ensure validity and reliability.

HCA 699 Topic 5 DQ 2

Why is it important to incorporate a theory or model related to change when implementing practice changes? Does the benefit of incorporating a change model outweigh the time and effort it took to include it?

HCA 699 Topic 5 Section D Change Model

Details:

Roger’s Diffusion of Innovation theory is a particularly good theoretical framework to apply to an EBP project. However, students may also choose to use change models, such as Duck’s Change Curve Model or the Transtheoretical Model of Behavioral Change. Other conceptual models presented such as a utilization model (Stetler’s model) and EBP models (the Iowa Model and ARCC Model) can also be used as a framework for applying your evidence-based intervention in a health care setting. HCA 699: Evidence Based Research Project

In 500-750 words (not including the title page and reference page), apply a change model to the implementation plan.

  1. Apply one of the above models and carry your implementation through each of the stages, phases, or steps identified in the chosen model.
  2. In addition, create a conceptual model of the project. Although you will not be submitting the conceptual model you design in Topic 5 with the narrative, the conceptual model should be placed in the appendices for the final paper.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required for the individual sections, but is required for the final paper.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Upon receiving feedback from the instructor, refine Sections D for your final submission. HCA 699: Evidence Based Research Project

HCA 699 Topic 6 DQ 1

When reviewing the literature and different types of evidence, there are often gaps in the findings. Are such gaps a help or a hindrance when wanting to create a change?

HCA 699 Topic 6 DQ 2

What is the difference between statistically significant evidence and clinically significant evidence? How would each of these findings be used to advance an evidenced-based project?

HCA 699 Topic 7 DQ 1 (this week has one discussion)

Research and EBP projects can be communicated in many ways. Which method do you think is most effective to get to the staff nurse level? To the advance practice nurses? How will you ensure that all appropriate audiences receive your information?

HCA 699 Topic 8 DQ 1

Post your Evidence-Based Practice Proposal Project Presentation as directed by the instructor. Review all of the presentations but provide critical commentary only to two others posted. This is a peer review of the proposal project, you will need to address the strengths of the proposal as well as recommendations for improvement. If a post already has two feedback posts then move on to another peer review proposal project presentation. You will be responsible for responding to each peer’s feedback that is posted to your original presentation post. HCA 699: Evidence Based Research Project

HCA 699 Topic 8 DQ 2

There is power in having data to support change. The EBP process is one way of advancing improvements in health care. Identify three strategies that you will now incorporate into your role in health care based on this course. Explain your rationale.

HCA 699 Topic 7 Evidence-Based Practice Proposal Final Paper

Details:

Throughout this course you will be developing a formal, evidence-based practice proposal.

The proposal is the plan for an evidence-based practice project designed to address a problem, issue, or concern in the professional work setting. Although several types of evidence can be used to support a proposed solution, a sufficient and compelling base of support from valid research studies is required as the major component of that evidence. Proposals are submitted in a format suitable for obtaining formal approval in the work setting. Proposals will vary in length depending upon the problem or issue addressed, but they should be between 3,500 and 5,000 words. The cover sheet, abstract, references page, and appendices are not included in the word count. HCA 699: Evidence Based Research Project

Section headings and letters for each section component are required. Responses are addressed in narrative form in relation to that number. Evaluation of the proposal in all sections is based upon the extent to which the depth of content reflects graduate-level critical-thinking skills.

This project contains six formal sections:

  1. Section A: Problem Description
  2. Section B: Literature Support
  3. Section C: Solution Description
  4. Section D: Change Model
  5. Section E: Implementation Plan
  6. Section F: Evaluation of Process

Each section (A-F, to be completed in Topics 1-5) will be submitted as separate assignments so your instructor can provide feedback for revision (refer to each Topic for specific assignments).

The final paper will consist of the completed project (with revisions to all sections), title page, abstract, reference list, and appendices. Appendices will include a conceptual model for the project, handouts, data and evaluation collection tools, a budget, a timeline, resource lists, and approval forms.

Refer to the “EBP Implementation Plan Guide, the “Evidence-Based Practice Project Proposal Format,” and the “Evidence-Based Practice Project Student Example” as tools for developing your proposal. HCA 699: Evidence Based Research Project

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is required for the final paper.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to Turnitin.

HCA699.R.EBPimplementationPlanGuide_student.docx HCA699.R.Evidence-BasedPracticeProjectProposalFormat_student.docxHCA699.R.EBPStudentExample_student.docx

HCA 699 Topic 5 Section E Implementation Plan

Details:

In 500-750 words (not including the title page and reference page) provide a description of the methods to be used to implement the proposed solution. Include the following:

  1. Describe the setting and access to potential subjects. If there is a need for a consent or approval form, then one must be created. Although you will not be submitting the consent or approval form(s) in Topic 5 with the narrative, the consent or approval form(s) should be placed in the appendices for the final paper.
  2. Describe the amount of time needed to complete this project. Create a timeline. Make sure the timeline is general enough that it can be implemented at any date. Although you will not be submitting the timeline in Topic 5 with the narrative, the timeline should be placed in the appendices for the final paper.
  3. Describe the resources (human, fiscal, and other) or changes needed in the implementation of the solution. Consider the clinical tools or process changes that would need to take place. Provide a resource list. Although you will not be submitting the resource list in Topic 5 with the narrative, the resource list should be placed in the appendices for the final paper. HCA 699: Evidence Based Research Project 
  4. Describe the methods and instruments, such as a questionnaire, scale, or test to be used for monitoring the implementation of the proposed solution. Develop the instruments. Although you will not be submitting the individual instruments in Module 5 with the narrative, the instruments should be placed in the appendices for the final paper.
  5. Explain the process for delivering the (intervention) solution and indicate if any training will be needed.
  6. Provide an outline of the data collection plan. Describe how data management will be maintained and by whom. Furthermore, provide an explanation of how the data analysis and interpretation process will be conducted. Develop the data collection tools that will be needed. Although you will not be submitting the data collection tools in Module 5 with the narrative, the data collection tools should be placed in the appendices for the final paper.
  7. Describe the strategies to deal with the management of any barriers, facilitators, and challenges.
  8. Establish the feasibility of the implementation plan. Address the costs for personnel, consumable supplies, equipment (if not provided by the institute), computer related costs (librarian consultation, database access, etc.), and other costs (travel, presentation development). Make sure to provide a brief rationale for each. Develop a budget plan. Although you will not be submitting the budget plan in Module 5 with the narrative, the budget plan should be placed in the appendices for the final paper.
  9. Describe the plans to maintain, extend, revise, and discontinue a proposed solution after implementation. HCA 699: Evidence Based Research Project

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required for the individual sections, but is required for the final paper.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Upon receiving feedback from the instructor, refine Section E for your final submission. HCA 699: Evidence Based Research Project

HCA 699 Topic 6 Section F Evaluation

Details:

In 500-750 words (not including the title page and reference page) develop an evaluation plan to be included in your final evidence-based practice project. Provide the following criteria in the evaluation, making sure it is comprehensive and concise:

  1. Describe the rationale for the methods used in collecting the outcome data.
  2. Describe the ways in which the outcome measures evaluate the extent to which the project objectives are achieved.
  3. Describe how the outcomes will be measured and evaluated based on the evidence. Address validity, reliability, and applicability.
  4. Describe strategies to take if outcomes do not provide positive results.
  5. Describe implications for practice and future research. HCA 699: Evidence Based Research Project

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

NR 509: Advanced Physical Assessment Examination:

NR 509 Week 1 Assignments

NR 509 Week 1 Shadow Health History Assignment Completed

Pre-brief

Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…………………… Interviewing patients is an art and should remain an essential skill for successful practice.

In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.

Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.

  • | Overview
  • | Transcript
  • | Subjective Data Collection
  • | Objective Data Collection
  • | Education & Empathy
  • | Documentation / Electronic Health Record
  • | Information Processing
  • | Lab Pass: Certificate of Completion

NR 509 Week 1 Shadow Health: Conversation Concept Lab

NR 509 Week 1 Assignment Shadow Health Digital Clinical Experience DCE Orientation Spring 2018

NR 509 Week 1 Quiz Questions and Answers

    A patient tells the FNP that he is very nervous, that he is nauseated, and that he “feels hot”. This type of data would be:
2.     The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
3.     The FNP is reviewing information about evidence-based practice. Which statement best reflects evidence-based practice?
4.     A 59-year-old patient tells the FNP that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the FNP best document his reason for seeking care?
5.     A 29-year-old woman tells the FNP that she has excruciating pain in her back. Which would be an appropriate response by the FNP to the woman statement?
6.     In recording the childhood illnesses of a patient who denies having had any, which note by the FNP would be most accurate?7.      If a female patient tells the FNP that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the FNP record this information?
8.     If a female patient tells the FNP that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the FNP record this information?
9.     Which of these statements represents subjective data the FNP obtained from the patient regarding the patient’s skin?
10.  The FNP is obtaining a history for a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
11.  Which statement indicates that the FNP understands the pain experienced by an elderly person?
12.  The FNP is performing a vision examination. Which of these charts is most widely used for visual examination?
13.  During a complete health assessment, how would the FNP test the patients hearing?
14.  The FNP has just completed an examination of a patient’s extra-ocular muscles. When documenting the findings, the FNP should document the assessment of which cranial nerves?
15.  A patient’s uvula rises midline when she says “ahh” and she has a positive gag reflex. The FNP has just tested which cranial nerve?
16.  During an examination the FNP notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action?
17.  A patient is unable to shrug her shoulders against the FNP‘s resistant hands. What cranial nerve is involved with successful shoulder shrugging?
18.  During an examination, the patient has just successfully completed the finger to nose and rapid alternating movements test and is able to run each heel down the opposite shin. The FNP would conclude that the patient’s___ function is intact
19.  A five-year-old child is in the clinic for checkup. The FNP would expect him to:
20.  When the FNP performs the confrontation test the FNP has assessed:
21.  Which of these statements is true regarding the complete physical assessment?
22.  Which of these statements is true regarding recording of data from the history and physical examination?
23.  Which of these is included in assessment of general appearance?
24.  The FNP is performing a review of symptoms. Which of these questions are appropriate as Health promotion questions to ask during this time?
25.  The FNP is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the community portion of the FICA questions?
26.  The FNP is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?

NR 509 Week 2 Shadow Health Respiratory Physical Assessment Spring 2018

Pre Brief
Tina had an asthma episode 2 days ago. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had ten episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Be sure to ask pertinent questions during the interview about related body systems. This case study will provide the opportunity to carefully assess lung sounds during the physical examination. Be sure to appropriately document your findings using correct medical terminology.

Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.

  • | Overview
    | Transcript
    | Subjective Data Collection
    | Objective Data Collection
    | Education & Empathy
    | Documentation / Electronic Health Record
    | Student Pre-Survey
    | Lifespan Activity
    | Review Questions
    | Self-Reflection Activity

NR 509 Week 2 Alternate Writing Assignment: Respiratory Summer 2018

Purpose

As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role.

Course Outcomes

This assignment is guided by the following Course Outcomes (COs):

  1. Apply advanced practice nursing knowledge to collecting health history information and physical examination findings for various patient populations. (PO 1, 2)
  2. Differentiate normal and abnormal health history and physical examination findings. (PO 1, 2)
  3. Adapt health history and physical examination skills to the developmental, gender-related, age-specific, and special population needs of the individual patient. (PO 1, 2)

The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4).

NOTEYou are to complete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.

Due Date: This alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session. The standard MSN Participation Late Assignment policy applies to this assignment.

Preparing the Paper:

  1. Select a focused body system from the weekly lesson which corresponds with the week of the written assignment.
  2. Carefully read and review the selected body system in your course textbooks.
  3. Incorporate at least onescholarly peer-reviewed journal article that relates to the body system. It may be useful to identify an article that relates to a disease that impacts the body system.
  4. The paper must clearly articulate the relevance of advanced physical assessment skills, techniques, application of advanced practice knowledge, and assessment modification (when necessary) to accommodate for specific patient populations.
  5. Provide concluding statements that should summarize key points of the overall assignment content.
  6. In-text citations and reference page(s) must be written using proper APA format (6thedition).

NR 509 Week 2 Shadow Health HEENT Physical Assessment Assignment Summer 2018

Pre-Brief
For the last week, Tina has experienced sore, itchy throat, itchy eyes, and runny nose. She states that these symptoms started spontaneously and have been constant in nature. … has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that her nose “runs all day” and has clear discharge. … denies cough and recent illness. … denies fevers, chills, and night sweats. This case study will allow you to use standard office equipment to physically examine the patient’s eyes, ears, nose, and throat. You will need to document what you find in the Electronic Health Record (EHR). Be certain to use medically appropriate terminology, such as “erythematous” to describe redness of the skin, mucous membranes, or conjunctiva.

  • | Overview
    | Subjective Data Collection
    | Objective Data Collection
    | Education & Empathy
    | Documentation / Electronic Health Record
    | Lifespan
    | Review Questions
    | Self-Reflection

NR 509 Week 2 Quiz

  1. A mother brings her two month old daughter in for an examination says “my daughter rolled over against the wall and now I have noticed that she has the spot soft on the top of her head, is there something terribly wrong?” The FNP‘s best response would be:
  2. During percussion the FNP knows that a dull percussion note elicited over a lung lobe. This most likely results from:
  3. The patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The FNP suspects Damage to:
  4. When examining the face, the FNP is aware that the two pairs of salivary gland‘s that are accessible to examination are the _____ glands
  5. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The FNP suspects damage to cranial nerve ____ and proceeds with the examination by____
  6. When examining a patient’s cranial nerve function, the FNP remembers that the muscles in the neck that are innervated by CN XI are the:
  7. The patient’s laboratory data reveal an elevated thyroxine level. The FNP would proceed with an examination of the _____ gland
  8. A patient says that she has recently noticed a lump in the front of her neck below her “Adams apple” that seems to be getting bigger. During the assessment, the finding that leaves the FNP to suspect that this may not be a cancerous thyroid nodule is that the lump:
  9. The FNP notices that the patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the FNP would assess the patient’s:
  10. The FNP is aware that the four areas in the body were lymph nodes accessible are the:
  11. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The FNP should know that floaters are usually not significant and are caused by:
  12. The FNP is preparing to assess the visual acuity of a 16-year-old patient. How should the FNP proceed?
  13. A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The FNP interprets these results to indicate that:
  14. A patient is unable to read even the largest letters on the Snellen chart. The FNP should take which action next:
  15. A patient’s vision is reported as 20/80 in each eye. The FNP interprets this finding to mean that
  16. When performing the corneal light reflex assessment, the FNP notes that the light is reflected at 2 o’clock in each eye. The FNP should
  17. The FNP is performing the diagnostic positions test. Normal findings would be which of these results?
  18. During an assessment of the sclera of an African-American patient, the FNP would consider which of these an expected finding?
  19. A 60-year-old man is at the clinic for an examination. The FNP suspects that he has ptosis of one eye. How should the FNP check for this?
  20. The FNP is doing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale gray and swollen. What would be the most appropriate question to ask the patient?
  21. The FNP is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
  22. During an oral assessment of a 30-year-old African-American patient, the FNP notices bluish lips and a dark line along the gingival margin. What would the FNP do in response to these findings
  23. During an assessment of a 20-year-old patient with a three day history of nausea and vomiting the FNP notices dry mucous and deep vertical fissures on the tongue. These findings are reflective of:
  24. The FNP is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate FNP reflects a correct understanding of tactile fremitus?
  25. The FNP student is reviewing physical assessment findings of the HEENT system associated with pregnancy. Which statement by the graduate FNP reflects a correct understanding of expected HEENT changes associated with pregnancy? During pregnancy:

NR 509 Week 2 Quiz Review – (Jarvis 8,9,13,14,15,16,18), (Swartz 4,6,7,8,9,10)

1.       What does dullness when percussing lung fields: Jarvis pg 427

2.       Facial sensation controlled by which CN: Jarvis 283,

3.       Know what two salivary glands are accessible during exam

4.       What CN is being … when pt shrugs shoulders Jarvis 646

5.       What muscles are being …. when …. CN 11 (spinal accessory nerve)

6.       Concern for malignant nodules versus benign lymph nodule

7.       Know what you’d do next if you palpated a submental lymph node: Jarvis pg 253

8.       Define visual acuity

9.       Know what to do if your patient can’t read the largest number on the Snellen chart: Jarvis 289

10.   Example of good visual acuity : Jarvis 289

11.   Example of poor visual acuity: Jarvis 289

12.   What is …. with corneal light reflex-

13.   Know normal variances of sclera : Jarvis 283

14.   Know how to check for Ptosis: Jarvis 292

15.   What does ptosis indicate: Jarvis 292

16.   Nasal fissure of pt with chronic allergies : Jarvis 271

·         Acute allergies : Jarvis p 363 .

17.   What is an abnormal palpation of sinuses: Jarvis 362

·         Normal palpation of sinuses

18.   Know normal variations in gingival margin

19.   Know what a dehydrated oral cavity will look like: Jarvis 387

20.   What is tactile fremitus, how do you test for it and what does it indicate. Jarvis 425

NR 509 Week 3 Alternate Writing Assignment Neurological System Summer 2018

Purpose

As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role.

The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4).

NOTEComplete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.

Due Date: Alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session.

Preparing the Paper:

  1. Select a focused body system from the weekly lesson which corresponds with the week of the written assignment.
  2. Carefully read and review the selected body system in your course textbooks.
  3. Incorporate at least onescholarly peer-reviewed journal article that relates to the body system. It may be useful to identify an article that relates to a disease that impacts the body system.
  4. The paper must clearly articulate the relevance of advanced physical assessment skills, techniques, application of advanced practice knowledge, and assessment modification (when necessary) to accommodate for specific patient populations.
  5. Provide concluding statements that should summarize key points of the overall assignment content.
  6. In-text citations and reference page(s) must be written using proper APA format (6thedition).

 NR 509 Week 3 Shadow Health Assessment Musculoskeletal Spring 2018

Subjective:

HPI: Ms. Jones presents to the clinic complaining of back pain that began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does……………………………… She presents today as the pain has continued and is interfering with her activities of daily living.

Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand for extended periods of time……………. use of tobacco, alcohol, and illicit drugs. She does not exercise.

ROS: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. •

Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has difficulties with range of motion…… lower back has impacted her comfort while sleeping and sitting in class…….. numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. •

Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.

Objective:

ROS: General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination.

Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities with full range of motion of shoulder, elbow, and wrist……………….. upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles.

ASSESSMENT: Low back muscle strain related to lifting

  • | Overview 

    | Transcript

    | Subjective Data Collection 

    | Objective Data Collection 

    | Education & Empathy 

    | Documentation

    | Lifespan

    | Review Questions

    | Self-Reflection

NR 509 Week 3 Shadow Health Neurological Physical Assignment Completed

Pre Brief

Two days after a minor, low-speed car accident in which Tina was a passenger, she noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to move her neck, and she believes her neck might … swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. … that she gets a headache every day that lasts approximately 1-2 hours. … occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This case study will allow you the opportunity to examine the patient’s optic nerve via use of the ophthalmoscope as well as assess her visual acuity. You will need to document your findings using appropriate medical terminology. Be sure to assess for foot neuropathy using the monofilament test. Reason for visit: Patient presents complaining of headache.NR 509 Neurological Results | Transcript

  • Interview Questions (113)
NR 509 Neurological Results | Subjective Data Collection: 18 of 20 (90.0%)
NR-509 Neurological Results | Objective Data Collection: 36.75 of 37 (99.32%)
NR 509 Neurological Results | Education & Empathy: 4 of 4 (100.0%)
  1. Symptoms
  2. Cause of Injury
  3. Medications
  4. Vision

NR 509 Neurological Results | Documentation / Electronic Health Record

NR 509 Neurological Results | Pre-Survey Lifespan

  1. Tina’s three-year-old neighbor presents to the clinic with fever, neck pain, headache, and confusion. He has no symptoms of an upper respiratory infection. The parents mention that they do not believe in immunizations. Based on the information given, what diagnosis is of the greatest concern? What is your next action?
  2. Tina’s 83-year-old great uncle forgets where he is during his yearly check-up. He doesn’t remember if he’s had memory problems before and no family members came to your office with him. List your differential diagnosis. What assessments would you perform?

NR 509 Neurological Results | Review Questions

  1. To assess spinal levels L2, L3 and L4 in Tina, which deep tendon reflexes would have to be tested?
  2. Imagine that you were preparing to irrigate a Foley catheter of a patient with a spinal cord injury at T4 in a urology clinic. Upon moving the leg bag, the patient became suddenly flushed and diaphoretic above the nipple line. What would you suspect was happening?
  3. Which of the following is not a common symptom of Parkinson’s disease?
  4. Name at least three ways to assess cerebellar function during a physical exam.
  5. If Tina had a fever and photophobia, you would have had to test for meningitis. Describe how you would have tested for the Kernig’s sign
  6. Suppose you assessed pain sensation over Tina’s left foot, and noticed that she had decreased sensation. How would you have proceeded with your exam?

NR 509 Neurological Results | Self-Reflection

  1. Explicitly describe the tasks you undertook to complete this exam.
  2. Explain the clinical reasoning behind your decisions and tasks.
  3. Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional practice.

NR 509 Week 4 Quiz Advanced Physical Assessment Chamberlain 2018

1.       A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the FNP expect to see during an assessment of this patient?

2.       The direction of blood flow through the heart is best described by which of these

3.       In assessing the carotid artery’s of an older patient with cardiovascular disease, the FNP would

4.       When listening to heart sounds the FNP knows that the valve closures that can be heard best at the base of the heart are

5.       The sack that surrounds and protects the heart is called the

6.       When assessing a newborn infant who is five minutes old the FNP knows that which of these statements would be true?

7.       The FNP is performing an assessment on an adult. The adults vital signs are normal and capillary refill is five seconds. What should the FNP do next?

8.       During an assessment of an older adult the FNP should expect to notice which finding as normal physiologic change associated with aging process?

9.       The mother of a three month old infant states that her baby has not been gaining weight. With further questioning the FNP finds that the infant falls asleep after nursing and wakes up after a short amount of time hungry again. What other information with the FNP want to have?

10.   In assessing a patient’s major risk factors for heart disease which would the FNP want to include when taking a history?

11.   The FNP is … the pulses of a patient who has been admitted for untreated hyperthyroidism. The FNP should expect to find a____pulse

12.   A patient complains of leg pain that wakes him at night. He states that he has been having problems with his legs. ….. his legs when they are … and disappears when he dangles them. He recently noticed a sore on the inner aspect of his right ankle. On the basis of this history information the FNP interprets that the patient is most likely experiencing

13.   During an assessment the FNP uses the profile sign to detect

14.   Which of these statements describes the closure of the valves in a normal cardiac cycle?

15.   When performing a peripheral vascular assessment on a patient the FNP is unable to palpate the ulnar pulses. The patient skin is warm and capillary refill is normal. The FNP should next

16.   A 67-year-old patient states that he “recently began have pain in his left calf when climbing the 10 stairs to his apartment”. This pain is relieved by sitting for about two minutes then he’s able to resume activities. The FNP interprets this patient is most likely experiencing

17.   In assessing a 70-year-old man the FNP finds the following blood pressure 140/100 mmHg, heart rate 104 and slightly irregular, split S2. Which of these findings can… by expected hemodynamic changes related to age?

18.   The FNP is examining the lymphatic system of a healthy three year old child. Which finding should the FNP expect?

19.   The FNP is preparing to perform modified Allen test. Which is an appropriate reason for this test?

20.   A 25-year-old woman is in her fifth month of pregnancy has a blood pressure of 100/70 mmHg. In reviewing her previous exam the FNP notes that her blood pressure in her second month was 124/80 mmHg. When evaluating this change what does the FNP know to be true?

21.   Findings from an … of a 70-year-old patient with swelling in his ankles include jugular venous pusations, 5 cm above the sternal angle when the head of his bed is …. 45°. The FNP knows that this finding indicate:

22.   The component of the conduction system referred to as the pacemaker of the heart is the

23.   The FNP is reviewing anatomy and physiology of the heart. Which statement best … by atrial kick?

24.   A 45-year-old man is in the clinic for a routine physical. During history the patient states he has been having difficulty sleeping. I’ll be sleeping great and then I wake up and feel like I can’t catch my breath. The FNP‘s best response to this would be

25.   When assessing a patient the FNP notes that the left femoral pulse as diminished 1+/4+. What should the FNP do next?

NR 509 Week 4 Shadow Health Cardiovascular Physical Assessment Assignment Summer 2018

Overview

Transcript

| Subjective Data Collection

| Objective Data Collection

| Education & Empathy

| Documentation

| Lifespan

| Review Questions

| Self-Reflection

NR 509 Week 4 Shadow Health Chest Pain Physical Assessment Assignment Summer 2018

Overview

Transcript

| Subjective Data Collection

| Objective Data Collection

| Education & Empathy

| Documentation

Document: Provider Notes

Document: Vitals

| Self-Reflection

NR 509 Week 4 Quiz Advanced Physical Assessment Chamberlain 2018

1.       A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the FNP expect to see during an assessment of this patient?

2.       The direction of blood flow through the heart is best described by which of these

3.       In assessing the carotid artery’s of an older patient with cardiovascular disease, the FNP would

4.       When listening to heart sounds the FNP knows that the valve closures that can be heard best at the base of the heart are

5.       The sack that surrounds and protects the heart is called the

6.       When assessing a newborn infant who is five minutes old the FNP knows that which of these statements would be true?

7.       The FNP is performing an assessment on an adult. The adults vital signs are normal and capillary refill is five seconds. What should the FNP do next?

8.       During an assessment of an older adult the FNP should expect to notice which finding as normal physiologic change associated with aging process?

9.       The mother of a three month old infant states that her baby has not been gaining weight. With further questioning the FNP finds that the infant falls asleep after nursing and wakes up after a short amount of time hungry again. What other information with the FNP want to have?

10.   In assessing a patient’s major risk factors for heart disease which would the FNP want to include when taking a history?

11.   The FNP is … the pulses of a patient who has been admitted for untreated hyperthyroidism. The FNP should expect to find a____pulse

12.   A patient complains of leg pain that wakes him at night. He states that he has been having problems with his legs. ….. his legs when they are … and disappears when he dangles them. He recently noticed a sore on the inner aspect of his right ankle. On the basis of this history information the FNP interprets that the patient is most likely experiencing

13.   During an assessment the FNP uses the profile sign to detect

14.   Which of these statements describes the closure of the valves in a normal cardiac cycle?

15.   When performing a peripheral vascular assessment on a patient the FNP is unable to palpate the ulnar pulses. The patient skin is warm and capillary refill is normal. The FNP should next

16.   A 67-year-old patient states that he “recently began have pain in his left calf when climbing the 10 stairs to his apartment”. This pain is relieved by sitting for about two minutes then he’s able to resume activities. The FNP interprets this patient is most likely experiencing

17.   In assessing a 70-year-old man the FNP finds the following blood pressure 140/100 mmHg, heart rate 104 and slightly irregular, split S2. Which of these findings can… by expected hemodynamic changes related to age?

18.   The FNP is examining the lymphatic system of a healthy three year old child. Which finding should the FNP expect?

19.   The FNP is preparing to perform modified Allen test. Which is an appropriate reason for this test?

20.   A 25-year-old woman is in her fifth month of pregnancy has a blood pressure of 100/70 mmHg. In reviewing her previous exam the FNP notes that her blood pressure in her second month was 124/80 mmHg. When evaluating this change what does the FNP know to be true?

21.   Findings from an … of a 70-year-old patient with swelling in his ankles include jugular venous pusations, 5 cm above the sternal angle when the head of his bed is …. 45°. The FNP knows that this finding indicate:

22.   The component of the conduction system referred to as the pacemaker of the heart is the

23.   The FNP is reviewing anatomy and physiology of the heart. Which statement best … by atrial kick?

24.   A 45-year-old man is in the clinic for a routine physical. During history the patient states he has been having difficulty sleeping. I’ll be sleeping great and then I wake up and feel like I can’t catch my breath. The FNP‘s best response to this would be

25.   When assessing a patient the FNP notes that the left femoral pulse as diminished 1+/4+. What should the FNP do next?

NR 509 Week 5 Shadow Health Abdominal Pain Physical Assessment Assignment Summer 2018

·  Overview

·  | Transcript

·  | Subjective Data Collection

·  | Objective Data Collection

·  | Education & Empathy

·  | Documentation

·         Document: Provider Notes

·         Document: Vitals

·  | Self-Reflection

NR 509 Week 5 Shadow Health Gastrointestinal Physical Assessment Assignment Summer 2018

Transcript

Subjective Data Collection

| Objective Data Collection

| Education & Empathy

| Documentation 

| Lifespan 

| Review Questions 

| Self-Reflection

NR 509 Week 5 Quiz 2 Practice Versions Advanced Physical Assessment Chamberlain 2018

1.       An older patient has been diagnosed with pernicious anemia. The FNP knows that this condition could be related to

2.       ….. examining a patient who tells the FNP “I sure sweat a lot especially on my face and feet but it doesn’t have an odor”. The FNP knows that this could … related to

3.       During an abdominal assessment the FNP elicits tenderness on light palpation in the right lower quadrant. The FNP interprets that this finding could indicate a disorder which of these structures?

4.       An Inuit visiting Nevada from anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinics air conditioning is broken and the temperature is very hot. The FNP knows that which of these statements is true about the Inuit sweating tendencies?

5.       The FNP notices that a patient has black, tarry stool and recalls that a possible cause would …

6.       ….. an abdominal …. deep palpation is used to determine

7.       The FNP is assessing the abdomen of an aging adult. Which of these statements regarding an aging adult and abdominal assessment is true?

8.       During examination the FNP finds that a patient has excessive dryness of the skin. The best term to describe this condition is

9.       A FNP notices that a patient has ascites, which indicates the presence of

10.   The FNP is performing percussion during an abdominal assessment. Percussion notes during the abdominal assessment may include

11.   The FNP is caring for a black child who has … with marasmus. The FNP would expect to find the

12.   … patient’s medical record that the patient has a lesion that is confluent in nature. On examination the FNP would expect to find

13.   The FNP is assessing the abdomen of a pregnant woman who is complaining of having acid indigestion all the time. The FNP knows that esophageal reflux during pregnancy can cause

14.   The patient has abdominal borborygmi. The FNP knows that this term refers to

15.   A patient has a terrible itch for several months that he … scratching continuously. On examination the FNP might expect to find

16.   During aging process, the hair can look gray or white and begin to feel thin and fine. The FNP knows that this occurs because of a decrease in number of functioning

17.   The FNP notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding the FNP would report this as a

18.   During an abdominal assessment the FNP would consider which of these findings as normal?

19.   A 52 -year-old Woman has a papule on her nose that has a rounded pearly border and a central red ulcer. She said she first noticed it several months ago and that it is slowly growing larger. The FNP suspects which condition?

20.   The FNP is listening to bowel sounds. Which of these statements is true about bowel sounds?

21.   The FNP is watching a new graduate FNP perform auscultation of a patient abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation proceeds percussion and palpitation of the abdomen?

22.   A patient is complaining of a sharp pain along the costovertebral angles. The FNP knows that this symptom is most often indicative of

23.   The patient is … of having inflammation of the gallbladder or cholecystitis. The FNP should conduct which of these techniques to assess for this condition?

24.   A newborn infant is in the clinic for a well baby check. The FNP observes the infant for possibility of fluid loss because of which these factors?

25.   During an assessment of a newborn infant, the FNP recalls that pyloric stenosis would … manifested by

NR 509 Week 5 Quiz: Skin, Hair, Abdomen

1.       Question: The FNP is assessing the abdomen of an aging adult. Which of these statements regarding the agind adult and abdominal assessment is true?

2.       Question: The FNP notices that a patient has had a black tarry stool and recalls that a possible cause would be

3.       Question: The FNP knows that during an abdominal assessment deep palpitation is used to determine

4.       Question: A patient has abdominal borboygmi. The FNP knows that this term refers to

5.       Question: During an abdominal assessment, the FNP would consider which of these findings as normal?

6.       Question: The FNP is caring for a black child who has been diagnosed with marasmus. The FNP would expect to find the

7.       Question: An Inuit visiting Nevada from Anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinic’s air conditioning is broken and the temperature is very hot. The FNP knows that which of these statements is true about the Inuit sweating tendencies?

8.       Question: The FNP is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

9.       Question: During an abdominal assessment, the FNP elicits tenderness on light palpation in the right lower quadrant. The FNP interprets that this finding could indicate a disorder of which of these structures?

10.   Question: A patient has a terrible itch for several months that he has been scratching continuously. On examination, the FNP might expect to find

11.   Question: The FNP is listening to bowel sounds. Which of these statements is true of bowel sounds?

12.   Question: A patient is complaining of a sharp pain along the costovertebral angles. The FNP knows that this symptom is most often indicative of

13.   Question: The FNP notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the FNP would report this as a

14.   Question: A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The FNP should conduct which of these techniques to assess for this condition?

15.   Question: The FNP just noted from a patient’s medical record that the patient has a lesion that is confluent in nature. On examination, the FNP would expect to find

16.   Question: During an examination, the FNP finds that a patient has excessive dryness of skin. The best term to describe this condition is

17.   Question: An older patient has been diagnosed with pernicious anemia. The FNP knows that this condition could be related to

18.   Question: A 52 year old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The FNP suspects which condition?

19.   Question: The FNP is watching a new graduate FNP perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

20.   Question: A newborn infant is in the clinic for a well-baby check. The FNP observes the infant for the possibility of fluid loss because of which of these factors?

NR 509 Week 5 Quiz Review

1.       Tenderness in RLQ is concerning for

2.       Inuit people tend to sweat more on face than trunk and extremities when exposed to heat

3.       spot on face with round pearly boarder with central red lesion concerning for

4.       Murphy sign= positive with deep palpation causes pain on inspiration

5.       Why do you auscultate first in abd assessment

6.       Tympany in the umbilical area

7.       Pt with decreased gastric secretions is at increase

8.       Another name for hyperactive bowels

9.       Black tarry stool concerning

10.   Lichenification caused by

11.   A papule is

12.   Older adults have

13.   CVA tenderness

14.   Confluent lesions

15.   Dryness of the skin

16.   Newborns are at greater risk of fluid loss

17.   High pitched irregular bowel sounds

18.   Changes in hair texture and color of an AA child with Marasmus

19.   Know how to assess for enlarged organs in the abd region

20.   Know three sounds heard in percussion

NR 509 Week 6 Shadow Health Mental Health Physical Assessment Assignment Summer 2018

NR 509 Mental Health Results | Transcript

NR 509 Mental Health Results | Subjective Data Collection

NR 509 Mental Health Results | Education and Empathy

NR 509 Mental Health Results | Documentation

NR 509 Mental Health Results | Life Span

NR 509 Mental Health Results | Review Questions

NR 509 Mental Health Results | Self Reflection

NR 509 Week 7 Shadow Health Comprehensive Health History and Physical Assessment Assignment

NR 509 Comprehensive Assessment Results: Experience Overview

  1. Digital Clinical Experience Score: Score 98.4%
  2. Student Performance Index: 121 out of 123

NR 509: Comprehensive Assessment Results: Transcript (FNP Student Conducting Interview)

NR-509 Comprehensive Assessment Results: Subjective Data Collection: 50 of 50 (100%)

NR 509: Comprehensive Assessment Results: Objective Data Collection: 71.0 of 73 (97.3%)

NR-509 Comprehensive Assessment Results: Documentation / Electronic Health Record

NR 509 Comprehensive Assessment Results: Plan My Exam

Your Final Plan

  1. Head and neck,
  2. Anterior chest,
  3. Posterior chest,
  4. Abdomen,
  5. Upper extremities,
  6. Lower extremities,
  7. Full body

NR 509: Comprehensive Assessment Results: Self-Reflection

  1. Explicitly describe the tasks you undertook to complete this exam.
  2. Explain the clinical reasoning behind your decisions and tasks.
  3. Identify how your performance could be improved and how you can apply “lessons
  4. learned” within the assignment to your professional practice.

NR 509 Week 7 Assignment Immersion Completion Spring 2018

__________, my name is ____________, I will be doing your exam today. I’ll begin with inspecting your face. I’ll note that I don’t see any discolorations or lesions & the head is midline & symmetrical.

  1. LYMPH NODES: Next, I’ll palpate the lymph nodes. I’ll begin with the preauricular lymph nodes & postauricular lymph nodes. Next the occipital lymph nodes. I’ll move forward to palpate the tonsillar lymph nodes, submandibular & submental. I’m palpating the anterior cervical lymph nodes & posterior cervical lymph nodes & lastly the supraclavicular lymph nodes. I don’t feel any enlargement & they’re equal bilaterally.
  2. FACE : I’m testing trigeminal nerve, which is cranial nerve # 5. Palpating over the masseter muscle as the pt clenches the jaw. I don’t feel any distortions & my pt has great strength. Now, I’m testing the sensory portion of the trigeminal nerve. I’ll ask my pt to close your eyes & let me know where you feel my touch. (>> Forehead, right cheek, left cheek, chin, nose)………. which is cranial nerve # 7. I’m going to ask you to do some facial expressions. I’m going to have you smile, next, frown for me. Now raise your eyebrows & puff up your cheeks, pucker your lips. I notice all expressions have bilateral symmetry.
  3. EARS
  4. EYES
  5. NOSE
  6. MOUTH
  7. NECK & THROAT
  8. HEART/CHEST((pt sitting))
  9. UPPER EXTREMITIES
  10. ABDOMEN((have pt lie down))
  11. LOWER EXTREMITIES

NR 509 Week 6 Quiz Practice 2 Versions Advanced Physical Assessment Chamberlain 2018

1.       A woman has come to the clinic to seek help with a substance-abuse problem. She admits to using cocaine just before arrival. Which of these assessment findings would the FNP expect to find when examining the woman?

2.       A 63-year-old Chinese American man enters the office with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflect the FNPs best course of action?

3.       The FNP is planning to assess new memory with the patient. The best way for the FNP to do this would be

4.       During the health history the FNP asks a female patient “how many alcoholic drinks do you have a week?” Which answer by the patient would indicate at risk drinking?

5.       Symptoms such as pain are often influenced by a person’s cultural heritage. Which of the following is a true statement regarding pain?

6.       The FNP suspect abuse when a 10-year-old child is taken to the urgent care center for leg injury. The best way to document the history and physical findings is to

7.       During a mental status assessment, which question by the FNP would best assess a persons judgment?

8.       The FNP is performing a mental status assessment on a five-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might leave FNP to be concerned about the girls mental status?

9.       During mental status examination, the FNP wants to assess a patient’s affect. The FNP should ask the patient which question?

10.   During an examination FNP notices a patterned injury on a patients back. Which of these would cause such an injury?

11.   The FNP is aware that intimate partner violence screening should occur with which situation?

12.   Which statement is best for the FNP to use when preparing to administer the abuse assessment screen?

13.   The FNP is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 12 g alcohol) Per day are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus and injuries in men?

14.   A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asked the FNP how many drinks a day safe for my baby? The FNP‘s best response is

15.   The FNP is performing the Denver II screen test on a 12 month old infant during a routine well child visit. The FNP should tell the infants parents that the Denver II

16.   Which term refers to a one produced by tearing or splitting of body tissue usually from blunt impact of a bony surface

17.   When reviewing the use of alcohol by older adults the FNP notes that the older adults have several characteristics that can increase the risk of alcohol use which would increase the bioavailability of alcohol in the blood for longer periods of time in the older adult?

18.   The FNP is reviewing concepts of cultural aspects of pain. Which statement is
true regarding pain?

19.   The FNP is planning to assess a child using behavioral checklist. This tool is most appropriate for a(an)

20.   The FNP is assessing orientation in a 79-year-old patient. Which of these responses … leave the FNP to … that the patient is … ?

21.   As a mandatory reporter of elder abuse, which of these must be present before an FNP notifies the authorities?

22.   A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the FNP‘s best response in this situation?

23.   For persons age 12 years and older which of these illicit substances was one of the most commonly used?

24.   Which of these individuals would the FNP consider at highest risk for suicide attempt?

25.   The FNP is …. a patient who has … for cirrhosis of the liver secondary to chronic alcohol use. During the physical … the FNP looks for cardiac problems that are … with chronic heavy use of alcohol such as

NR 509 Week 7 Quiz Practice 2 Versions Advanced Physical Assessment Chamberlain 2018

1.       During an examination of an aging male the FNP recognizes that normal changes to expect would be:

2.       During a health history, a 22-year-old woman asks “can I get that vaccine for HPV? I have gentle warts and I’d like them to go away!” What is the FNP‘s best response?

3.       During a speculum inspection of the vagina the FNP would expect to see what at the end of the vaginal canal?

4.       A 62-year-old man is experiencing fever, chills, malaise, urinary frequency and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. The symptoms are most consistent with which of the following?

5.       When performing a genital examination on a 25-year-old man the FNP notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information the FNP would:

6.       The mother of a 10-year-old boy asks the FNP to discuss the recognition of puberty. The FNP should reply by saying:

7.       The uterus is usually … tilting forward and superior to the bladder. This position is known as

8.       A male patient with possible fertility problems asks the FNP where sperm is produced. The FNP knows that sperm production occurs in

9.       A 15-year-old boy is seen in the clinic for complaints of dull pain and pulling in the scrotal area. On examination the FNP palpates a soft, irregular mass posterior to and above the testes on the left. This mass collapses when the patient is supine in refills when he is up right. This description is consistent with:

10.   In performing an assessment of a woman’s axillary lymph system the FNP should assess which of these nodes?

11.   A patient contacts the office and tells the FNP that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the FNP‘s best response?

12.   An 11-year-old girl is in the clinic for a sports physical. The FNP notices that she has begun to develop breasts, and during the conversation the girl reveals that she is worried about her development. …. which of these techniques to best assist the young girl in understanding the expected sequence for development? The FNP should:

13.   A 54-year-old woman who has just completed menopause is in the clinic today for yearly physical examination. Which of these statements should the FNP include in patient education? A post menopausal woman:

14.   A 62-year-old man states that his doctor told him that he has an inguinal hernia. He asks the FNP to explain what a hernia is……:

15.   When performing a genital assessment on a middle-age man, the FNP notices multiple soft, moist, painless papules in the shape of cauliflower like patches scattered across the shaft of the penis. These lesions are characteristics of:

16.   If a patient reports a recent breast infection, then the FNP should expect to find_____node enlargement

17.   A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asked “am I normal? I don’t seem to need a bra yet, but I have some friends who do. What if I never get breasts?” The FNP‘s best response would be:

18.   Which of these statements about the testes this true?

19.   During an examination FNP observes a female patients vestibule and expect to see the

20.   A 14-year-old girl is anxious about not having reached menarche. When taking history, the FNP should ascertain which of the following? The age:

21.   A woman who is 22 weeks pregnant has a vaginal infection. She tells the FNP that she is afraid that the infection will hurt the fetus. The FNP knows that which of these statements is true?

22.   In performing a breast examination the FNP knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant

23.   An accessory glandular structure for the male genital organs is the

24.   Which of these statements is true regarding the penis?

25.   A woman who is 8 weeks pregnant is in the clinic for a check up. The FNP reads on her chart that her cervix is … cyanotic. The FNP knows that the woman is exhibiting____sign and _____sign

NR 509 Week 8 Reflection MSN program outcome 1 and the MSN Essential

Reflect back over the past eight weeks and describe how the achievement of the course outcomes in this course have prepared you to meet the MSN program outcome #1 and the MSN Essential I.

NR 509 Week 1 Discussion (Patient Information: JDS, 30, M, African American, Cigna)

NR.509 Week 2 Discussion (Patient Information: KMW, 27, F, African American, Aetna)

NR 509 Week 3 Discussion (Patient Information: SJS 33, F, African American, Cigna)

Using a friend, family member, or colleague, perform a neurovascular (include all cranial nerves), musculoskeletal, and cardiopulmonary (includes the heart, lungs, and peripheral vasculature) exam. Document the physical examination findings in the SOAP note format.

Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included………… plan portion of the SOAP note, but these sections will not be graded.

You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of headache, back pain, and cough. ______ ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.

* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often.

NR.509 Week 4 Discussion (Patient Information: NJL, 22, M, African American, Cigna)

Using a friend, family member, or colleague, perform a detailed men’s health history. Document the history and the expected normal physical examination findings in the SOAP note format.

Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included…………..assessment and plan portion of the SOAP note, but these sections will not be graded.

You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of penile discharge, rectal bleeding, or frequent urination. You should also focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.

* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often.

NR 509 Week 5 Discussion (Patient Information: JDS, 21, M, African American, Blue Cross Blue Shield)

Using a friend, family member, or colleague, perform a detailed women’s health history. Document the history and the expected normal physical examination findings in the SOAP note format.

Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included.  You may include the assessment and plan portion of the SOAP note, but these sections will not be graded.

You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of burning while urinating, irregular menstrual cycle, or pelvic pain………. focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.

* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often.

NR 509 Focused Exam Cough Assignment Completed Shadow Health

Introduction

Daniel “Danny” Rivera is an 8-year-old boy who comes to the clinic with a cough. Students determine if Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems.

Case Highlights
  • Ask about a variety of psychosocial factors related to home life, such as second-hand smoke exposure
  • Observe non-verbal cues as Danny presents with intermittent coughing and visible breathing difficulty
  • Rule out asthma, a common childhood affliction, by examining Danny
NR 509 Focused Exam Cough | Transcript
  • Interview Questions (76)
  • Statements (8)
  • Exam Actions (96)

NR 509 Focused Exam Cough | Subjective Data Collection: 20 of 20 (100.0%)

NR-509 Focused Exam Cough | Objective Data Collection: 12.6 of 13 (96.92%)

NR 509 Focused Exam Cough | Education & Empathy:  4 of 5 (80.0%)

  • Symptoms
  • Medications
  • Vitamins
  • Secondhand Smoke
  • Family History

NR 509 Focused Exam-Cough | Documentation / Electronic Health Record

  • Document: Vitals
  • Document: Provider Notes

NR 509 Focused Exam Cough | Self-Reflection

  • Explicitly describe the tasks you undertook to complete this exam
  • Explain the clinical reasoning behind your decisions and tasks
  • Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional nursing practice.

NURS 6670 PMH NP Role II: Adult-Syllabus

Student Support and Calendar Information

So you have all key information available to you off-line, it is highly recommended that you print the following items for your reference:

  • This Syllabus, including the Course Schedule that is linked on this page as a PDF
  • Course Calendar
  • Student Support

Credit Hours

  • 5 credits (3 didactic and 2 practicum credits)

Walden University assigns credit hours based on the number and type of assignments that enable students to achieve the course learning objectives. In general, each semester credit equals about 42 hours of total student work and each quarter credit equals about 28 hours of total student work. This time requirement represents an approximate average for undergraduate work and the minimum expectations for graduate work. The number and kind of activities estimated to fulfill time requirements will vary by degree level and student learning style, and by student familiarity with the delivery method and course content. NURS 6670 PMH NP Role II: Adult-Syllabus.

Course Description

Continuing from the lifespan approach, the learner in this final course for the psychiatric mental health nurse practitioner (PMHNP) focuses on psychiatric mental health issues that occur in adults and older adults. Selection of assessment approaches for the adult and older adult as well as differential diagnosis, application of diagnostic criteria, appropriate diagnostic testing, and diagnostic case formulation will be undertaken. The learner will use both psychotherapeutic approaches coupled with psychopharmacologic approaches to treat common psychiatric mental health conditions of adults and older adults. Through these practicum experiences, learners will focus on the application of didactic concepts to patient care situations. NURS 6670 PMH NP Role II: Adult-Syllabus.

Course Prerequisites

NURS 6640: Psychotherapy With Individuals

NURS 6650: Psychotherapy With Groups

NURS 6660: Psychiatric Mental Health Nurse Practitioner Role 1: Child and Adolescent

Course Outcomes

  1. Evaluate clients using comprehensive integrated psychiatric assessments in adults and older adults
  2. Apply appropriate diagnostic criteria to psychiatric and mental health disorders in adults and older adults
  3. Evaluate efficacy of treatment approaches to psychiatric and mental health disorders in adults and older adults
  4. Apply strategies for engaging in professional practice for PMHNP
  5. Implement evidence-based treatment approaches for psychiatric and mental health disorders in adults and older adults. NURS 6670 PMH NP Role II: Adult-Syllabus.
  6. Assess knowledge of concepts and principles related to treatment of psychiatric and mental health disorders in adults and older adults

To access the Alignment Chart for this course, please click on the following link:

Document: NURS 6670 Alignment Chart (PDF)

Course Materials

The process for receiving course texts and materials varies by program. Review the information below to make sure you have all course texts and materials before the term starts.

If your course texts and materials are being provided to you by Walden University as part of your course tuition, you should have received the items noted below. When you receive your package, make sure that all required course texts and materials have been included. NURS 6670 PMH NP Role II: Adult-Syllabus.

If you are required to purchase materials for this course, please visit the university bookstore via your Walden student portal to ensure you are obtaining the correct version of any course texts and materials noted below. When you receive your package, make sure that all required course texts and materials have been included.

For missing, incorrect, or damaged materials, please contact the Student Support Team. Contact information for the Student Support Team can be located in the Student Support area of the course navigation menu.

Course Text

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Note: While only the print edition of this book is referenced here, electronic versions also may be available and may be acceptable for use in this course.

Other readings (journal articles, websites, book excerpts, etc.) are assigned throughout the course and may be found within each week and within the Course Schedule. NURS 6670 PMH NP Role II: Adult-Syllabus.

Course Readings List

The Course Readings List contains all of the required Walden Library resources for this course. Please click on the following link to access the list:

NURS 6670 Course Readings List

Media

Assigned course media elements may be found in one or more weeks of the course and are available via a streaming media player or a hyperlink to the individual item.

Course Assignments

Online Discussion and Clinical Supervision

The exchange of ideas between colleagues engaged in scholarly inquiry is a key aspect of graduate-level learning and is a requisite activity in this course.

Requirements: You are expected to participate at least two separate days a week in the weekly Discussion area. Discussion topics/questions are provided in the Discussion area. In addition, you are expected to respond to your fellow students’ postings. To count as participation, responses need to be thoughtful; that is, they must refer to the week’s readings, relevant issues in the news, information obtained from other sources, and/or ideas expressed in other class members’ postings. Where appropriate, you should use references to support your position. The Discussion questions require a response to one other student’s posting; it should be no more than two paragraphs long. NURS 6670 PMH NP Role II: Adult-Syllabus.

All Discussion postings need to be made in each week’s Discussion area of the course, unless otherwise stated. Please do not e-mail postings to the Instructor or other students. Refer to the Discussion area for specific instructions.

Discussions will be graded according to the Discussion Rubric found in the Course Information area.

Assignments and Projects

An Assignment or Project often is a writing assignment submitted to the Instructor for evaluation. Complete Assignment or Project directions are in the Assignments or Projects areas, including how and where to submit the Assignment or Project and the due date.

Please note that you should keep copies of your Assignments and Projects on your computer in case of any technical difficulties.

Information on scholarly writing may be found in the APA manual and at the Walden Writing Center website. NURS 6670 PMH NP Role II: Adult-Syllabus.

Please refer to the APA Guide or visit the Walden University Online Writing Center at

Writing Center

Walden University expects you to act with integrity and honesty in your academic courses. Refer to the Guidelines and Policies and Academic Integrity areas for more details.

Check the Course Information area for any rubrics relating to the Assignments and Projects.

Practicum Activities

  • The practicum experience in this course will assist your transition from the role of learner to that of scholar-practitioner. To achieve this transition, you will engage in a relationship with a clinical instructor and preceptor, focusing on roles and role functions and the achievement of individualized learning objectives. The primary objective of your practicum is to provide you with the basic skills necessary to serve as a mid-level provider of primary care to selected populations and prepare you to take the appropriate national certification exam. NURS 6670 PMH NP Role II: Adult-Syllabus.
  • The practicum component of the course will be graded as Satisfactory or Unsatisfactory. In order to pass the course, you must earn a grade of Satisfactory on all required practicum activities including journal entries and time logs.
  • At the end of the course, you must also ensure that your practicum preceptor submits an online evaluation of your performance. You will also complete an online evaluation of your practicum experience at the end of the course. These evaluations will not only provide information about the progress of individual students, but also help program leadership to continuously work on the course review and improvements. You will receive an Incomplete (I) as a grade if any of the above evaluations are not received by the posted deadlines.

Time Logs: Students are required to keep a log of the time spent related to their practicum experience and enter every patient they see each day. Students can access their time log from the Welcome Page in their Meditrek account. Students will track time individually for each patient they work with. Students are required to continuously input their hours throughout the term. Logs are reviewed by instructors in Weeks 4, 7, and 10. Please print and keep your completed Meditrek Log at the end of your clinical experiences for future use as a component of your portfolio.

Grading Criteria and Total Components of a Grade

Course grades will be based on participation (postings) and completion of assignments as listed below.

Note: All assignments must be completed to pass the course.

Grading Scale

Letter grades will be assigned as follows:
90%–100% = A
80%–89% = B
70%–79% = C
70% or below = F

Please see below for the policy on Incomplete (I) grades.

Course Evaluation and Grading

Important Note: This course contains weighted grading. Assignments are weighted differently depending on their type. The total points achieved for each assignment will be weighted based on the percentage values noted in the Weighted Total (%) column of the table that follows. NURS 6670 PMH NP Role II: Adult-Syllabus.

 

Week 1 2 3 4 5 6 7 8 9 10 11 Total Points % of Grade
Discussions (100 pts each) X X X X X X 600 15%
Clinical Supervision X S/U
Assignments (100 pts each) X X
X
X X 500 15%
Exams (75 pts each) X X 150 50%
Board Vitals (20 pts each) X X X X X X X X X X 200 10%
Fitzgerald Exam (100 pts) X 100 10%
Practicum Journal Entries X X X X X X S/U
Decision Trees X X X S/U
Total 1550 100%

Feedback Schedule

  • The Instructor will log into the course at least 3–4 times during the week to monitor the weekly Discussion area. Feedback will be provided via the Discussion area and/or the Announcements page. Requests for more specific feedback may be made in the Discussion area or in the Contact the Instructor thread.
  • The Instructor will respond to at least one main post each week but will usually not respond to all posts.
  • Timely Review and Return of Student Work. As a guideline, faculty members are expected to review and return graded student work for all coursework within 10 calendar days.
  • Each Instructor has a unique way of providing feedback. If you think that you are not getting enough feedback, you are strongly encouraged to contact your Instructor and ask for more. Contact information for your Instructor can be found under the Contact the Instructor area. For more information on Instructor feedback, go to the Faculty Accessibility section of Faculty and Student Guidelines for Online Courses, located in the Guidelines and Policies area. NURS 6670 PMH NP Role II: Adult-Syllabus.

Preferred Methods for Delivering Assignments

Submitting Course Postings to the Weekly Discussion Areas

Be sure that you post to the correct Discussion area each week. Do not e-mail postings to the Instructor. For all initial Discussion postings, make sure that the first sentence of your posting reads Main Question Post. For your responses to others’ postings, make sure that the first sentence of your response reads Response. These actions will ensure easily identifiable subject lines for your postings and responses.

Submitting Assignments and Projects

Assignments and Projects are submitted according to the instructions in the Assignments or Projects areas and are named according to the week in which the Assignment or Project is submitted. Directions for naming each Assignment or Project are included in each week’s Assignment or Project area.

E-mailing Your Instructor

When e-mailing the Instructor, please use the following heading for your e-mail subject line: last name + your first initial + course number (e.g., RideSNURS6640) so that your Instructor will recognize and read your e-mail. NURS 6670 PMH NP Role II: Adult-Syllabus.

Policies on Late Assignments

Discussion and Assignment Postings

No credit will be given for Discussion and Assignment postings made after the week in which they are due unless prior arrangements are made with the Instructor. Exceptions will be made only for those rare situations that legitimately prevent a student from posting on time. Points will be deducted from late postings.

Assignments

Assignments are due by Day 7 of the week in which they are assigned unless otherwise noted. Failure to meet the deadline without prior approval will result in at least a 3-point deduction per day. Any Assignment submitted after Day 4 of the week following that in which it is assigned will receive zero points. NURS 6670 PMH NP Role II: Adult-Syllabus.

Keeping Your Coursework

You will have access to the course and your coursework from the course start date until 60 days after the course ends. After this time, you will no longer be able to access the course or related materials. For this reason, we strongly recommend that you retain copies of your completed assignments and any documents you wish to keep. The University is not responsible for lost or missing coursework.

Instructor Feedback Schedule

The Instructor will log in to the course during the week to monitor the weekly Discussion area. Feedback will be provided via the comments in the My Grades area, the Discussion area, and/or the Announcements page.

You can expect your weekly assignment grades to be posted within 10 calendar days of a due date. Instructor feedback and explanation are provided whenever full credit is not achieved. Depending on the nature of the feedback, Instructor responses may be posted to the Discussion area or included in the My Grades area. The goal of your Instructor is to act as a discussion and learning facilitator rather than a lecturer. The Instructor will not respond to every posting by every individual, so please feel free to ask your Instructor if you would like some personal feedback on a particular assignment posting or any time you have any questions regarding your assignments or your grade. NURS 6670 PMH NP Role II: Adult-Syllabus.

Classroom Participation

In accordance with U.S. Department of Education guidance regarding class participation, Walden University requires that all students submit at least one of their required Week 1 assignments (which includes posting to the Discussion Board) within each course(s) during the first 7 calendar days of class. For courses with two-week units, posting to the Discussion Board by Day 7 meets this requirement. The first calendar day of class is the official start date of the course as posted on your myWalden academic page.

Assignments submitted prior to the official start date will not count toward your participation.

Financial Aid cannot be released without class participation as defined above.

Students who are taking their first class with Walden and do not submit at least one of their required Week 1 assignments (or at least one Discussion post) by the end of the 7th day will be administratively withdrawn from the university. NURS 6670 PMH NP Role II: Adult-Syllabus.

Students who have already taken and successfully completed at least one or more class(es) with Walden, and who do not participate within the first 7 days, will be dropped from that class.

If you have any questions about your assignments, or you are unable to complete your assignments, please contact your Faculty Member. NURS 6670 PMH NP Role II: Adult-Syllabus.


Checklist

The weekly course checklist below outlines the assignments due for the course.

For full assignment details and directions, refer to each week of the course. All assignments are due by 11:59 p.m. Mountain Time (MT) on the day assigned (which is 1:59 a.m. Eastern Time (ET) the next day). The time stamp in the classroom will reflect Eastern Time (ET), regardless of your time zone. As long as your submission time stamp is no later than 1:59 a.m. Eastern Time (ET), you have submitted on time. NURS 6670 PMH NP Role II: Adult-Syllabus.

To view the Course Calendar:

Course Calendar

To View a Printable Course Schedule

For full assignment details and directions, refer to each week of the course.

Click on the NURS 6670 Course Schedule (PDF) link to access the Course Schedule.

Document: NURS 6670 Course Schedule (PDF)

Checklist

Module Assignment Title
Psychiatric Assessment of the Adult and Older Adult
Learning Resources Required Readings
Required Media
Optional Resources
Discussion Interview Format. NURS 6670 PMH NP Role II: Adult-Syllabus.
Assignments Week 1 Practicum Journal Entry: Certification Plan
Depressive Disorders
Learning Resources Required Readings
Required Media
Optional Resources
Assignments “Captain of the Ship” Project – Depressive Disorder
Week 2 Practicum Journal: Safe Prescribing
Board Vitals
Personality Disorders
Learning Resources Required Readings
Required Media
Optional Resources
Discussion Treatment of Personality Disorders
Assignments Decision Tree
Fitzgerald Health Education Associates (FHEA) PMHNP 150 University Exit Comprehensive Exam
Board Vitals
Substance-Related and Addictive Disorders
Learning Resources Required Readings
Required Media
Optional Resources
Discussion Clinical Supervision – Kaltura
Assignments Week 1 Practicum Journal Entry: Certification Plan
Week 2 Practicum Journal: Safe Prescribing
Week 3 Practicum Journal: Decision Tree
Board Vitals. NURS 6670 PMH NP Role II: Adult-Syllabus.
Bipolar Disorders
Learning Resources Required Readings
Required Media
Optional Resources
Assignments “Captain of the Ship” Project – Bipolar Disorders
FHEA Exam Follow-up
Practicum: Decision Tree
Board Vitals
Anxiety Disorders, PTSD, and Related Disorders
Learning Resources Required Readings
Required Media
Optional Resources
Discussion Treatment of Anxiety Disorders
Assignments Midterm Exam
Week 6 Practicum Journal: Reimbursement Rates
Board Vitals
Obsessive-Compulsive Disorders
Learning Resources Required Readings
Required Media
Optional Resources
Assignments “Captain of the Ship” Project – Obsessive-Compulsive Disorders
Week 7 Practicum Journal: Checkpoint for Certification Plan
Week 5 Practicum: Decision Tree
Week 6 Practicum Journal – Reimbursement Rates
Board Vitals. NURS 6670 PMH NP Role II: Adult-Syllabus.
Neurocognitive Disorders
Learning Resources Required Readings
Required Media
Optional Resources
Discussion Treatment of Neurocognitive Disorders
Assignments Practicum: Decision Tree
Board Vitals
Schizophrenia Spectrum and Other Psychotic Disorders
Learning Resources Required Readings
Required Media
Assignments “Captain of the Ship” Project – Schizophrenia Spectrum and Other Psychotic Disorders
Week 9 Practicum Journal: State Practice Agreements
Board Vitals
Sleep/Wake Disorders and Parasomnias
Learning Resources Required Readings
Required Media
Optional Resources
Discussion Treatment of Sleep/Wake Disorders
Assignments Week 10 Practicum Journal: Checkpoint for Certification Plan. NURS 6670 PMH NP Role II: Adult-Syllabus.
Week 8 Practicum: Decision Tree
Week 9 Practicum Journal: State Practice Agreements
Board Vitals
Gender Dysphoria, Paraphilic Disorders, and Sexual Dysfunction
Learning Resources Required Readings
Required Media
Discussion Assessment and Treatment of Gender Dysphoria, Paraphilic Disorders, and Sexual Dysfunction
Assignments Final Exam
Board Vitals. NURS 6670 PMH NP Role II: Adult-Syllabus.

Treatment-resistant bipolar disorder

Abstract

Despite the remarkable increase in medications validated as effective in bipolar disorder, treatment is still plagued by inadequate response in acute manic or depressive episodes or in long-term preventive maintenance treatment. Established first-line treatments include lithium, valproate and second-generation antipsychotics (SGAs) in acute mania, and lithium and valproate as maintenance treatments. Recently validated treatments include extended release carbamazapine for acute mania and lamotrigine, olanzapine and aripiprazole as maintenance treatments. For treatment-resistant mania and as maintenance treatments, a number of newer anticonvulsants, and one older one, phenytoin, have shown some promise as effective. However, not all anticonvulsants are effective and each agent needs to be evaluated individually. Combining multiple agents is the most commonly used clinical strategy for treatment resistant bipolar patients despite a relative lack of data supporting its use, except for acute mania (for which lithium or valproate plus an SGA is optimal treatment). Other approaches that may be effective for treatment-resistant patients include high-dose thyroid augmentation, clozapine, calcium channel blockers and electroconvulsive therapy (ECT). Adjunctive psychotherapies show convincing efficacy using a variety of different techniques, most of which include substantial attention to education and enhancing coping strategies. Only recently, bipolar depression has become a topic of serious inquiry with the dominant controversy focusing on the place of antidepressants in the treatment of bipolar depression. Other than mood stabilizers alone or the combination of mood stabilizers and antidepressants, most of the approaches for treatment-resistant bipolar depression are relatively similar to those used in unipolar depression, with the possible exception of a more prominent place for SGAs, prescribed either alone or in combination with antidepressants. Future work in the area needs to explore the treatments commonly used by clinicians with inadequate research support, such as combination therapy and the use of antidepressants as both acute and adjunctive maintenance treatments for bipolar disorder.

Main

With the first report of lithium’s efficacy in 1949 by Cade, bipolar disorder has the longest record of treatment efficacy among the major Axis I disorders. Furthermore, after more than half a century of clinical research, multiple agents from many different pharmacological classes have shown at least some efficacy, while many other agents (albeit without a consistent database demonstrating their utility) are prescribed regularly by clinicians. Yet, despite this plethora of choices, treatment of bipolar disorder remains suboptimal from the points of view of clinicians and patients alike. Whether measured by recovery time from manic or depressive episodes or preventive efficacy of maintenance treatments, bipolar disorder is characterized by sluggish responses, inadequate responses, poor compliance and recurrences in controlled clinical trials. Results of naturalistic studies additionally show pervasive, often chronic symptoms, multiple episode recurrences, very infrequent euthymic periods when measured over years and marked functional disability in many patients. Thus, despite the explosion of options over the last quarter century when lithium dominated treatment, treatment resistance remains a central problem in bipolar disorder.

Natural history of treated bipolar disorder

Without a consensual definition of treatment resistance, it is impossible to estimate the number of treatment-resistant bipolar patients. However, observing the course of naturalistically treated patients may give some indication of how effective typical treatments are. A number of studies over the last decade have demonstrated both high recurrence rates and symptom chronicity of bipolar patients treated naturalistically. In the largest recent naturalistic study in the United States, Judd et al. followed both bipolar I patients (n=146) and bipolar II patients (n=86) for a mean of approximately 13 years, using prospective mood ratings. Bipolar I patients were symptomatically ill for 47% of the weeks, while bipolar II patients were symptomatic for 54% of the observed weeks. Subsyndromal symptoms were more common than syndromal states in both bipolar Is and IIs. Depressive symptoms were more common than manic/hypomanic symptoms by a 3:1 ratio in bipolar I patients. In bipolar II patients, depressive weeks outnumbered hypomanic weeks by a 39:1 ratio. Polarity shifts occurred an average of 3.5 times per year in Bipolar Is and 1.3 times per year in Bipolar IIs. Thus, for these patients, symptoms were chronic, subsyndromal and primarily depressive. Since these patients were treated in an open, naturalistic manner, it is impossible to make judgments as to whether a systematic treatment algorithm might have improved the outcome of these bipolar patients. Nonetheless, it is clear that, for many patients, although treatment might be more effective than no treatment, mood symptoms and polarity shifts still dominate the clinical picture, implying that our typical treatments are woefully inadequate for sustaining euthymic mood over a long period of time.

Additionally, other studies of bipolar patients consistently demonstrate that naturalistically treated patients do poorly, as measured by social relationships, occupational status, quality of life and other measures of function. Of course, a clear relationship exists between symptom/syndromal outcome and functional outcome. This relationship, however, is far from linear and may best be described as circular, with poor outcome in either domain predicting poor outcome in the other domain. Thus, whether measured by symptom/syndrome/recurrence status or functional status, the majority of treated bipolar patients have a less than satisfactory outcome.

Definitions of treatment-resistant bipolar disorder

No consensual definitions of treatment-resistant bipolar disorder exist. A number of parameters should be considered in the definition, as delineated in .

Table 1 Considerations for criteria for treatment resistance in bipolar disorder

First, the phase of the disorder should be specified. In most studies, these are either acute manias or breakthough episodes during maintenance treatment. Definitions of treatment-resistant bipolar depression have generally not been considered. For bipolar depression, criteria used for treatment-resistant unipolar depression would apply, with the proviso that failure to respond to mood stabilizers as well as antidepressants should be added to the definition. Since most definitions of treatment resistance are symptom and syndrome based, functional outcome is rarely considered in the definition of treatment resistance. However, from the patient and family’s viewpoint and from a public health perspective, it should be considered. HCA 699, NR 509 and NURS 6670 Bank

Most definitions for treatment resistance in acute episodes (either mania or depression) utilize the failure to respond to a specified number of treatments that are generally considered effective. Similarly, treatment resistance in maintenance treatment is typically defined as continued cycling despite adequate trials of previously demonstrated effective treatments. In most studies, failure to respond to a specified number of prior treatments (typically two or three) is used as the threshold for treatment resistance. Some studies, however, include subjects who either fail to respond or are intolerant of prior treatments. Conflating treatment resistance with treatment intolerance unfortunately dilutes the sample treated, since these two groups are arguably distinct. A similar distinction has been made in the treatment-resistant depression literature in which treatment-non-responsive patients who have been unable to tolerate adequate antidepressant trials are specified as pseudoresistant to distinguish them from true treatment failures. Some authors additionally require the absence of antidepressants in the definition of both acute mania and maintenance treatment, reasoning that the antidepressant could either exacerbate the mania or ‘drive’ the mood instability. Finally, given the frequency with which bipolar patients are treated with medication combinations, future definitions of treatment resistance in bipolar disorder should consider requiring a failure to respond to one or more combination treatments, whether in acute mania or in maintenance treatment.

Since treatment non-compliance in bipolar disorder is so common, especially in maintenance treatment, both researchers and clinicians alike need to be alert to patients whose seeming treatment resistance is based not on a failure to respond but simply because treatment was discontinued, either fully or partially. Treatment strategies would surely differ between non-compliance-precipitated episodes and cycling vs true breakthrough episodes. Of course, if a manic episode occurs in the context of non-compliance, it is imperative to establish whether the patient discontinued treatment and the episode followed, or whether the patient became hypomanic, discontinued treatment at that point and then became even more symptomatic.

First-line treatments for bipolar disorder

Established first-line treatments, used for at least a decade and/or for which there are ample clinical and research data, are listed in .

Table 2 First-line treatments for bipolar disorder

For acute mania, first-line treatments have long included lithium, valproate and first-generation antipsychotics (FGAs). However, among the FGAs, only chlorpromazine has received a Food and Drug Administration (FDA) indication for this purpose. Five of the second-generation antipsychotics (SGAs) are FDA indicated for acute mania. Even though their use in treating acute mania is relatively recent, they are listed as first-line agents since they are generally used first line in most inpatient settings. No published data currently exist supporting the use of one of the SGAs vs another in treating acute mania. Nonetheless, at least in inpatient settings, aripiprazole and ziprasidone are prescribed less frequently than risperidone, olanzapine or quetiapine. This assuredly reflects both the earlier release in the Unites States of the three latter agents as well as the greater sedation associated with their use. Sedation is often used on inpatient units for behavioral control as well as for treating the acute mania itself.

For maintenance treatment, lithium has long been a mainstay, receiving an FDA indication for this purpose in 1974. Valproate (either divalproex sodium or generic valproic acid) is not FDA indicated for maintenance treatment in bipolar disorder, due to its lack of separation from placebo in a large, placebo-controlled study. A number of methodological factors may explain this unanticipated result, including the requirement of more consistent euthymia in subjects and the use of a non-enriched sample (in contrast to later studies evaluating olanzapine and lamotrigine in which study design utilized an enriched sample). Nonetheless, clinical consensus, Expert Consensus Guidelines, published algorithms and Practice Guidelines all support the efficacy of valproate as a first-line maintenance treatment in bipolar disorder.HCA 699, NR 509 and NURS 6670 Bank

Recently validated treatment options in bipolar disorder

Although carbamazepine was the first anticonvulsant used in treating acute mania, few well-controlled studies supported its use as a first-line agent in treating acute mania (). Additionally, the loss of the original patent protection well over a decade ago stopped any pharmaceutical firm support for research into carbamazepine’s efficacy. More recently, however, an extended release preparation of carbamazepine has shown efficacy as an acute antimanic treatment in two double-blind, placebo-controlled studies. On the strength of these data, carbamazepine-ER received an FDA indication for acute mania.

Table 3 Recently validated treatment options in bipolar disorder

Until 2003, lithium was the only mood stabilizer with an FDA indication as a maintenance treatment in bipolar disorder. Over the last 2 years, however, three additional treatments have received FDA indications as maintenance treatments. HCA 699, NR 509 and NURS 6670 Bank

In two studies, evaluating recently manic/hypomanic and recently depressed patients, lamotrigine successfully prevented mood episode recurrences as measured by the time to intervention. Since the design for these two studies is identical, with the exception of the pole of the most recent episode (recently manic/hypomanic vs depressed), the results of these two studies were combined and the data reanalyzed. In this analysis, lamotrigine effectively prolonged the time to intervention for both manias and depressions independently compared to placebo (P=0.034 and 0.009, respectively). Of note, lithium was used as an active comparator in these studies. In the combined analysis, lithium was significantly more effective than lamotrigine in prolonging time to mania, P=0.03 (even though both active treatments were more effective than placebo), while lithium was not more effective than placebo in prolonging time to depression, P=0.12.

Two SGAs have additionally demonstrated efficacy as maintenance treatments in bipolar disorder with both receiving FDA indications. Olanzapine has been evaluated in three different controlled trials with comparisons to placebo, lithium and divalproex. In the placebo-controlled trial, olanzapine significantly decreased total relapses (relapse rates=80 vs 47%, P<0.001), manic relapses (41 vs 16%, P<0.001) and depressive relapses (48 vs 34%, P<0.02). In a 1-year trial with no placebo controls, olanzapine (mean daily dose=13.5 mg) was somewhat more effective than lithium (mean serum level=0.7 mEq/l) in preventing symptomatic recurrence of mood episodes (P=0.055). No significant difference in depressive recurrence rates were seen, while significantly fewer olanzapine-treated patients had manic/mixed recurrences compared to lithium-treated patients (23 vs 14%, P<0.02). In the 47-week non-placebo-controlled trial comparing olanzapine vs divalproex sodium, no significant differences between the two medications were seen in overall recurrence rates (P=0.42). However, treatment discontinuation rate during this study across both treatment groups was 84%, with the majority of patients discontinuing for reasons other than lack of efficacy. HCA 699, NR 509 and NURS 6670 Bank

In a 6-month study, aripiprazole was more effective than placebo in preventing mood episodes (43 vs 25%, P=0.013) in 161 patients.

Treatment-resistant bipolar disorder

Aside from the treatments described above, a remarkable variety of other approaches for treatment-resistant bipolar disorder, listed in , have been described.

Table 4 Options for treatment-resistant bipolar disorder

With. the exception of adjunctive psychotherapies (reviewed below), none have been validated by large-scale controlled studies. Some of these approaches have even been shown to be ineffective, but are still prescribed occasionally and may be of benefit to a few patients. Additionally, there is a presumption that a medication that is ineffective in treating acute mania will not be effective in other phases. After a negative set of studies for acute mania, new treatments are often abandoned as potential maintenance treatments. This is neither logically nor empirically so. As an example, lamotrigine is ineffective in acute mania but has shown efficacy in bipolar depression and as a maintenance treatment.

Anticonvulsants

Aside from the anticonvulsants listed above, all recently released anticonvulsants and one older agent have been evaluated, either in open-case series or in some controlled trials, in bipolar disorder. In the following review, only case series with five or more subjects will be discussed. HCA 699, NR 509 and NURS 6670 Bank

Ironically, phenytoin, the oldest of the agents, is the only anticonvulsant in  with any substantially controlled data supporting its use in bipolar disorder. In a double-blind placebo-controlled, add-on study of a small (n=30) sample of acutely manic patients, phenytoin 300–400 mg daily demonstrated additive efficacy to haloperidol. In a second small (n=23) study by the same group, phenytoin was compared to placebo when added blindly to ongoing maintenance treatment using a crossover design of 6 months each. Phenytoin-treated patients had fewer recurrences (P=0.02).

Oxcarbazepine, a congener of carbamazepine, has been prescribed over the last few years for treating both acute mania and as a maintenance treatment. Only one double-blind, placebo-controlled study for acute mania has been published, but only seven subjects were included in the study. Three other controlled studies (two of which had sample sizes of 12 and 20, respectively) in acute mania have been published, comparing oxcarbazepine to lithium, valproate or haloperidol, but none were placebo controlled. In these studies, oxcarbazepine seemed equivalently effective to the active comparators. Despite the lack of controlled data, clinicians prescribe oxcarbazepine given its biological similarity to carbamazepine and its record of better tolerability. Owing to patent issues, large-scale studies on oxcarbazepine’s efficacy in bipolar disorder are unlikely to be forthcoming.

Four open studies, with an aggregate of 79 subjects, have examined the potential efficacy of levetiracetam in bipolar disorder., , ,  In the largest of these reports, 34 patients who were either manic/hypomanic or depressed received 500–3000 mg daily of levetiracetam adjunctively The more mildly depressed patients seemed to respond although the open design of the study precludes any clear interpretation of the results seen. In earlier open trials, mania/hypomania seemed to improve when levetiracetam was prescribed either as a solo treatment or in an add-on design in daily doses up to 4000 mg. HCA 699, NR 509 and NURS 6670 Bank

Three open studies have evaluated the efficacy of zonisamide in mania or bipolar depression., ,  In the largest and most recent of these reports, zonisamide 100–500 mg daily was added to the ongoing regimen of 62 bipolar outpatients, most of whom were treatment-resistant with either predominantly manic/hypomanic or depressive symptoms. Those with manic/mixed symptoms seemed to respond, while those with depressive symptoms showed a more modest response. Of note, only 18% of patients completed the 1-year trial, mostly due to worsening mood state or lack of improvement. Modest weight loss was observed over the course of the trial.

When first evaluated in the treatment of bipolar disorder, topiramate showed promise, both for the initial positive reports in open trials and for its documented weight-losing properties. Unfortunately, in a series of controlled trials for acute mania, topiramate was no better than placebo. A monotherapy trial comparing topiramate vs placebo in acute manic episodes in children and adolescents was terminated prematurely due to the negative adult data. However, analysis of the smaller than designed sample showed some efficacy of topiramate compared to placebo. Finally, a relatively large open-label study of adjunctive topiramate as a maintenance therapy showed efficacy in both manic and depressive phases and in overall symptom reduction. Thus, topiramate’s efficacy as a maintenance treatment, either adjunctively or as a solo agent, is still unknown. HCA 699, NR 509 and NURS 6670 Bank

Despite a number of positive open trials and widespread clinical use, gabapentin has not shown antimanic or general mood-stabilizing properties in two controlled trials. In the first trial, gabapentin was an ineffective add-on treatment compared to placebo in manic/hypomanic outpatients. Gabapentin was also ineffective in (mostly) rapid cyclers whether rated for antimanic, antidepressant or overall mood-stabilizing properties. It may, however, be helpful in treating anxiety in bipolar patients.

Three trials, all open label, with a total of 47 treatment-resistant subjects have evaluated the efficacy of tiagabine in both manic, depressive or maintenance phases of treatment., ,  None of the three trials showed particular efficacy in doses between 1 and 40 mg. Four subjects across the three studies (8.5%) without a prior history of epilepsy had either well-documented or presumptive seizures. With both poor efficacy and tolerability concerns, tiagabine should not be considered a primary option even for treatment-resistant bipolar disorder. HCA 699, NR 509 and NURS 6670 Bank

Combination treatments

Despite the focus on placebo-controlled monotherapy studies, whether for acute mania or as a maintenance treatment, monotherapy in clinical practice is the exception rather than the rule. As an example, using data collected a decade ago on bipolar outpatients, fewer than one in five were on monotherapy and the majority of patients were being treated by three or more medications, with one-third receiving four or more medications. Similarly, in the Stanley Foundation Bipolar Network database reported in 2004, bipolar patients received a mean of four different psychotropic medications during 1 year. Finally, a pharmacy database recently found that 55% of bipolar outpatients were taking two or more medications (Market Measures, 2003, unpublished data). HCA 699, NR 509 and NURS 6670 Bank

In treating acute mania, a substantial database consistently demonstrates the superiority of combination treatment over monotherapy. The most common design is the comparison of an SGA plus an older mood stabilizer, typically lithium or valproate, compared to lithium or valproate alone. Consistently, the combination, with controlled studies available for risperidone, olanzapine and quetiapine, shows significantly greater efficacy. In some of these add-on studies, only patients who have failed monotherapy are included, while other studies examine combination vs single treatment in all eligible patients. Response rates for combination treatments of acute mania generally exceed those of lithium or valproate by 20–25%. No published studies have evaluated the additive efficacy of lithium or valproate to an SGA. In the only study of its type, valproate showed additive efficacy in the treatment of acute mania when added to a FGA.

Far fewer studies have compared the efficacy of a combination treatment to monotherapy in the maintenance phase of bipolar disorder. The few published controlled studies are marred by small sample sizes, large dropout rates or unrepresentative tertiary care patients. Over the last decade, only three controlled trials of combination maintenance treatment of bipolar disorder have been published., ,  In the only large-scale controlled study, olanzapine plus lithium or valproate was compared to lithium or valproate alone over 18 months in 99 patients who had responded to the combination for acute mania. Dropout rates were very high; 69% of those on combination and 90% of those on lithium or valproate alone discontinued the study, with the majority of dropouts occurring for reasons other than relapse. Modest additional significant efficacy was seen with the combination as measured by median time to symptomatic relapse (as measured by rating scale scores) P=0.023, but not by syndromal relapse rates (29 vs 31%) or time to syndromal relapse.

An initial maintenance treatment pilot study compared the relative efficacy of lithium plus divalproex sodium vs lithium alone in bipolar patients treated for up to 1 year. Combination treatment was significantly more effective than lithium alone in preventing relapse (0/5 vs 5/7, P=0.014). Combination treatment was associated with significantly greater side effect burden and a higher study dropout rate due to side effects. Despite these intriguing preliminary findings, a larger followup study has not been presented or published. HCA 699, NR 509 and NURS 6670 Bank

A larger crossover study compared lithium, carbamazepine and the combination in 52 bipolar I and II patients, with each subject receiving each medication and the combination for 1 year each. Using Clinical Global Improvement (CGI) scores, the three treatments did not differ significantly, although a good treatment response was seen in 33% of patients on lithium, 31% on carbamazepine and 55% on the combination. Of note, the combination was significantly more effective in rapid cycling patients who did poorly on both solo agents. Additionally, a subset of patients showed differential improvement to one or the other monotherapy, implying that trials of multiple monotherapies may be worthwhile for those who do not respond to the first agent. HCA 699, NR 509 and NURS 6670 Bank

Clinically, and in case reports and case series, virtually all medications with mood-stabilizing properties have been used in combination. (This includes clinical situations in which patients are sometimes treated with four or more mood stabilizers.) The only combination that may be relatively contraindicated is that of carbamazepine and clozapine, since each produces potentially serious hematological effects. With many medication combinations, especially those involving carbamazepine and/or valproate, pharmacokinetic interactions must always be considered.

High-dose thyroid augmentation

The use of high-dose thyroid augmentation for treatment-resistant bipolar disorder has been evaluated, mostly in open trials, for over 20 years. Despite this length of time, only a handful of reports, none large-scale and none using classic-controlled methodologies, have been published. (One of the older studies employed the only controls – single- or double-blind placebo substitution – in four of 10 treatment responders.) In aggregate, only 29 subjects, some of whom were unipolar depressives, all from the same research group, have been evaluated in the studies published over the last 15 years., ,  (Some of the subjects in two earlier reports are included in the later paper.) Nonetheless, high-dose thyroid hormone augmentation continues as a potential option for treatment-resistant bipolar disorder. HCA 699, NR 509 and NURS 6670 Bank

The paradigm of thyroid augmentation for bipolar disorder – which is distinct from the use of subreplacement doses of tri-iodothyronine as an adjunct for treatment-resistant depression – typically involves administering high doses of L-thyroxine for months to years with the goal of decreasing cycle frequency, mood episode amplitude or both. Mean doses of L-thyroxine in the two recent publications were 379 and 482 mcg, between 3 and 4.5 × the daily thyroid replacement dose in the United States. Thus, patients were treated with supraphysiological doses. In both open studies, treatment-resistant patients showed clear improvement with mean follow-ups of 2 and 4 years, respectively. Side effects were surprisingly minimal, given the high doses of thyoxine prescribed. Concerns regarding the potential for the development of osteoporosis in patients taking high doses of thyroid hormone over extended time periods continue despite preliminary reassuring results.

Clozapine

Alone among the SGAs, clozapine has not been the subject of large-scale double-blind studies in bipolar disorder. This assuredly reflects clozapine’s side effect profile, compliance burden and dangers of the drug such as cardiomyopathies, seizures and agranulocytosis with the mandated regular checks of white cell counts. Another factor explaining the lack of controlled studies is clozapine’s loss of patent protection years ago. Nonetheless, a large uncontrolled literature suggests that clozapine must be considered as a treatment for refractory bipolar disorder, similar to its use in schizophrenia.

Despite the limitations of an uncontrolled database, clozapine has shown efficacy in treating acute mania, decreasing depressive symptoms and in overall mood stabilization. Psychotic symptoms do not predict an inherently better response to clozapine among treatment-resistant bipolar patients. Furthermore, among treatment-resistant patients, compared to schizophrenic patients, those with bipolar disorder may be more responsive to clozapine. Required doses for optimal effect in bipolar disorder may be less than for treatment-resistant schizophrenia.

Only one study has systematically compared clozapine as an add-on study to a treatment as usual group using a random assignment but not blinded design. In this study of 38 treatment-resistant bipolar I and schizoaffective patients, after 6 months of treatment, clozapine significantly decreased symptoms by 30% or more in 82% of patients compared to 57% in the treatment as usual group. Using multiple rating scales, clozapine addition was consistently significantly more effective other than in depression rating scale scores (with the difference in depression scores differing at a significance level of 0.06).

Electroconvulsive therapy

Although uncommonly used in bipolar disorder, electroconvulsive therapy (ECT) remains an important option for treatment-resistant bipolar disorder in manic and depressive phases and as a maintenance treatment.

For acute mania, only two relative small prospective, controlled studies have systematically compared ECT to other treatments – lithium, and lithium plus haloperidol. ECT was slightly more effective than lithium in one study and clearly more effective than the combination treatment in the other study. It is estimated that ECT is associated with remission or marked clinical improvement in 80% of those treated. No consistent evidence exists suggesting the need for more ECT treatments in manic compared to depressed patients. HCA 699, NR 509 and NURS 6670 Bank

No controlled studies have examined maintenance ECT. Naturalistic studies, which have typically included both unipolar and bipolar patients, consistently suggest efficacy. In the most recent case series, 13 treatment-resistant bipolar I, II and schizoaffective patients, 10 of whom were over 65 years old, showed overall improvement (as measured by decreased numbers of hospitalizations) with maintenance ECT. Maintenance ECT was generally given weekly, with no patient able to extend beyond 3-week treatment intervals. Additionally, two patients refused further maintenance ECT after four treatments: one discontinued treatment due to cognitive side effects, while another showed cardiac complications. Thus, although maintenance ECT may be effective, longer times between treatments (e.g., monthly intervals) is unlikely to be effective and, in older patients, medical complications may be significant. HCA 699, NR 509 and NURS 6670 Bank

Omega-3 fatty acids

Although an initial double-blind, placebo-controlled study indicated the potential efficacy of omega-3 fatty acids as an adjunctive treatment in bipolar disorder, no positive data have emerged over the last 5 years. In the initial study, 30 bipolar patients (40% rapid cyclers), not selected for operationally defined treatment resistance, were assigned to omega-3 fatty acids, 9.6 g/day added to their ongoing treatment regimen vs placebo for 4 months. Those treated with omega-3 fatty acids showed significantly longer period of remission (P=0.002), primarily due to prevention of depressive symptoms. These results were consistent with a small open trial of 12 patients with bipolar I depression treated with the omega fatty acid eicosapentanoic acid (EPA) in which eight of 10 patients treated for at least 1 month showed an antidepressant response.

Unfortunately, the largest recent study in this area showed negative results. As part of the Stanley Foundation Bipolar Network studies, 121 bipolar patients were treated with the omega-3 fatty acid EPA, 6 g daily vs placebo in a double-blind fashion for either bipolar depression or rapid cycling. No difference between drug and placebo was apparent in either subgroup.

At this point, the utility of omega-3 fatty acids in treatment-resistant bipolar disorder is obscure. Further problems in the area include ignorance about which omega-3 fatty acids should be prescribed, in what proportion, at what dose, and the inability to ascertain the quality of the product since it is not FDA regulated. HCA 699, NR 509 and NURS 6670 Bank

Calcium channel blockers

A number of calcium channel blockers have been evaluated as treatments of acute mania and as maintenance treatments in bipolar disorder for over 20 years. Results for verapamil are mixed at best. Although some studies showed preliminary positive results, other, better controlled studies demonstrated little efficacy. In the most recent report, 37 women, some of whom were pregnant, were treated with verapamil as monotherapy in an open fashion. Manic or mixed syndromes responded better than depressive syndromes. HCA 699, NR 509 and NURS 6670 Bank

Individual calcium channel blockers differ in their affinity for the different calcium channel subtypes. Thus, data for one agent may not generalize to the others. Additionally, verapamil may not penetrate the blood–brain barrier efficiently. Therefore, nimodipine, the most lipophilic calcium channel blocker with the greatest potential to enter the central nervous system, has also been evaluated in treatment-resistant bipolar disorder. A first open case series of six acutely manic patients demonstrated some efficacy. In the largest controlled study, 10/30 bipolar patients responded to nimodipine with moderate or marked improvement. After the effective addition of carbamazepine to four treatment nonresponders, blind substitution of nimodipine for verapamil led to an increase in manic symptoms, consistent with the differential effects of individual calcium channel blockers. In two patients, the blind substitution of isradipine, an agent more similar to nimodipine than verapamil, sustained clinical response.HCA 699, NR 509 and NURS 6670 Bank

Benzodiazepines

Benzodiazepines have been used for decades to slow down manic patients, typically in combination with lithium, anticonvulsants or antipsychotics. As solo agents for acute mania, they show efficacy. Clonazapem and lorazepam have been the subject of most studies, with more convincing data for the former. This may reflect the relatively higher doses (adjusted for relative potency) of clonazepam used in many of the studies.HCA 699, NR 509 and NURS 6670 Bank

Other agents

A number of other agents, suggested as effective antimanic agents or as maintenance treatments for treatment-resistant bipolar patients, have been the subject of small preliminary series. The most unusual of these was that of D-amphetamine, which showed efficacy in doses of 60 mg daily in 5/6 acutely manic inpatients.

Donepezil, a reversible acetylcholinesterase inhibitor, was evaluated in doses of 5–10 mg in 11 treatment-resistant bipolar I patients, 10 of whom were manic, hypomanic or mixed. Six patients were markedly improved within 6 weeks, all at the 5-mg dose. No followup studies have emerged. HCA 699, NR 509 and NURS 6670 Bank

Mexiletine, an antiarrhythmic medication with additional anticonvulsant and analgesic properties, showed efficacy in doses of 200–1200 mg daily when given to 20 treatment-resistant or treatment-intolerant bipolar patients. Of the 13 completers, six (46%) were considered full responders, including all manic or mixed patients. A followup double-blind, placebo-controlled study by the same group evaluated mexiletine in 10 manic or hypomanic subjects. Changes in YMRS scores favored mexiletine, but did not reach statistical significance.

Psychosocial adjunctive therapies

Of the treatments listed in , the most consistent and largest database has demonstrated the additive efficacy of a variety of psychological therapies in bipolar disorder. In all studies, medication plus a structured psychotherapy has been compared to medication plus a less structured psychotherapy or medication alone. Building on earlier studies, ,  over the last 5 years, a variety of psychotherapy techniques have been evaluated, including family-focused treatment (FFT), cognitive therapy (CT), group psychoeducation, and interpersonal and social rhythm therapy (IPSRT). For all approaches, the addition of the structured psychotherapy added additional benefit, as measured by a variety of outcome variables, including longer survival time before relapse, fewer relapses, greater reductions in symptom rating scales, enhanced compliance, fewer days in mood episodes, improved social functioning, and fewer and shorter hospitalizations. HCA 699, NR 509 and NURS 6670 Bank

Family-focused treatment

Adapted from earlier studies on family interventions for schizophrenic patients, FFT is an amalgam of psychoeducation, communication skills training for dealing with intrafamilial stress and problem-solving skills, administered as approximately a 20-session therapy over 9 months. Inherent in this treatment model is the need for at least one relative with whom the patient either lives or is in regular contact (four or more hours weekly). When compared to a control group (n=70) that received two educational sessions and emergency counseling sessions as needed, patients (n=31) receiving FFT showed fewer relapses and longer time to relapse and greater improvement in depressive symptoms (but not manic symptoms) over one year. Improvements were greatest among FFT patients whose families were high in expressed emotion, a construct composed of critical comments towards the patient and/or overinvolvement with the patient. A 2-year followup showed continuation of treatment effect with FFT patients experiencing fewer relapses (35 vs 54%, hazard ratio=0.38), longer survival intervals (74 vs 53 weeks, P=0.003), greater medication adherence and greater reduction in mood symptoms. Medication adherence mediated positive effects on mania symptoms but not depressive symptoms.

Another study from the same group compared FFT (n=28) to a briefer individual therapy that was supportive, educational and problem-focused (n=25). Over the first year of followup, FFT demonstrated some weakly greater treatment efficacy compared to individual therapy. Over the 2-year study period (including 1 year of treatment and another year of followup) however, FFT was associated with significantly fewer total relapses and fewer hospitalizations. HCA 699, NR 509 and NURS 6670 Bank

Cognitive therapy

When combined with pharmacotherapy, individual CT administered in 12–18 sessions over the first 6 months with two booster sessions over the next 6 months (n=51) has also demonstrated efficacy in bipolar disorder compared to pharmacotherapy alone (n=52). CT patients had fewer relapses at 12 months (75 vs 44%, P=0.004), fewer bipolar episodes (P=0.008), fewer days ill (P=0.008) and fewer days in hospital (mean=10 vs 18 days, P=0.02). Significant additional benefits were seen in medication compliance, mean depressive symptom ratings and enhanced social functioning. At 2-year followup (after the original 6-month treatment period) differences between the two groups had faded over the last 18 months of followup, with overall effect of relapse reduction strongest during the first 12 months of treatment.

Group psychoeducation

Group education with 8–12 patients per group was compared with nonstructured group interaction over 21 sessions in 120 remitted bipolar I and II patients in maintenance pharmacotherapy, followed over 2 years. Fewer patients receiving group education relapsed (67 vs 92%, P<0.001). Numbers of depressions, manias, hospitalizations and days of hospitalizations were also significantly reduced.

Interpersonal and social rhythm therapy

IPSRT, an individual therapy derived from interpersonal therapy, focuses on resolution of interpersonal problems, prevention of future problems in these areas, the importance of maintaining regularity in daily routines, and the links between mood symptoms and the quality of social relationships and social roles. IPSRT was compared to intensive clinical management (ICM), which focused on education, symptom and medication review and nonspecific support. In a study of 175 subjects with bipolar I disorder treated during an acute stabilization phase and then a two-year maintenance phase with subjects assigned to either the same or different treatment protocol during the two phases, IPSRT administered during the acute phase was associated with a longer time until a mood episode (P=0.01). This improvement was related to the increase in regularity of social rhythms (P<0.05). IPSRT administered during the maintenance phase did not show enhanced efficacy compared to ICM. HCA 699, NR 509 and NURS 6670 Bank

Combined psychotherapies

A combination of IPRST and IFIT for 1 year was significantly more effective than a control group (derived from the data of the earlier FFT study, in extending the time to relapse, with mean survival times=43 vs 35 weeks (P<0.02), and in reducing depressive symptoms (P<0.0001), but not manic symptoms.

Psychotherapy summary

The demonstrated efficacy of a number of different psychotherapies in decreasing mood symptoms, delaying time to relapse, and reducing hospitalization rates and days likely reflects some common positive effect of what, at first glance, seem like different treatment approaches. The clearest common elements of these psychotherapies are education and the development of more effective coping mechanisms. (Seemingly, the latter can be addressed through individual IPT-focused therapy CT, or family problem-solving approaches.) At this point, it would be impossible to suggest one psychotherapeutic approach over another. Group therapy would seem to be the most economical; family-focused therapy may be optimal for bipolar patients with intrusive, hostile families. The relatively weaker comparative efficacy data of IPSRT may reflect, among other factors, the strengths of the comparison treatment, which incorporated many effective psychotherapeutic principles. HCA 699, NR 509 and NURS 6670 Bank

Since few practitioners, especially physicians, are trained in any of the structured approaches just described, the efficacy of multiple approaches may indicate a set of core principles (as yet unidentified through research) for effective psychotherapy with bipolar patients. However, given some of the commonalities used in the therapies, experienced clinicians can consider adapting the principles and using them in a flexible manner, as is universal in nonresearch settings. The important principle, however, is that adjunctive psychotherapies add significantly (both statistically and clinically) to the efficacy of pharmacological treatment regimens.

Bipolar depression

Until recently, bipolar depression has received far less attention than mania. With increasing data demonstrating that depression is the dominant pole in bipolar disorder, and with the emergence of lamotrigine as the first mood stabilizer with better efficacy at either treating or preventing depression than mania, research on optimal treatments for bipolar depression has been increasing. A full exploration of the controversies about treating bipolar depression is beyond the scope of this article. Interested readers may find a number of recent reviews and meta-analyses., , ,  However, despite the greater recent interest in the topic, a lack of a sufficient database and disagreements about its classic treatment have precluded a consensual treatment algorithm for treatment-resistant bipolar depression. HCA 699, NR 509 and NURS 6670 Bank

First-line treatment of bipolar depression

The two key differences between the algorithm for treating unipolar depression vs bipolar depression are: (1) the more prominent place of mood stabilizers as acute treatment for bipolar depression, and (2) the concerns about the potential mood-destabilizing effects of antidepressants in bipolar patients. Additionally, the risk/benefit ratio in prescribing antidepressants in bipolar depression differs between bipolar I and bipolar II patients, since both the likelihood and potential negative consequences of a pharmacological switch differ between these two bipolar subtypes. HCA 699, NR 509 and NURS 6670 Bank

Most. Practice Guidelines/Expert Consensus panels or Treatment Algorithms, ,  recommend mood stabilizers, specifically lithium or lamotrigine as first-line treatments for bipolar I depression. For severe depression, lithium or lamotrigine plus an antidepressant should be considered. For bipolar II depression, however, either lamotrigine or lithium plus an antidepressant has been recommended. Another first-line option for acute bipolar I depression is olanzapine/fluoxetine combination (OFC), which has been shown to be significantly more effective than placebo or olanzapine alone. (Of note, in this large study, fluoxetine alone was not studied, thereby precluding knowing whether OFC’s efficacy was solely due to fluoxetine with olanzapine presumably decreasing the likelihood of pharmacological mania or due to a unique synergistic effect of the medication combination.) HCA 699, NR 509 and NURS 6670 Bank

The place of antidepressants in treating bipolar depression has been the largest source of controversy. One group of experts focus on: (1) the potential negative consequences of antidepressants – the risk of pharmacological manias/hypomanias and mood destabilization; (2) the greater database on lithium’s efficacy in preventing suicide compared to antidepressants; (3) the lack of consistent efficacy of antidepressants in both acute bipolar depression and their lesser efficacy compared to mood stabilizers in preventing depression; and (4) the efficacy of lithium and lamotrigine for both acute bipolar depression and as maintenance treatments. In contrast, others examine the same database and conclude that the database for efficacy of mood stabilizers in treating bipolar depression is weak, the efficacy of antidepressants greater and the switch rate associated with the newer antidepressants substantially lower than for the first-generation agents (tricyclics and monoamine oxidase inhibitors).

In general, however, we can assume that lithum, lamotrigine, OFC and antidepressants (combined with mood stabilizers) comprise first-line treatments for bipolar I depression. HCA 699, NR 509 and NURS 6670 Bank

Treatment-resistant bipolar depression

Mood stabilizers other than lithium or lamotrigine comprise a first set of options for treatment-resistant bipolar depression. Two small controlled studies have examined the efficacy of valproate in bipolar depression. In the first study, valproate was slightly more effective than placebo, but with the small sample size (n=43), the difference was nonsignificant. In the other study, divalproex was more effective than placebo in improving depression symptoms in 25 outpatients with bipolar I depression (P=0.0002). Remission rates also favored divalproex (46 vs 25%), with the difference not reaching statistical significance. HCA 699, NR 509 and NURS 6670 Bank

Three small placebo-controlled double-blind studies, all 20 years old, have examined the efficacy of carbamazepine in bipolar depression. Carbamazepine was effective, but larger studies are needed.

In one single-blind study, topiramate was equivalently effective to bupropion when added to mood stabilizers in 36 patients with bipolar depression. No placebo control was used in this study.

In the one controlled study on the topic, gabapentin was not more effective than placebo in improving bipolar depression symptoms.

Quetiapine at doses of 300–600 mg daily was significantly more effective than placebo as a solo treatment for bipolar I or II depression, beginning at week 1 in a large (n=542), double-blind, placebo-controlled trial. Response rates were 58% for both quetiapine doses compared to 36% for placebo (P<0.001). In the OFC study, olanzapine alone showed some efficacy, but less than was seen with the combination. Comparable data for other SGAs are lacking. HCA 699, NR 509 and NURS 6670 Bank

Two small (n=22 and 21, respectively), preliminary placebo-controlled double-blind studies have suggested the efficacy of pramipexole, a D2, D3 agonist when added to stable doses of mood stabilizers in bipolar depression. With a mean dose of 1.7 mg daily in both studies, and despite the small number of subjects, pramipexole was associated with a significantly higher response rate in depressive symptoms compared to placebo in each study. HCA 699, NR 509 and NURS 6670 Bank

With concerns about both abuse and switch potential, except for small case series, there are few studies on stimulants for bipolar depression. A recent double-blind, placebo-controlled study, however, demonstrated the efficacy of modafanil, used as a stimulant but with an unknown mechanism of action, as an adjunctive treatment in 85 patients with bipolar depression. At a mean daily dose of 177 mg, by week 2, patients treated with modafanil showed significantly more improvement than placebo-treated patients. Using a 50% decrease in depressive symptoms to define response, modafanil was more effective than placebo (response rates=44 vs 22%, P<0.04). Modafanil was not associated with more manic/hypomanic switches. HCA 699, NR 509 and NURS 6670 Bank

Although for bipolar I depression the use of antidepressants without mood stabilizers is never recommended in Practice Guidelines and the like, preliminary data, all from Amsterdam and colleagues, suggest that patients with bipolar II depression and even some with bipolar I depression may be effectively treated with newer antidepressants as solo agents with minimal risk of pharmacological hypomanias/manias., , , , ,  Fluoxetine was evaluated in three of four studies, , ,  with venlafaxine used in the other. Questions have been raised about the diagnosis of bipolar II disorder in two of these studies (with the diagnosis being made retrospectively by chart review in the largest study). Although these findings are controversial, they do open the possibility that the newer antidepressants may be associated with lower switch rates for bipolar II patients than previously recognized and may be safely used. HCA 699, NR 509 and NURS 6670 Bank

As with unipolar depression, ECT should always be considered for treatment-resistant bipolar depression.

Finally, it must be acknowledged that clinicians routinely add to mood stabilizers the same set of adjunctive and combination therapies for treatment-resistant bipolar depression that they do with unipolar patients. Unfortunately, no studies have examined either the efficacy or switch rate associated with these more aggressive clinical strategies. HCA 699, NR 509 and NURS 6670 Bank

Prevention of bipolar depression

Although most treatment recommendations specifically suggest using antidepressants for acute depressive episodes with the goal of discontinuing them as soon as possible (with the assumption that the patient will continue to be on mood stabilizers), recent evidence has suggested that longer-term mood stabilizer/antidepressant treatment may be helpful for some bipolar patients. In two separate retrospective analyses, bipolar patients who continued on antidepressants along with their mood stabilizers had fewer depressive relapses (32 vs 68% and 36 vs 70%) and no increase in manic episodes. Additionally, in the larger of the two studies, patients continued on maintenance antidepressants were significantly less likely to develop a manic episode. (P=0.003). Patients in these studies were clearly a small subgroup of the total bipolar depressed patient population. Nonetheless, these retrospective analyses suggest that some bipolar patients whose illness is dominated by depressions may do best on a maintenance combination of mood stabilizers and antidepressants. HCA 699, NR 509 and NURS 6670 Bank

Future directions

Systematic study of treatment-resistant bipolar disorder is still in its infancy. Beyond the consistent observation that SGAs in combination with either lithium or valproate are effective antimanic regimens, and that clozapine or ECT should be considered in refractory cases, the literature has little to guide clinicians. Owing to both proprietary concerns by pharmaceutical companies and the desire for hypothesis-driven and methodologically ‘correct’ studies, funding agencies shy away from the messy treatments regularly prescribed by clinicians. Although virtually all areas need more study, the three most vital are: combination treatments as maintenance therapy in bipolar disorder; the use of antidepressants, singly, in combination, with and without mood stabilizers for treatment-resistant bipolar depression; and maybe most important, techniques to enhance compliance, since rates of study completion in maintenance treatments of bipolar disorder are abysmally low. Finally, the psychotherapy data must be translated into clinically usable tools, focusing on techniques that are less manual driven and more adaptable to the realities of clinical practice. HCA 699, NR 509 and NURS 6670 Bank

Conclusion

Our ability to effectively treat refractory bipolar disorder remains problematic. Although we have established treatments for acute mania and maintenance treatments that are statistically more effective than placebo, too many patients either do not respond or do not adhere to treatment sufficiently to receive benefit. Additionally, our database on depression, the dominant pole of bipolar disorder, is very small, although growing. For now, optimal therapy for treatment-resistant bipolar disorder will consist of using treatments for which little or only preliminary data exist, as listed in  and , or medication combinations. The recent solid data on the additive efficacy of a variety of psychotherapeutic techniques must be publicized and optimal methods of utilizing these techniques in clinical practice must be explored. One can only hope that, a decade from now, clinical research can usefully inform clinicians on the basis of good data rather than Expert Consensus. HCA 699, NR 509 and NURS 6670 Bank

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