Clinical Scenario

Clinical Scenario:The healthcare team at a university-based community clinic is interested in addressing a sudden increase of illicit substance-use among community dwellers.  The clinic is staffed with Nurse Practitioners (NPs) and Certified Nurse-Midwives (CNMs) serving the needs of the community. Each member of the healthcare team will address substance-misuse prevention and screening as it relates to a specific population (i.e., Adolescents, Adults, Pregnant Women). As a member of the healthcare team that cares for adolescents primarily, you will conduct a limited search of the most current evidence to address a clinical question.  After completing the search and the appraisal of the evidence you are expected to provide a brief presentation of the findings to the healthcare team.

PICO:In adolescents, how does a web-based motivational intervention compared to screening alone impact substance use?

Population:Adolescents

Intervention:Web-based motivational intervention

Comparison:  Screening alone

Outcome:Substance use

A rationale and “answer” must be provided for each item. Students whose rationales show evidence of critical thinking  will score higher than students who simply give a ‘yes’ or ‘no’ answer, or a response that says “Yes, the views of the target population were sought.  They were also considered.”  Such an answer, while technically two sentences, is simply parroting the question and gives the reader no additional information on how the objective was met.  

Submitting your Critical AppraisalSave your appraisal as a word doc, and label your  appraisal with your last name and its title:  Smith_CPGappraisal.  Upload to the assignment dropbox.

 

Rubric

CPG Critical Appraisal

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CPG Critical Appraisal

CriteriaRatingsPts

This criterion is linked to a Learning OutcomePICO Question

The PICO question at the top of the worksheet is complete and reflective of the Faculty-provided PICO question.

3pts

Full Marks

0pts

No Marks

3pts

This criterion is linked to a Learning OutcomeValidity

The 5 questions related to guideline validity are answered clearly and succinctly with evidence from the guideline. The student demonstrates graduate-level critical thinking in responses. Guideline page numbers are included where applicable.

7to >5.0pts

Full Marks

The student performs at a graduate student level giving significant demonstration of critical thinking, and understanding of concepts.

5to >3.0pts

Moderately Well Done

The student makes a few errors, or does not sufficiently demonstrate critical thinking, or understanding of concepts.

3to >0pts

Needs Attention to Concepts

7pts

This criterion is linked to a Learning OutcomeResults

The 3 questions related to the guideline results are answered clearly and succinctly with evidence from the guideline itself. The student demonstrates graduate-level critical thinking in responses. Guideline page numbers are included where applicable.

7to >5.0pts

Full Marks

The student performs at a graduate student level giving significant demonstration of critical thinking, and understanding of concepts.

5to >3.0pts

Moderately Well Done

The student makes a few errors, or does not sufficiently demonstrate critical thinking, or understanding of concepts.

3to >0pts

No Marks

7pts

This criterion is linked to a Learning OutcomeResults Application

The 3 questions related to the application of the results “Will the results help me in caring for my patient?” are answered clearly and succinctly with evidence from the guideline itself. The student demonstrates graduate-level critical thinking in responses. Guideline page numbers are included where applicable.

7to >5.0pts

Full Marks

The student performs at a graduate student level giving significant demonstration of critical thinking, and understanding of concepts.

5to >3.0pts

Moderately Well Done

The student makes a few errors, or does not sufficiently demonstrate critical thinking, or understanding of concepts.

3to >0pts

No Marks

7pts

This criterion is linked to a Learning OutcomeSpelling/ Grammar/ APA

The student demonstrates graduate level spelling, grammar, and APA formatting of citations within the answers. Page numbers ought to be included when direct quotes are provided. The CPG reference at the top of worksheet is in correct APA format.

3pts

Full Marks

No Errors in Spelling, Grammar, APA

0pts

No Marks

3pts

This criterion is linked to a Learning OutcomeOverall Appraisal

Overall Appraisal: In one succinct paragraph, give a narrative overall appraisal that includes a summary of the strengths and weaknesses of the guideline, as well as its use for the identified PICO question. Use APA format for citations and scholarly graduate level writing.

3to >2.0pts

Full Marks

The student wrote a succinct paragraph that hit the strengths and weaknesses, as well as the applicability for the identified PICO question.

2to >0pts

No Marks

The paragraph did not address the strengths and weaknesses sufficiently, or did not include the utility of the guideline for the identified PICO question.

3pts

Total Points:30

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VI

Clinical Scenario

Report Issue

 Respond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described.

In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.

Main Post

Clinical Scenario

The patient is a tall, lanky 67-year-old male with end-stage renal failure and cirrhosis of the liver.  He presents to the Emergency Department (ED) with an inguinal hernia that he cannot reduce.  He rates his pain 10/10 on a scale of 1-10, with 0 being no pain and 10 being extreme pain.  The patient appears uncomfortable, complains of dizziness, and constipation.  Social history consists of smoking a pack a day or cigarettes for 25 years, moderate alcohol consumption, daily marijuana use, poor diet, and decreased mood.  His medications are centered around pain control and include the use of narcotics every 4 hours.  The patient is given a dose of Toradol 30mg, intravenously (IV).  After ten minutes, the patient is asking for more pain medication.  Fentanyl 50 mcg, IV is given with no pain relief reported by the patient.  Finally, Hydromorphone 1mg, IV is administered.  After an hour, the patient still reports pain 10/10.

Pharmacokinetics and Pharmacodynamics

Pharmacokinetics studies the absorption, distribution, metabolism, and excretion of drugs within the body system (Ball, Dains, Flynn, Solomon, & Stewart, 2019).  The use of pharmacokinetics enables providers to determine the appropriate drug for a patient’s diagnosis.  Pharmacodynamics refers to how the body is affected by the use of certain medications (Fox, Hawney, & Kaye, 2011).  Due to the individualized nature of the human body, finding a drug that responds with minimal side effects are desired.Pharmacokinetics, as it relates to this patient’s pathophysiology, creates difficulty for the patient due to the diagnosis of kidney failure and cirrhosis.  Cirrhosis of the liver prevents the body from absorbing, distributing, and metabolizing the drug.  With significant disease process in effect, it is difficult for the body to absorb the drug at a rate that provides effective pain control.  The first-pass metabolism with hydromorphone is decreased in liver cirrhosis and has a likelihood of high hepatic extraction (Wehrer, 2015).  Whereas, fentanyl, is a protein-bound medication is reportedly unaffected by cirrhosis (Wehrer, 2015).  Though the patient tolerated the fentanyl in our case, no specific relief is found due to the chronic nature of the pain. Decreased kidney function reduces the excretion of drugs from the body creating an accumulation of medication in the entire body (Ball et al., 2019).  Frequent use of medications creates a tolerance to that medication and accelerates metabolism of the drug.  Tolerance and increased metabolism results in ineffective pain management outcomes (Ball et al., 2019).  The use of opioids for pain management, in this case, may create an antagonist effect causing unwanted consequences such as constipation, the potential for abuse, and withdrawal (Walter, Knothe, & Lotsch, 2016).  Due to the patient’s continued alcohol consumption and disease processes, the use of acetaminophen or ibuprofen is not encouraged (Wehrer, 2015).

Contributing Factors