The Hardest & Most Rewarding job

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By Rosabel Zohfeld, MSN-Ed, APRN, FNP-C

In my nearly 15 years in the medical field, I have done a little bit of everything; I have never found another job as hard as being a mother. I began to work in the healthcare field in 2007 as a medical receptionist, a stress tech (doing cardiac stress testing), a medical assistant (sort of), and an EMT (driving an ambulance) while going to school at night to finish my nursing degree. Finally, I graduated with a BSN in 2014; I continued to work in the same ER where I have done EMT and my nursing internship. I moved to Texas the following year, 2015, and continued to work in the emergency room; at the end of the same year, 2015, I delivered my first child. I remember how I thought I could take a sabbatical to stay home and care for my baby, but that lasted 10 days only. Somehow I found myself working as a nurse for hospice. My child was barely 6 months old, and once again, I had the need to spend more time with my child; I was working Monday-Sunday, having to do calls, and sometimes having to go in the middle of the night. So I looked for an M-F position in the post-operative department. I cross-trained in the post-anesthesia care unit and began to work in pre-op and post-op; I had to work some weekends as I traveled all over surgery centers and hospitals in the Austin, Texas, area. During that time, I finished my master of science in nursing as a clinical nurse educator. The year 2018 came, when I began my post-master degree as a family nurse practitioner. I continued to work as a PACU nurse and sometimes would work in the emergency room as needed.

May 2020 came in, and I graduated as an FNP, right in the middle of a world pandemic (COVID-19). My second child, born in January 2021, was a game-changer, for good, of course. Although, It was quite a challenge with added responsibilities as a mother of two and my husband being an active duty service member. Both of our families were/are far away, mine in South America and his in Chicago, Illinois. Oh, how can I forget those days when my first child was sick, and I couldn't find anyone to help me care for him while I went to work. One time I had no other choice than leave work. What else could I have done? I am a nurse, but first a mother. 

Being a nurse is easy compared to being a stay-at-home mom/wife and caring for two little ones, even if just one or four or five of them. The running around, the laundry, washing bottles, feeding... my point is, being a mother is a gratifying job that no money cant pay. In my particular case, things have changed, as my husband finally retired after 20 years in the U.S Army. I clearly said to him, "now it is my turn." It is my turn to focus on my nursing career while he helps me care for my children. Still, I am a mom, and I can't just go to work without caring for them. I still put both of the children to sleep after a long workday. I still take time whenever possible to be with them. Being a mother is a job that never ends, never sleeps. 

This is for all the mothers out there. You are not alone! Whether you work outside the home or just at home, all the mothers out there. Many of us get you. Make it a point to surround yourself with other mothers that understand your situation. Do not listen to the naysayers. Do not listen to those who may shame you. I have been there, and I have been criticized for working and not-working. I have decided that no matter what we do people will always talk, so for bad or good, follow your instinct and always do what is best for you as a person and your. Family! Because mother's day is every day!

On Nursing Burnout

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by Rosabel Zohfeld, APRN, MSN-Ed, FNP-C

Burnout is characterized by exhaustion, depersonalization (cynicism), and reduced personal accomplishment. In general nursing, burnout contributes to nurses leaving their positions. Nurses may become exhausted doing their best to care for patients. They may express cynicism through negative behaviors, poor communication with others, and incivility toward co-workers. There is a lack of motivation,  decreased personal job-related self-esteem, reduced personal accomplishment, and a lack of job- satisfaction with high-stress levels.

We could all agree that nurses are human beings with identical physiological needs to their patients. We must eat, and evacuate our bowels and bladders, we need rest. We can get sick as anyone else. 

Although we have a moral and ethical responsibility to our patients, especially on hospital floors I think there must be times where we can have at least a 30-minute uninterrupted lunch, dinner, or breakfast whichever may be the case according to the working schedule. Management must work with us to make sure that there is enough personnel to relieve nurses as needed. If we continue to treat our nurses as the heroes without capes that are made of steel we are going on the wrong path. In my nursing career, I have always and continue to advocate for a safe working environment for all, patients and workers regardless of their job description. I know we as nurses want to prove to the world how strong we are, and don’t get me wrong we are, but above all, we are humans who can get as sick or worse than our patients if we do not take care of ourselves. Working 12 hr. Shifts on our feet, with little to no breaks, on top of the emotional burdens of taking care of very Ill patients, can be exhausting, and stressful. It leads to cynicism, an unsafe work environment, and negative vibes, with a huge impact on the care of patients. A decline in job satisfaction. It is a cycle that is not fair to the employee nurse, the patients, and even the employer. 

So what to do? 

It is easier said than done. 

Employers must make sure to prioritize efficient staff, to empower and train nurses in recognizing burnout and how to address it from the beginning. Make sure that nurses are part of the conversation and place a support program in place. Nurses, be aware of the situations that cause/trigger stress and try to minimize it. Practice self-care, make sure you are getting adequate sleep, healthy nutrition, exercise, make sure you are staying hydrated at all times, develop self-copying mechanisms, and set healthy boundaries for yourself and others. Build a support system, do not be afraid to ask for help if you need it. Try your best at having a work-life balance. Do not deny or hide your feelings, it does not help in the long run. Have faith and believe in yourself.

Together we can combat nurse burnout. Be part of the conversation. It's okay to talk about it, get it out of your chest. Prioritize your mental health. Remember, you are human and have physical, emotional, and physiological needs. So do not neglect yourself. After all, if you don’t help yourself how can you help others?

What is Complicated Grief

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By Rosabel Zohfeld, MSN-Ed, APRN, FNP-C

Complicated grief can be described as chronic, complex, pathological, persistent, prolonged, unresolved, and traumatic grief.  Complicated grief is a form of acute grief that can be disabling with troubling thoughts, dysfunctional behaviors, and emotions as well as in the adaptation to the loss.

The prevalence is approximately about 7% in the general population. This prevalence varies depending on the close relationship that the individual had with the deceased or lost individual, as well as the culture and setting where it occurs. The loss of a spouse is estimated to have a 10 to 20% rate of complication. The loss of a child can be as high as 60% more complicated in parents who reside in western countries. Suicide, homicide, and disaster-related generally report complicated grief that ranges from 20% to 40% of the cases.

What are the risk factors?

• Being older than 61 yrs. of age

• Female

• Low socioeconomic status

• Prior psychiatric history

• Unexpected or violent death of a loved one

• Death of a child, spouse, or young person

• Non-Caucasians

Pathogenesis:

The pathogenesis of complicated grief is not known. However, preliminary studies suggest that the neurobiology of complicated grief may differ from that of typical acute grief. Several psychological models of complicated grief have been proposed including a model based upon the loss of an attachment relationship 

Signs and symptoms 

• Prolonged acute grief lasting at least 6 to 12 months after the loss
• preoccupation with the deceased, and feelings of sorrow, emotional pain, frustration, anxiety, and guilt
• Loss of interest in ongoing life, difficulty envisioning a meaningful life without the deceased, and feeling estranged from others
• Inadequate regulation of emotions
• Excessively avoiding reminders of the loss
• Disbelief and difficulty accepting the death; feeling stunned, dazed, lost, unfocused, or emotionally numb; and intrusive thoughts or images of the death
• Maladaptive rumination about the circumstances or consequences of the death such as guilt and self-blame regarding the deceased or the death 
• intense emotional and/or physiologic reactions such as increased somatic symptoms and/or insomnia 
• Dysfunctional behaviors that are characterized by -Excessively seeking proximity to the deceased through objects like pictures, keepsakes, clothing, or places associated with the loved one
• Impaired functioning, difficulty trusting or caring for others, impaired concentration, or interference with performing daily activities

Unfortunately, suicidal ideation and behavior occur in approximately 40% to 60% of individuals with complicated grief. Patients with complicated grief may attempt suicide to find the person who died. The primary deterrents to suicide include family members.

Complicated grief is often accompanied by comorbid psychopathology such as 

•Unipolar major depression 

●PTSD 

●Anxiety disorders 

•Generalized anxiety disorder 

•Panic disorder – 10 to 20 percent

Complicated grief is associated with adverse consequences that may include 

●Increased use of alcohol and tobacco

●Poor quality of life

●General medical illnesses

●Increased mortality due to general medical conditions and suicide

Diagnosis:

A trained mental health provider may use the following criteria to diagnose an individual with complicated grief:

The patient is experiencing the death of a loved one for at least six months or more

At least one of the following symptoms has been present:

• Persistent, intense yearning or longing for the person who died

• Frequent preoccupying thoughts about the deceased

• Frequent intense feelings of loneliness or that life is empty or meaningless without the person who died

• Recurrent thoughts that it is unfair or unbearable to live without the deceased, or a recurrent urge to find or join the deceased

• Frequent troubling rumination about the circumstances or consequences of the death

• Recurrent disbelief or inability to accept the death

• Anger or bitterness about the death

• Persistently feelings of shock, stun, or numbness since the death

• Marked change in behavior such as avoiding people, places, or situations that remind one of the loss

• Intense emotional or physiologic reactions 

• Wanting to see, touch, hear or smell things to feel close to the person who died

Evaluation

The initial evaluation for patients with a possible diagnosis of complicated grief includes:

• a psychiatric history

• mental status examination

• general medical history, physical examination

• focused laboratory tests. 

All patients with complicated grief must be queried specifically about suicidal ideation and behavior.

Where Can you find help?

If you or a loved one is experiencing signs and symptoms of complicated grief, there is help available. A trained mental health professional can help you or your loved one with the diagnosis and treatment and can refer you to other professionals as well as provide you with the necessary resources to help you overcome complicated grief.

Sources:

https://www.uptodate.com/contents/complicated-grief-in-adults-epidemiology-clinical-features-assessment-and-diagnosis?search=complicated%20grief&source=search_result&selectedTitle=1~30&usage_type=default&display_rank=1#H4668475

Understanding the Epidemic of Obesity: Causes, Effects, and Solutions

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By Rosabel Zohfelf, MSN-Ed, APRN, FNP-C

Obesity is a global health challenge that has reached epidemic proportions, affecting millions worldwide. Obesity is characterized by excessive body fat accumulation, posing significant health risks and socioeconomic burdens. Understanding the causes, effects, and potential solutions for obesity is crucial in developing effective strategies to combat this widespread issue.

According to the Centers for Disease Control and Prevention (CDC), the latest update (2023) on the prevalence of obesity in the U.S. obesity affects 100.1 million (41.9%) adults and 14.7 million (19.7%) children. This accounts for approximately $147 billion in annual healthcare costs.

Pathophysiology

         The pathophysiology of obesity is complex. It involves the interaction of numerous hormones, cytokines, and neurotransmitters. The mechanisms contributing to the imbalance of energy intake and expenditure have yet to be understood entirely. The adipocyte, a fat cell, is the cellular basis of obesity. Adipocytes secrete hormones and cytokines known as adipokines. Adipokines play a role in the regulation of food intake, lipid storage, metabolism, and insulin sensitivity. Also, they regulate the alternative complement system, blood pressure, angiogenesis, vascular homeostasis, inflammatory and immune responses, female reproduction, and energy metabolism. The accumulation of visceral fat causes dysfunction of adipocytes. It also results in alterations in the regulation and interaction of hormones. These alterations, together with low-grade inflammation, contribute to the causes and complications of obesity. Cardiovascular disease and type 2 diabetes mellitus are among the complications of obesity Symptoms. 

         Obesity has no specific symptoms. The main signs of overweight and obesity are a high body mass index (BMI) and an unhealthy body fat distribution. Obesity can cause complications such as metabolic syndrome, type 2 diabetes, high blood cholesterol, high triglycerides, heart disease, high blood pressure, atherosclerosis, heart attacks, stroke, obstructive sleep apnea, obesity hypoventilation syndrome, back pain, osteoarthritis, non-alcoholic fatty liver disease, urinary incontinence, gallbladder disease, emotional distress, depression and increased risk for certain cancers such as cancer of the esophagus, colon, rectum, pancreas, kidney, ovaries, endometrium, gallbladder, breast and or liver (NIH, 2018).

The American Heart Association (AHA) recommends that all obese patients participate in a medically supervised weight loss program. It is recommended for two or three times a month for at least six months. The treatment plan for weight loss involves:

• Eating fewer calories than the body needs.
• Exercising for 30 minutes at least five days a week.
• Changing unhealthy behaviors.

Obesity can raise blood cholesterol and triglyceride levels, increase blood pressure, and induce diabetes. In some people, diabetes makes other risk factors much worse. Obese people are at higher risk for heart attack, heart disease, and stroke. Obesity is also a major cause of osteoarthritis, gallstones, and respiratory problems. 

There are two types of obesity: visceral obesity and Peripheral obesity. Visceral obesity occurs when body fat distribution is localized around the abdomen and upper body, resulting in an apple shape. Visceral obesity is associated with metabolic syndrome (hypertriglyceridemia, hypertension reduced high-density lipoprotein, increased low-density lipoproteins, hypertension, and insulin resistance), accelerated lipolysis, and has an increased risk for inflammation, type 2 diabetes mellitus, cardiovascular complications, and cancer. Peripheral obesity occurs when body fat distribution is extraperitoneal and is distributed around the thighs, buttocks, and through muscle, resulting in a pear shape. This second one is more common in women. 

Causes of Obesity include:

1. Poor Diet: High consumption of processed foods, sugary beverages, and calorie-dense meals contributes to obesity. These foods often lack essential nutrients and are high in sugars, unhealthy fats, and empty calories.

2. Lack of Physical Activity: A sedentary lifestyle, devoid of regular physical exercise or activity, plays a significant role in the development of obesity. Modern advancements have reduced physical activity levels, exacerbating the problem.

3. Genetic and Environmental Factors: Genetic predisposition can influence an individual's susceptibility to obesity. Additionally, environmental factors such as socioeconomic status, cultural norms, and neighborhood characteristics can impact dietary habits and activity levels.

4. Psychological Factors: Emotional and psychological issues like stress, depression, and anxiety can lead to unhealthy eating habits and overeating, contributing to obesity.

Effects of Obesity:

1. Health Complications: Obesity increases the risk of numerous health issues, including diabetes, heart disease, stroke, high blood pressure, certain cancers, osteoarthritis, and respiratory problems.

2. Mental Health Challenges: Obesity can adversely affect mental health, leading to depression, anxiety, low self-esteem, and body image issues.

3. Reduced Quality of Life: Obese individuals often face reduced mobility, fatigue, and limitations in daily activities, impacting their overall quality of life.

4. Economic Impact: The economic burden of obesity is substantial, encompassing healthcare costs, lost productivity, and reduced work efficiency due to illness and disability.

Solutions to Combat Obesity:

1. Promoting Healthy Eating: Encouraging a balanced/healthy diet rich in fruits, vegetables, whole grains, and lean proteins while reducing the intake of sugary and processed foods can play a pivotal role in obesity prevention.

2. Encouraging Physical Activity: Creating environments that promote physical activity, such as accessible parks, safe cycling paths, and active transportation options, can encourage regular exercise and mitigate obesity risks.

3. Education and Awareness: Raising awareness about the importance of a healthy lifestyle, nutrition, and physical activity through educational programs can empower individuals to make informed choices regarding their health.

4. Policy Interventions: Implementing policies that promote healthier food options, regulate the marketing of unhealthy products, and incentivize physical activity can significantly reduce obesity rates.

Obesity is a multifaceted issue with far-reaching consequences on public health and well-being. Addressing this epidemic requires a comprehensive approach involving individuals, communities, healthcare systems, and policymakers. By fostering a culture of healthy living, improving access to nutritious foods, and encouraging regular physical activity, we can work towards a healthier future for future generations. 

*This article was updated on 10/12/2023.

Live, Work and Learn!

For the first time, I didn’t follow my gut feelings. This time I thought I could just keep going and prove (to whom???) that I could do it. I knew it, deep inside me. I was being set up for failure from the beginning, with poor training, poor communication, no feedback, lots of passive-aggressive behavior towards me, and worse yet, the harassment and mistreatment from my coworker. This all proved my theory that it is better to leave early and not wait for things to get better on their own when one knows they are already damaged. 3 weeks into the job, I knew that I couldn’t continue to work there, but I kept giving my best…

Since then,  I have learned that it is best to speak sooner. I thought I could make it work; I didn't want to quit. I began to regret leaving my previous job, one where I felt valued and appreciated for one that seemed too good to be true, with apparent better work-life balance, schedule, and pay. Only to find out that it wasn't the case. I never felt so miserable, but instead, I wanted to keep trying... I should have just said, "This isn't for me." I wanted to fix it (wrong)... until one day, out of the blue, without even a warning, I heard from the never-present manager that we weren't compatible. I couldn't even defend my actions; I wasn't given a chance to say what went on. The company didn't care what I had to say, so I knew I was wasting my whole being. Enough said; it was time to go. Luckily, it wasn't for too long; now I stand taller, I no longer have to be in a toxic working environment, and better yet, I know what to ask my future employer, and I know that I deserve better!

Now I have a list of questions for my future employer. I want to make sure I don’t make the same mistake. 

In the meantime, I do not want to get discouraged, but the reality is we are living in unprecedented times. Health care work is not what most people think; we providers, especially nurses, face several challenges. Nevertheless, the best course of action is to move forward, even if that means doing something totally different. 

 

The Power of Journaling

 

Sometime in the early 2000s, a good friend mentioned that I always had a notebook with me ever since he knew me. He wasn't wrong; the truth is, it came so naturally that it wasn't until later in life that I discovered what a fantastic way to cope with life, in general, was journaling. Let me begin by telling you a bit about me. I was born in 1982 in Colombia, South America, the only child of two educators. In all honesty, all I saw at my home was my father and my mother devouring books. I began to love reading and writing at age 5, as I can remember. Also then, I dreamed of becoming a medical doctor. Time went by; my mother passed away when I was 17. I had nothing to lose after all. The most precious person in my life was gone. I said yes to the opportunity to come to the U.S. 18 years later; I am a family nurse practitioner, married with two children, and still dreaming.

In the meantime, journaling has been the most unique and powerful tool. Through the years for me, through the good times and not so good. I have memories of working in an emergency room, perhaps at one of the worse shifts, 3 pm to 3 am. It wasn't always slow; it was pretty busy. So I didn't have a notebook; I would just grab a piece of blank paper and write it down. Whatever emotions I was going through at the time—what a saving tool. 

I have discovered that journaling has helped me with my goals, cope with emotions, and even allow me to revisit the past to learn from it. I believe that during the COVID-19 pandemic, many have turned to different ways to cope and overcome. I love journaling because one can be as creative and fun. Sometimes I do what I call brainstorming, write down any thought that comes to mind; sometimes, I write prayers or even thank you notes to myself or my loved ones. While journaling, I can reflect on my daily emotions, tasks, accomplishments, and even plan. There are no limits when journaling. 

So are you journaling?

Attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a neuropsychiatric condition.  It affects children, adolescents, and adults worldwide.  Patterns of diminished attention and increased hyperactivity or impulsivity are characteristics of ADHD. Often there is significant impairment in academics, social, and interpersonal situations. ADHD is associated with other comorbid disorders such as learning disabilities, anxiety, mood, and disruptive behavior disorders.

Risk factors

• Genetics

• Family history

• Neurochemical factors

• Neurophysiological factors

• Developmental factors

• Psychological factors

ADHD affects up to 5 to 8% of school-age children; 60-85% of those diagnosed in childhood continue to be symptomatic during adulthood. Previously there were two subtypes of ADHD. Inattentive and Hyperactive/impulsive type. Currently, these subtypes by three specifiers:

1. Combined presentation

2. Predominantly inattentive presentation

3. Predominantly hyperactive/impulsive presentation

Clinical Manifestations:

ADHD is characterized mainly in adults by inattention, impulsiveness, restlessness, executive dysfunction, and emotional dysregulation. These symptoms together lead to marked deficits in normal daily functioning. The predominant features of ADHD in adults differ from typical ADHD features in children. Inattention symptoms are more prominent in adults, while signs of hyperactivity or impulsivity are less noticeable.

Hyperactivity symptoms

• Restlessness

• Verbosity

• Constant activity, fidgeting 

• A tendency to choose very active jobs

Impulsivity symptoms 

• Ending relationships abruptly and often

• Quitting jobs

• Overreacting to frustrations

• More driving violations

Inattention symptoms

• Procrastination

• Difficulty making decisions

• Poor time management 

• Difficulty in organizing activities, prioritizing tasks, following through, and completing tasks

• Forgetfulness

How is ADHD diagnosed?

ADHD is usually diagnosed during childhood or late adolescence. The individual presents a persistent inattention or hyperactivity-impulsivity pattern that interferes with normal function and development. It requires continuous impairing of inattentiveness or hyperactivity in at least two different settings. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) gives diagnosis criteria to children and adults with ADHD. The DSM-5 requires that at least six inattentive or hyperactive-impulsive symptoms be present before age 12 to diagnose ADHD. 

To diagnose ADHD in adults and adolescents 17 years or older only five signs are needed for diagnosis. Symptoms might be different at older ages. Fidgetiness and verbal impulsivity, respectively, and extreme restlessness or wearing others out with their activity are signs in adults diagnosed with ADHD.

ADHD can be diagnosed by trained professionals such as psychiatrists, pediatricians, and nurse practitioners.

Course and prognosis:

The course of ADHD can be variable; overactivity is often the first symptom to remit, while inattention and distractibility are the last. Remission usually occurs between ages 12-and 20 years of age. Unfortunately, most patients with ADHD undergo partial remission while being vulnerable to mood, antisocial, and drug abuse behaviors. Approximately 60% of all cases persist into adulthood, while learning difficulties continue through life. Monitoring the pharmacological treatment for patients with ADHD is an essential part of the drug response and patient compliance. The goal is to reduce symptoms of ADHD and improve quality of life.

Treatment:

Pharmacologic treatment is considered the first-line treatment for ADHD. Long-acting stimulants are FDA approved for the adult treatment of ADHD. Stimulants are contraindicated in children, adolescents, and adults with known cardiac abnormalities and risks. The FDA approves some non-stimulant medications for the treatment of ADHD. Some antidepressants can be used in children older than six years, with variable success in treating ADHD.

Psychopharmacologic therapy may be needed indefinitely or for life. 

Although ADHD is a psychological condition, it is not a disability. Individuals with ADHD can find help and solutions to overcome any difficulties they may face. Cognitive Behavioral Therapy (CBT) can also help. A trained specialist can guide you or your loved one in managing stress, eating right, getting enough rest, and getting the proper medication to help overcome the symptoms of ADHD. To find out more about treatment options for ADHD, talk to your doctor or healthcare professional.

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.

Sadock, B. J., & Sadock, V. A. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolter Kluwer/Lippincott Williams & Wilkins.

https://www.psychiatry.org/psychiatrists/practice/dsm

https://www.cdc.gov/ncbddd/adhd/diagnosis.html

https://www.uptodate.com/contents/approach-to-treating-attention-deficit-hyperactivity-disorder-in-adults?search=adhd%20treatment&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

Case Study: Hyperlipidemia

 

Case Summary

 

Chief Complaint

“I need refills.”

History and Physical

Mrs. JT s is a 56-year-old woman who presents to the pharmacotherapy clinic for intake. She has recently moved to your area and has not seen her primary care provider for the last 11 months. Her prescriptions have expired, and she is coming to you for “refills.”

Past Medical History

·      Obesity (BMI 31.5 kg/m²)

·      Dyslipidemia × 4 years

·      HTN × 15 years

·      Postmenopausal—has not had GYN screening since the onset of menopause (14 years ago)

Family History

·      Father: age 74 with extensive cardiovascular history, most notably first MI at 42.

·      Mother: died at age 61 from MVA, medical history unknown.

·      Patient has one older sister with hypertension and a history of “mini-strokes” and only one younger sister with hypertension.

·      Her children’s medical conditions are noncontributory.

Social History

·      Patient is married with three children who live out of state.

·      College graduate, works as a librarian.

·      Denies current alcohol and tobacco use but does admit to occasional marijuana use when she is visiting her children.

·      Began sporadic exercise regimen when diagnosed with dyslipidemia. Medications (Per Patient History; She Did Not Bring Records)

·      Metoprolol tartrate 50 mg po BID

·      Ezetimibe 10 mg po once daily

·      Aspirin 81 mg PO once daily

·      Ibuprofen 200 mg, four tablets po PRN leg cramps

·      Naproxen 220 mg, two tablets po PRN leg cramps

·      Garlic capsules

Allergies

“Statin” drugs—states she had occasional leg cramps after starting atorvastatin.

Review of Systems

The patient states that she just needs refills. She is argumentative about getting labs done and cannot understand why you would not just refill her medications. She denies any acute changes in health. She denies unilateral weakness, numbness/tingling, or vision changes. She denies CP and only has SOB when she walks in the park. With further questioning, you find that she rarely exercises, but when she does go for a walk, she typically overdoes it. She denies bowel or urinary habits changes and states she does not need to have GYN follow-ups anymore because she has gone through “the change.” She denies any lower extremity edema.

Physical Examination

·      Gen

·      Obese, somewhat agitated Caucasian woman

·      VS

·      BP 162/92, P 89, RR 18, T 37.2°C; Wt. 94 kg, Ht. 5′8″

·      Skin

·      Warm and dry to touch, normal turgor, (–) for acanthosis nigricans

·      HEENT

·      PERRLA; EOMI; funduscopic exam deferred; TMs intact; oral mucosa clear

·      Neck/Lymph Nodes

·      Neck supple, no lymphadenopathy, thyroid smooth and firm without nodules

·      Chest

·      CTA bilaterally, no wheezes, crackles, or rhonchi

·      Breasts

·      Normal, slightly fibrotic, no lumps or discharge

·      CV

·      RRR, no MRG, regular S₁, and S₂; no S₃ or S₄

·      Abd

·      (+) BS, no hepatosplenomegaly

·      Genit/Rect

·      Deferred

·      Ext

·      No pedal edema pulses 2+ throughout

·      Neuro

·      No gross motor–sensory deficits present

Labs (Fasting)

·       Na 142 mEq/L

·       K 4.9 mEq/L

·       Cl 103 mEq/L

·       CO2 23 mEq/L

·       BUN 16 mg/dL

·       SCr 0.9 mg/dL

·       Glucose 105 mg/dL

·       Hgb 11.6 mg/dL

·       Hct 34%

·       Ca 8.2 mg/dL

·       Mg 2.0 mg/dL

·       AST 28 units/L

·       ALT 31 units/L

·       T. bili 0.5 mg/dL

·       T. prot 7.1 g/dL

Fasting lipid profile:   ·       TC 240 mg/dL

·       HDL 41 mg/dL

·       LDL 163 mg/dL

·       TG 183 mg/dL

·       hsCRP 4.6 mg/L

Assessment

Mrs. Thorngrass is an obese Caucasian woman who presents to the pharmacotherapy clinic for intake. She has a significant family history of cardiovascular disease. She has uncontrolled hypertension, treated with metoprolol tartrate and dyslipidemia treated only with ezetimibe and garlic. She reports an allergy to atorvastatin but admits that her leg cramps have not improved since discontinuing the drug and coincide with her rare bouts of exercise. She reports liberal use of ibuprofen and naproxen to relieve the cramps. She also has previously undiagnosed anemia.

CASE SUMMARY TABLE:

Symptoms	·       Leg cramps ·       Hyperlipidemia
Recommended Drugs	1.     Lovastatin (Burchum & Rosenthal, 2018.p. 578). 2.     Colesevelam (Burchum & Rosenthal, 2018.p. 578). 3.     Ezetimibe (Pignone, 2018).
Drug Categories & Subcategories	4.     Lovastatin: HMG-CoA Reductase Inhibitors [Statins] (Burchum & Rosenthal, 2018.p. 578). 5.     Colesevelam: Bile-Acid Sequestrants (Burchum & Rosenthal, 2018.p. 578). 6.     Ezetimibe: cholesterol absorption inhibitors (Vallerand, Sanoski & Deglin, 2017. p. 540).
Drug of Choice	·      Ezetimibe (Zetia)
Rationale	Ezetimibe (Zetia): The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline on the treatment of cholesterol recommends that adults with an LDL-C level greater or equal than 190 mg/dl be treated with high-intensity statin therapy or non-statin drugs to help reduce the LDL-C levels. Ezetimibe is the drug of choice for this patient since she has a known allergic reaction to statins. When statins are not possible, treatment with ezetimibe is an option. (Pignone, 2018).
Contraindications and Risks	·       Ezetimibe is contraindicated in hypersensitivity; Acute liver disease with moderate or severe hepatic impairment; concurrent use of fibrates. It may cause fetal harm in pregnancy by interfering with cholesterol synthesis. There is potential for adverse effects in nursing infants. Use with caution in children; safety has not been established in children > 10 years of age (Vallerand et al., 2017. p. 540).
Family Teaching	It is recommended that all patients with high cholesterol levels (hyperlipidemia) undergo lifestyle modifications such as weight loss, a diet with low saturated fats, and aerobic exercise. Compliance with the pharmacologic treatment is essential to reduce the risks of cardiovascular disease, stroke, and or heart attack (Pignone, 2018).

 

 

Prescription Pad

Rosabel V. Zohfeld

9999 Mozart Street

Round Rock, TX. 786999

Ph. 512-599-9999 fax: 877-579-9999

 

DEA # RZ123456

NPI #1122334455

License # 99999

 

Patient’s Name:  J. K                                                                         DOB April 30, 1956

Address: 123 South West Rd, Austin TX, 79999.                             Date. June 30, 2018.    F

Allergies: Statins                                                                                Weight: 94 kg

 

Rx:   1. Ezetimibe (Zetia) 10 (ten) mg tablets. Take 1 (one) tablet once daily for high cholesterol. It may be taken with or without meals.

Dispense: # 30 (thirty) tablets with #3 (three) refills before September 30, 2018.

Void after 30 days.

 

Substitution Permitted_______________ Dispense as written_____X_______

 

 

Signature: 

 

 

 

 

Hyperlipidemia

 

Population:

According to the CDC, approximately 33.5% of 71 million adult Americans have high cholesterol. Only 1 out of every 3 adults with hyperlipidemia has the condition under control (CDC, 2015). While not addressed in the 2013 ACC/AHA blood cholesterol guidelines, elevated cholesterol in pediatric patients is a growing concern. Nonetheless, it is addressed in other guidelines (Burchum & Rosenthal, 2018.p. 571).

Pathophysiology

Hyperlipidemia is defined as having too much cholesterol in the blood. An increase in the levels of lipoproteins in the blood results in deposits of fat in the heart, liver, and muscle (McCance, Grey, & Roadway, 2014.p.75). In general, cholesterol has no energy value; however, it serves as the component of the outer membrane of cells and is part of vitamin D, digestive bile, and several sex hormones. While cholesterol comes from animal food sources, our body can also make a certain amount of cholesterol. Too much cholesterol (in excess) in our blood can negatively affect the arteries by adhering to the walls of the arteries as fatty plaque. Arteries then can become clogged and disrupt the normal flow of blood. High cholesterol increases the risk for cardiovascular disease and stroke. A family history of high cholesterol is also a genetic predisposition for high.  Lipids in the blood (UCDavis, 2018).

 

 

Drug: Ezetimibe (Zetia).

 

Drug Class	Cholesterol Absorption Inhibitors (Vallerand et al., 2017.p. 540).
Subclass	Lipid-lowering agents (Vallerand et al., 2017.p. 540).
Indications	Ezetimibe is indicated for managing dyslipidemias, primary cholesterolemia, familial hypercholesterolemia, and sitosterolemia (Vallerand et al., 2017.p. 540).
Mechanisms of Action	Ezetimibe inhibits cholesterol absorption in the small intestine (Vallerand et al., 2017.p. 540).
Pharmacodynamics	When taken orally, Ezetimibe has an unknown onset, peak, and duration (Vallerand et al., 2017.p. 540).
Pharmacokinetics	Ezetimibe is rapidly converted to ezetimibe-glucuronide (active) following oral administration. Its bioavailability is variable. Ezetimibe’s distribution is unknown. Its metabolism and excretion undergo enterohepatic recycling. It is primarily eliminated in feces with minimal renal excretion. Ezetimibe has a half-life of 22 hours (Vallerand et al., 2017.p. 540).

 

Generic Name	Ezetimibe (Vallerand et al., 2017.p. 540).
Brand Name	Zetia, Ezetrol (Vallerand et al., 2017.p. 540).
Dose	10 mg by mouth once daily (Vallerand et al., 2017.p. 540).
Indications	Hypercholesterolemia (Burchum & Rosenthal, 2018.p. 585).
Instructions	Take one 10 mg tablet once daily with or without food (Burchum & Rosenthal, 2018.p. 585).
Side/Adverse effects	·       Some of the side/ adverse effects of Ezetimibe are cholecystitis, cholelithiasis, increased liver enzymes (in conjunction with HMG-CoA reductase inhibitors), nausea, pancreatitis, rash, and angioedema (Vallerand et al., 2017. p. 540).
Outcomes	Treatment with Ezetimibe aims to decrease serum LDL and total cholesterol levels (Vallerand et al., 2017.p. 541).
Counseling: What the patient Needs to know	Hyperlipidemia: High cholesterol can increase the risk of developing heart disease, heart attack, and stroke significantly. There are treatment options available. High cholesterol levels can be lowered with a healthy diet low in saturated fats, weight loss, exercise, and medications. The risk of developing cardiovascular decreases as the cholesterol levels decreases. A lipid-lowering treatment can be lifesaving. (Rosenson, 2018).  You need to know that untreated high cholesterol can lead to plaque buildup in the blood vessels (atherosclerosis). This increase in plaque buildup increases your heart attack, stroke, and peripheral artery disease risks. The treatment of high cholesterol is a lifelong process. It takes approximately 6 to 12 months for the effects of medication and lifestyle modifications to notice results. You must follow your treatment as prescribed and continue with necessary follow-ups with your primary care provider.  It is essential to be compliant with your treatment. Always consult with the health care provider if your medication is not working for you before making any changes or taking any over-the-counter supplements. Unfortunately, garlic supplements have not been proven effective in lowering cholesterol levels (Rosenson, 2018). Ezetimibe: Take ezetimibe as directed. Take it at the same time each day, even when feeling well. If a dose is missed, take the dose as soon as you remember. Do not take more than one (1) dose per day. This medication helps control but does not cure elevated serum cholesterol levels. Ezetimibe should be used in conjunction with diet restrictions, exercise, and smoking cessation. Ezetimibe is not indicated for weight loss. Notify the health care professional if unexplained muscle pain, tenderness, or weakness occurs. The risk may increase when used with HMG-CoA reductase inhibitors. Notify health care professionals of all prescriptions and or over-the-counter medications such as vitamins or herbal products. It is essential to follow up to determine the effectiveness and monitor side effects (Vallerand et al., 2017.p. 541). Ibuprofen & Naproxen: these two drugs belong to the non-steroidal anti-inflammatory drugs (NSAIDS). They should only be used briefly. Liberal use is not recommended. Only a low dose in older adults is recommended due to the risk for gastrointestinal and cardiovascular disease (Galicia-Castillo & Weiner, 2017).  It is recommended to get back on the treatment for high cholesterol with Ezetimibe. Follow up in a month to see if there has been improvement with the leg cramps. Minimize the use of Ibuprofen and Naproxen. If leg cramps do not get, better further testing is recommended before adding another pharmacologic treatment (Rosenson, 2018).

 

References:

 

Centers for Disease Control and Prevention, CDC. (2015). Division for Heart Disease and Stroke Prevention; Cholesterol Fact Sheet. Retrieved June 29, 2018, from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm

Burchum, J. R., & Rosenthal, L. D. (2018). Lehne's pharmacology for nursing care (10th ed.). St. Louis, MO: Elsevier/Saunders.

Galicia-Castillo, C. M., & Weiner, D. K. (2017). Treatment of Persistent Pain in Older Adults. In M. Crowley. (Ed.). UpToDate. Retrieved from https://www.uptodate.com/contents/treatment-of-persistent-pain-in-older-adults?csi=92c10aa9-4c4f-429e-82e4-218c482f5e31&source=contentShare

McCance, K. L., Grey T. C., & Rodway, G. (2014). Altered Cellular and Tissue Biology. In K.L. McCance & S. E. Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and children (p.75). St. Louis, MO: Mosby Elsevier.

Pignone, M. (2018). Management of elevated low-density lipoprotein-cholesterol (LDL-C) in primary prevention of cardiovascular disease. In G.M. Saperia (Ed). UpToDate. Retrieved from 

https://www.uptodate.com/contents/management-of-elevated-low-density-lipoprotein-cholesterol-ldl-c-in-primary-prevention-of-cardiovascular-disease?csi=7120eab6-27a2-4cfe-bf9a-70d3daf57a91&source=contentShare

Rosenson, S. R. (2018). Patient Education: High Cholesterol Treatment Options (Beyond the Basics). In G. M. Saperia (Ed.). UpToDate. Retrieved from https://www.uptodate.com/contents/high-cholesterol-treatment-options-beyond-the-basics?csi=0d03a5f0-5e24-4f42-8ef7-4a415d7e500d&source=contentShare

UCDavis. (2018). Hyperlipidemia: Overview of Hyperlipidemia (High Blood Cholesterol). Retrieved from https://shcs.ucdavis.edu/topics/hyperlipidemia

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia: F.A. Davis Company.