L.N. is a 49-year-old white woman with a history of type 2 diabetes, obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side, with her weight fluctuating between 165 and 185 lb.

Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A1c of 7.4%.

Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.

One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm.

Questions

1. What are the effects of controlling BP in people with diabetes?
2. What is the target BP for patients with diabetes and hypertension?
3. Which antihypertensive agents are recommended for patients with diabetes?

Select three bills of interest to you. Track the progress of one on the Internet and Do a brief legislative analysis of one of the bills. Document results in journal form. Include contact with your representative in the Illinois General Assembly. 

3.Discuss analysis of bill in class

4. Legislative analysis:

• written clearly, succinctly, using correct grammar, punctuation, sentence structure 

•organized

•includes a summary of the highlights of the bill.

•includes your thoughtful and critical analysis on the content of the bill

The purpose of this assignment is to give you an idea of how challenging it is when health care is a scarce resource. There will never be enough money for everyone to have every health care service they may need or want. Who makes these decisions? Perhaps a government agency, perhaps an insurance company. It is easy to blame a nameless, faceless business for denying care. But what if it was you? What if you worked in that field and the burden to allocate too few resources to too many needy patients sat on your shoulders? Might you have a completely different perspective? How do payors determine what to cover? The answer is simple and complex at the same time. Payers generally do not cover anything experimental. They have clear policies for what specific plans cover. They often require preauthorization to ensure that the test/procedure is truly necessary and that it is supported by best practice showing improved quality outcomes.

In this case you are not working for an insurance company. You are a senior executive in a hospital. The hospital sets aside charity care monies each year to assist needy patients. There are always more needy patients than there are funds. When the funds are gone, they are gone. This year, you are tasked with distribution of the money.

None of the patients have insurance or any significant funds. You have 1 million dollars. It cannot be used for more than one patient.

The patients are as follows:

1.  Patient A is a 70 y/o retired business executive who needs a $500,000 heart transplant and $500,000 in post care surgery (i.e. medications, rehab, follow- ups, etc.)

2.  Patient B is a toddler with cerebral palsy (affect a person’s ability to move and maintain balance and posture) who needs $500,000 for ongoing care. With expert care the expected lifespan is teenage.

3.  Patient C is a 32 year old mother of 2 who needs a $750,000 bone marrow transplant and $500,000 in post care surgery (i.e. medications, rehab, follow- ups, etc.).

4.  Patient D is a 38 y/o athlete who needs a hepatitis C drug that costs $30,000/ month. The patient could live a normal life span as long as the drug is provided.

5.  Patient E is a micro-premature baby who is costing $10,000 day with a 20% chance of survival. The hospital stay is expected to be 12 months minimum, not including any needed surgical procedures, and not including likely life-long health care needs if he survives.

Determine the distribution of health care funds

Include the following aspects in the assignment:

Ø  Which patient should receive the funding and why?

Ø  If the funds were available to be shared among the patients, would you have chosen differently?

Ø  How did you feel having to make a choice?

Ø  Discuss if this exercise has changed your view of the challenges behind paying for health care

NR 701 Week 3 Questions

· What are the potential benefits and harms related to your selected practice problem when considering a research-based intervention for your practice change project?

· Are there competing personal or professional values related to this research-based intervention that might impact the implementation of this intervention in your practice setting?

· What types of objections might be raised? How will you explain your decision to key stakeholders to address these objections?

In the past weeks, I have discussed the prevalence of obesity in the country and at the local level. Obesity is a growing epidemic especially in the United States and many other countries around the world. According to Dai, et al. (2020), in the years between 1990 and 2017, the obesity-related deaths and disability-adjusted life years have vastly increased for both men and women, globally. It is our job as DNPs to look into the various practice problems and, through research evaluation, ascertain the information needed to create research-based intervention and decrease the burden of disease.

I consider obese persons to be part of a vulnerable population. This conclusion is apparent in that: 1) there is a social stigma associated with personal appearance; 2) ridicule toward obese people is real; 3) personal appearance plays a large role in self-worth; and 4) because most obese people are desperate to lose weight, they can easily be taken advantage of. And of course, being pregnant also adds to the vulnerability of this subpopulation. Because of all this, it is important to remember that we must remain ethical when considering a research-based intervention. There are benefits and harms associated with almost all interventions; it is important to remember that risks must be minimalized. Respect for persons, beneficence, and justice are important ethical ideals when performing the research, and they must also carry over to the implementation of the findings (Favaretto, et al., 2020). The plan for my change project includes two steps. The first is to incorporate education of diet and exercise, including healthy eating choices and preparation demonstrations. The second part involves the patient tracking their exercise on a fitness tracker given to them at their first prenatal visit. They will be shown how to log their daily meals and exercise. Then at every prenatal visit, they can bring in their log so as to discuss their progress. We must remember to congratulate even the smallest improvement and encourage future improvement.

When introducing intervention for the pregnant, obese population, the benefits could be great. These include having a healthier pregnancy and baby, avoiding complications of pregnancy such as gestational diabetes and hypertension/preeclampsia, living a healthier lifestyle that can be carried over past the postpartum period, and lowering the risks of future weight-related problems such as cardiac disease and diabetes. But we must be careful about how we approach the patient so as to avoid harm. Obese patient care, especially when pregnant, can harbor great embarrassment and low self-esteem. Because of this, discussing weight is something that needs to be ethical and humane. One of the worst things that can happen in this situation is that the patient may be so embarrassed and upset that she may not return for prenatal care. That can have grave implications for both mother and fetus. This can also lead to depression and self-isolation, which as obstetrical providers, we know that this can lead to suicide ideations.

There are some personal and professional values that conflict when putting an intervention into place to help pregnant women with weight loss. As a professional nurse-midwife, I want my patients to be at the peak of health. I look past the pregnancy and down the lifespan of my patient. I truly care about each and every patient’s well-being just as if they were family or friends. And so, therefore, I want to push through with interventions on weight loss. But there is that part of me that makes me ambivalent about upsetting or hurting the feelings of my patients by bringing up sensitive issues like their weight. Of course, these women know they have weight problems, but I can be a source of embarrassment as many of these women are not happy with their appearance or are depressed because of it. In the end, it is important to address this sensitive issue with tact and empathy so that we can minimize the harms of this type of intervention.

I am anticipating that many questions would be raised especially by the organization administration including the chief financial officer, as well as the mesosystem of managers. One of the most important objections I anticipate is over the cost of implementing the program. Who will pay for the fitness trackers? What are the costs associated with teaching about sound dietary choices and demonstrations of healthy cooking? I would recommend a cost/savings analysis be performed. In addition, emphasis will be placed on the benefits of a healthier population, such as shorter hospital lengths of stay, fewer complications with procedures or surgery, improved patient satisfaction, and an increase in payments from third-party payors. We should also see a drop in readmissions of women with postpartum preeclampsia. In addition, the nursing load would be lighter with a healthier population. I would explain that as an option, we can involve the local health departments and ask for assistance with the healthier eating and cooking portion of the intervention as they have specialists that work with WIC programs and others of the like. In the end, the organization would be making money. We have an obligation as health care providers to help improve the health of the patients, community, and world. It is projected that by 2025, 20.5 million Americans will be morbidly obese and as this number increases, so does the expenditures. (Cecchini, 2018).

Cecchini, M. (2018). Use of healthcare services and expenditure in the US in 2025: The effect of obesity and morbid obesity. PLoS ONE, 13(11), 1-14: e0206703. https://doi.org/10.1371/journalpone.0206703

Dai, H., Aisalhe, T., Chalghaf, N., Ricco, M., Bragazzi, N., & Wu, J. (2020). The global burden of disease attributable to high body mass index in 195 countries and territories, 1990-2017: An analysis of the Global Burden of Disease Study. PLOS Medicine, 17(7), 1-19: e1003198. https://doi.org/10.1371/jounal.pmed.1003198 (Links to an external site.)

Favaretto, M., Clercq, E., Gaab, J., & Elger, B. (2020). First do no harm: An exploration of researchers’ ethics of conduct in Big Data behavioral studies. PLoS ONE, 15(11), 1-23: e0241865. https://doi.org/10.371/journal.pone (Links to an external site.).0241865

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