The field of nursing has changed over time.


The field of nursing has changed over time. In a 750-1,000 word paper, discuss nursing practice today by addressing the following:

  1. Explain how nursing practice has changed over time and how this evolution has changed the scope of practice and the approach to treating the individual.

  1. Compare and contrast the differentiated practice competencies between an associate and baccalaureate education in nursing. Explain how scope of practice changes between an associate and baccalaureate nurse.

  1. Identify a patient care situation and describe how nursing care, or approaches to decision-making, differ between the BSN-prepared nurse and the ADN nurse.

  1. Discuss the significance of applying evidence-based practice to nursing care and explain how the academic preparation of the RN-BSN nurse supports its application.

  1. Discuss how nurses today communicate and collaborate with interdisciplinary teams and how this supports safer and more effective patient outcomes.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

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 LopesWrite. Please refer to the directions in the Student Success Center.

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KINE 4304 – 001: Fall 2018

KINE 4304 – 001: Fall 2018

Guidelines for the document: 

1. Submit your class project in a word document

2. Your name, class, title, etc. on a cover sheet

3. Font: Arial 10, line spacing 1.5. Format: APA 

4. Include the page number (i.e., at the bottom of the page) after the cover sheet

5. Cite your references in the text (remember you must include professional peer-reviewed articles for section one)

6. The document has to be properly stapled and be free of grammatical and spelling errors

7. The reference list (i.e., APA format) should appear at the end of section I

The Class Project includes two (2) sections. 

First section: Literature review (60% of grade):

You are required to search information that addresses the following topic: “The potential effects of exclusive aerobic exercise training for the prevention and treatment of major chronic diseases.” 

The literature review must include ONLY peer-reviewed scientific articles. You need to cite at least five or more different scientific publications. You might use the link below when searching for peer-reviewed articles.

**The first section should address, report, discuss, explain, and summarize questions such as: what is known about the topic (e.g., inactivity, amount of physical activity, chronic diseases, etc.); the positive and/or negative effects of aerobic training, the potential assessments needed; the recommendations for program implementation (e.g., supervised or non-supervised), the potential benefits and outcomes, etc. **

Second Section: Case Study – Exercise Prescription (40% of grade):

Provide a prudent, yet effective and comprehensive exercise prescription (i.e., aerobic, resistance, and flexibility training) for losing weight for middle-age woman (age; 46 years old) whose physician has advised her to shed 20 pounds, of excess weight. You will need to explain in full detail the justification for the implementation of health appraisal and pre-assessments during an aerobic exercise training program. Be sure to address the FITT principle and then explain how you would apply the training principles (i.e., progressive overload, specificity, periodization, etc.) into her training program. 

Please be sure to provide the rationale (in other words, you are required to explain in full details each of your statements) for each of your recommendations and suggestions during the early stages of her potential exercise prescription (i.e., risk stratification, pre-assessments, exercise testing, starting point, etc.). In addition, please calculate and classify her BMI accordingly. Height = 5 feet 6 inches (1 foot = 12 inches; 1 inch = 2.54 cm); weight = 169 pounds

Background: Currently she doesn’t have to much free time during the week to engage in regular exercise training; however, she has decided that she needs to start doing something in order to take care of herself. She has been inactive for the past two years; however, she used to do some Pilates and yoga twice a week. Now she realizes that she needs to engage in a more comprehensive and structured exercise program.

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Drug use – Heroin

Topic: Drug use – Heroin


Introduction to this drug use: Clearly identify the problem and discuss specific statistics from your community related to this problem. You may use city or county data. Community/City is Chicago, Illinois.

Problem description: Utilize one scholarly reference to describe this drug use. Discuss reasons why this may be a problem in your community. Cite all sources.

Community resources: Describe at least two available community resources (in Chicago, Illinois) to which you may refer people who have this problem or an increased potential for acquiring this problem. You are to provide the names of these resources and brief descriptions. You may use online resources if community resources are not available.

Conclusion/future implications for nursing: Provide a summary of your findings. Discuss the use of SBIRT in nursing practice.

References: Provide all references for all sources utilized. Use APA format.

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Teen fitness program

(Teen fitness program!)

Develop and submit a comprehensive and detailed Event Proposal of professional quality and style.

The proposal will include the Following Subheadings:  Description, Six Critical Dimensions; Event Elements; Timeline, Implementation; Marketing Plan, Marketing Materials (brochure, flyer, e-mail messages, facebook posts, twitter posts, Instagram, etc.); Budget Justification, Budget, Site/Venue Details and Diagram Site Plan, Logistical requirements, Infrastructure requirements, Safety and Security, Décor and Staging, Activities, Information (data) Management Plan, and Evaluation Plan.

Be particularly attentive to the significance, innovation, approach and environment of the event your are proposing

Detailed instructions:


Event Proposal

Your proposal will be lengthy (likely 40+ pages). Please format it as you would if you were actually presenting it to funders or your superiors for review. Be sure to look at the ‘report’ and ‘proposal’ templates which are available online and on MAC and PC word programs. 

Please present your best work (professional) as your final submission. Your final product should be clear, detailed and comprehensive with a professional appearance.Suggested Organization: 



Event Goals Event Objectives Strategies to achieve Objectives 

DESCRIPTION Overview Describe overall event Identify keynote speaker – explain why speaker was selected Six Critical Dimensions of the event experience identify and describe how you are managing them: Include as subheadings. List and describe the Event Elements

TIMELINE Detailed Planning timeline Detailed Event Production timeline (Day of the event –what happens when with actual hours etc.) EVENT MANAGEMENT collateral materials admissions control systems attendee services you will provide protocol requirements MARKETING Marketing plan (what will you do, when will you do it, and who will recevie it?) Provide ALL marketing materials (flyers, brochures, e-mail blasts, facebook posts, etc). These must be developed and presented in professional quality. (DO NOT just say these things ‘will be developed’). Actual materials must be included in your proposal and should include: Press Release Public Service Announcement to Radio and/or TV to get coverage be sure to include ALL contact info E-mail scripts and schedule of distribution E-mail 1: Insert Subject; Date of Release: List of Recipients, continue for all E-mails Facebook 1: Topic Line, Posted where or to whom, date of Release Twitter 1: Posted where or to whom, date of Release Brochure Flyer 

VENUE Describe the site/venue explaining why/how this venue is ideal for this event Provide an accurate diagram site plan. Be sure to identify all event elements within the site plan. 

LOGISTICS Explain the logistical requirements associated with this program and how they will be incorporated into your overall event plan and budget. 

INFRASTRUCTURE describe the infrastructure requirements and plans transportation, parking, waste management, utilities, labor etc 

SAFETY safety and security plans on-site communications first aid and medical services 

DÉCOR Describe the décor in detail Describe and diagram staging Describe and give examples of ALL signage 

TECHNOLOGY List technology and media equipment and technicians needed for the event

PROGRAM Overview of Program Describe Entertainment Components Provide logistical requirements associated with each element

BUDGET—-Detailed budget outlining ALL specific costs for event components (be sure you are within the stated budget).

INFORMATION (Data) MANAGEMENT Outline and describe the data management plan you would employ for the event (registration information, vendor information, evaluation information,financial information etc). What data will you collect? (name, address, etc???) How will you collect the data? To whom and how will the data be distributed? How will the data be stored? 

EVALUATION Describe how the overall event will be evaluated, how the evaluation will be completed and how outcomes will be used. From participant perspective From vendor perspective From organization (sponsor) perspective Describe performance evaluation of staff and how the evaluation will be completed vendors volunteers

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I selected the Iowa model of evidence-based practice.  Titler and colleagues initially developed the Iowa model of evidence-based practice in 1994 to provides direction

for the development of evidence-based practice in clinical agency were triggers that can be problem-focused evolving from risk management data, process improvement data,

benchmarking data, financial data, clinical problems, knowledge-focused such as new research findings, change in national agencies or organizational standards and guidelines,

an expanded philosophy of care, or questions from institutional standards committee initiate the change; and the focus should always be to make the change based on the best

available evidence (Grove, 2015, p. 483). 

This model should be effective for implementing EBP in any area of practice as long as triggers are evaluated and prioritized based on the needs of the practice to prompt a

focused action from the organization, an action that is guided by the most appropriate evidence-based research practice available. Once the trigger is prioritized, a group is

formed to search for the best evidence to manage the issue and evaluate all factors such as cost, the strength of the evidence, and the impact of such evidence on the triggers.

This group will assemble relevant research and related literature, critique and synthesize the research for use in practice and if there is sufficient research base, it will proceed

and make changes as deemed necessary as the research progresses. Once the research is completed, results are evaluated and decision is made to make the changes as approved

at the organizational level.

Barriers to this implementation can be the lack of research evidence available on the effectiveness of measures to address the particular trigger; the transfer of evidence-

based research to a particular trigger might not produce expected results based on other factors independent from studies that produced the evidence in use. For example, 

patients’ multiple chronic illnesses can affect their response to treatments, not all patients respond the same way to a particular treatment, regardless of the strength of the

evidence. Other barriers include the cost of implementation related to training staff. Effective EBP implementation at the practitioner and organizational levels within a health

care setting is essential to provide safe, effective and patient-centered care; nurses play a pivotal role to sustain the use of EBPs in clinical setting, and the contextual quality

of an organization that facilitate successful implementation should involve an organizational culture that is value-oriented and learning-oriented and receptive to change, and

a transformational leadership style determined by the leadership and practice of management (El-Mallakh at al., 2013, p. 42).


Grove, S. K., & Burns, N. (2017). The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence (8th ed.). St. Louis, Mo: Elsevier Sanders. 483

El-Mallakh, P., Howard, P. B., Rayens, M. K., Roque, A. & Adkins, S. (2013). Organizational fidelity to a medication management evidence-based practice in the treatment of

schizophrenia. Journal of Psychosocial Nursing & Mental Health Services, 51(11), 35-44

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The “John Hopkins Nursing Evidence-Based Practice Model” uses a process called PET (Dang & Dearholt, 2017). This stands for practice question, evidence, and translation. With the Institute of Medicine  publication calling for higher educated nurses working at the full extent of their license (Campaign for Action, 2017), this involves understanding how to implement evidence-based practice. However, barriers exist, including, the demands of patient care which limits their time to implement these practices. With the John Hopkins approach the process is simplified and easy to understand, reducing the cost of entry. With the PICO framework, the nurse is able to better identify the problem in the form of a tangible question. Through the evidence phase, research is conducted and critiqued in order to determine strengths and weakness of articles before committing to a practice. Lastly, through the translation phase, nurses are able to determine if the practice is feasible and pilot a project (Parkosewich, 2013).

                I am working on rolling out new psychotropic review for my company. This form is used by the nurses to identify psychotropic and spark conversation with the provider in order to reduce the amount of psychotropic medications used in the facilities. Through this course I have developed a PICO statement and completed a lot of research. By using the John Hopkins model, I would be able to further identify key items such as stakeholder analysis. Additionally, by using this model I would want to identify a project leader and change champions to push the new review forward. Milestones will need to be identified and pre and post measurements taken. Also, barriers would need to be identified with a plan to overcome them. Eventually this form will be added to the EMR but initially it will be a paper form and would not be financially impactful on the company as we do have a form and process already. Barriers may include nurses who are used to the old form and resistant to change. However, with proper dissemination on the evidence of using the new form this could be overcome. Additionally, providers may not be on board when a higher questioning of psychotropic medications is presented. However, as part of the role out process infographics and information on why this is important and what our companies views are will help nurses to have meaningful conversations to overcome this barrier.


Campaign for Action. (2017). Infographic – the future of nursing. The National Academies of Sciences, , 1. Retrieved from

Dang, D., & Dearholt, S. (2017). Center for evidence-based practice. Retrieved from

Parkosewich, J. A. (2013). An infrastructure to advance the scholarly work of staff
nurses. The Yale Journal of Biology and Medicine, 86(1), 63-77. Retrieved from

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Cleveland Clinic

Cleveland Clinic 

3 pages

  • Describe and discuss the cleveland clinic  facility’s Utilization Management program.

  • Compare and critique the facility’s Utilization Management program to that of a model facility and whether the facility adheres to the recognized standard for utilization management, including utilization review and whether this review leads to improvement in the quality of care.

  • Identify areas for improvement in the facility’s Utilization management program, if any, and any recommendations you think should be implemented to improve the quality of patient care.

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A Study in Diabetes Management rewrite

A Study in Diabetes Management

            This paper has been written by reviewing the subjective and objective data provided in the case study to diagnose Mrs. Wu and develop a treatment plan for her diagnosis. SOAP note will be provided and the rest of the paper will be created using the national guidelines for Diabetes.


Primary Diagnosis

Type 2 diabetes mellitus (E11.9).


Type 2 diabetes mellitus is a heterogenous disease that occurs when there is a progressive loss of b-cell function and/or mass, typically due to inflammation, metabolic stress, or genetics. This leads to decreased insulin secretion, which is compounded by decreased insulin resistance, all leading to hyperglycemia; clinically, this typically presents as polyuria and polydipsia, though not all will experience these (American Diabetes Association, 2018).

Pertinent positive and negative findings and rationale.

The patient has fatigue, no weight loss despite exercise, polyuria, and polydipsia, all of which are signs and symptoms of type 2 diabetes (Castonguay & Miquelon, 2018). She has glucose in her urine, her fasting glucose is 130 mg/dL, total cholesterol, LDL, VLDL, and triglycerides are all elevated, HDL is low, HgbA1C is 6.8%, and her BMI is 30.2, which are all found in type 2 diabetes mellitus (American Diabetes Association, 2018).

This diagnosis was chosen because of the patient’s symptoms and lab values, which all indicate a diagnosis of type 2 diabetes. Per the American Diabetes Association, her fasting plasma glucose of 130 mg/dL and A1C of 6.8% are both diagnostic of type 2 diabetes (2018).

Secondary Diagnosis

Hyperlipidemia (E78.5).


Hyperlipidemia is a heterogenous disease, which can be genetic-related and/or due to poor diet and decreased physical activity. When the lipid levels are not in the correct range, blood vessel injury and plaque formation can form. Unfortunately, there are not many signs and symptoms of hyperlipidemia and it can go undetected unless the patient has lipid levels checked or if the patient presents with more severe cardiovascular symptoms (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

Pertinent positive and negative findings and rationale.

All of the patients  cholesterol values are abnormal, leading to a diagnosis of hyperlipidemia and putting her at very high risk of developing atherosclerotic cardiovascular disease (Jellinger et al., 2017).

Mrs. R has elevated total cholesterol level of 215 mg/dL, LDL 144 mg/dL, VLDL 36 mg/dL, triglycerides 229 mg/dL, and a low HDL of 32mg/d, which all indicate a diagnosis of hyperlipidemia (Jellinger et al., 2017). Hyperlipidemia and type 2 diabetes mellitus are very commonly found to co-exist (American Diabetes Association, 2018).

Differential Diagnosis

Differential diagnosis

                Obesity (E66.9). a body mass index (BMI) of 30kg/m2 or higher indicates obesity and is defined as an excess of body fat (Dunphy et al., 2015).  According to the AACE/ACE (2017), a BMI of 30kg/m2 is classified as obese, where as a BMI = 25-29kg/m2 are identified as overweight.  Obesity occurs when the consumption of calories far exceeds the metabolic needs of the body (Dunphy et al., 2015).  Bullock-Palmer (2015) stated that the prevalence of obesity is greater among black and Hispanic females when compared to Caucasian females in the United States.  CVD risk in females increases proportionately with the increase in BMI (Bullock-Palmer, 2015).

                Rationale. Mrs. R’s calculated BMI=30, which identifies her as overweight for her given height.  The most common presenting symptoms for obesity are shortness of breath, decreased energy, fatigue, weakness, joint pain, depression, and increased daytime sleepiness (Dunphy et al., 2015).  Its treatment consists of lifestyle interventions and behavioral modifications (Cefalu et al., 2015). Some pertinent positives for Mrs. R.’s obesity are fatigue, decreased energy, and weakness.  Over the past 3 months, she has gained 3 pounds despite going to the gym and walking on the treadmill.  Exercising makes her hungrier and therefore causing her to eat more.  Pertinent negatives are daytime sleepiness, shortness of breath and depression




Type 1 diabetes mellitus.

Mrs. R needs a spot urinary albumin-to-creatinine ratio done in order to further assess for renal function; this should be done annually along with eGFR. She will need another HgbA1C done in three months, then quarterly until it is normal; at that point, it can be increased to twice annually. This is used to assess the average of Mrs. R’s blood glucose levels over the previous three months so that adjustments may be made to her management if necessary (American Diabetes Association, 2018).

Mrs. R will need a fasting CMP done annually to assess electrolyte levels and fasting serum glucose. A vitamin B12 baseline level is needed since Metformin is associated with vitamin B12 deficiency with prolonged use, and a repeat level every 2-3 years is recommended. Assessing LFT levels annually are also recommended, since Metformin is contraindicated with decreased liver function (American Diabetes Association, 2018).

A comprehensive foot exam is needed, which includes a thorough skin inspection; assessment for foot deformities; neurological assessment with a 10-g monofilament and either a pinprick, temperature, or vibratory exam with a 128-Hz tuning fork; and a vascular assessment including pulses of the feet and legs. An annual 10-g monofilament will need to be done and at least a brief foot inspection must be done at every visit. This assesses for peripheral neuropathy that may develop and detect early skin issues (American Diabetes Association, 2018).


Mrs. R should have repeat lipid levels, especially LDL, three months after initiating statin therapy, then annually thereafter, unless circumstances require more frequent monitoring. This helps assess if her atorvastatin dosage is correct so that adjustments may be made as necessary (American Diabetes Association, 2018).

Health maintenance.

It should be determined if Mrs. R has ever had a mammogram; if she has not, it should be recommended to schedule one as soon as possible, since the current recommendation for women age 50-74 years is that a mammogram be performed every other year (USPSTF, 2016). It also should be determined if Mrs. R has ever had a colonoscopy; if she has not, it should be recommended to schedule one as soon as possible, since the current recommendation is that screening begin at age 45 for people who do not have risk factors, and again every 10 years minimum (Wolf et al., 2018). She also needs to make sure that her hepatitis B, influenza, and pneumococcal vaccinations are kept current, since diabetes makes her at higher risk of contracting hepatitis B and having greater chance of complications from influenza and pneumococcal diseases (American Diabetes Association, 2018).


Type 2 Diabetes Mellitus.

Metformin ER 500mg

Sig: Take 1 (one) tab every evening with food. Disp: #30. RF: 2

Glucagon Emergency Kit

Sig: Inject 1mg IM as directed. Disp: 1 kit. RF: 2

Onetouch Delica 33gauge Lancets

Sig: Test blood glucose BID, more frequently as needed. Disp: 200 (2 boxes). RF: 4

Onetouch Ultra2 glucometer

Sig: Test blood glucose BID, more frequently as needed. Disp: 1 kit. RF: 1

Onetouch Ultra Blue test strips

Sig: Test blood glucose BID, more frequently as needed. Disp: 100 (1 box). RF: 4

Women’s Daily Multivitamin over the counter

Sig: Take 1 (one) tab daily


Mrs. R will be prescribed Metformin, as it is a first-line medication for type 2 diabetes for symptomatic patients with an A1C <9% and eGFR >99 mL/min/1.73. It could help her with weight loss and has been shown to decrease total cholesterol and LDL levels (American Diabetes Association, 2018). She will be started on 500mg of extended release (ER), which can increase by 500mg per day every week as tolerated to a maximum dose of 2000mg per day until blood glucose goals are achieved (Epocrates, 2016).

Glucagon is important for diabetics to have if blood glucose readings are <54 mg/dL or if she is unconscious due to hypoglycemia. Mrs. R and her family must be taught how to administer glucagon in case of emergency (American Diabetes Association, 2018).

For Mrs. R to test her blood sugar, she will need lancets, test strips, and a glucometer. Once her blood glucose has stabilized, she may not need as many lancets and test strips (American Diabetes Association, 2018).

Mrs. R should continue her multivitamin, especially since her metformin can result in deficiency in vitamin B12 (American Diabetes Association, 2018).


Atorvastatin 10mg

Sig: Take 1 (one) tab daily. Disp: #30. RF: 2


Atorvastatin is a first-line medication for hyperlipidemia and is recommended by the American Diabetes Association in type 2 diabetic patients 40-75 years of age without known atherosclerotic cardiovascular disease, but with LDL levels >100 mg/dL (2018). At 10-20mg daily, it has been shown to decrease LDL levels by 30-50%, but can be increased to 40-80mg daily if needed to decrease LDL levels by 50% or more (American Diabetes Association, 2018).


Acetaminophen 500mg over the counter

Sig: Take 1 (one) tab every 4-6 hrs prn. Do not exceed 4000mg in 24 hrs.


Acetaminophen is a recommended first-line medication in the pharmacologic management of osteoarthritis of the knee. NSAIDs are also first-line, but the gastric side effects can be more harmful, especially since she is already taking metformin, which can have gastric side effects as well; so acetaminophen will be recommended until it no longer provides relief (Hochberg et al., 2012).



Type 2 diabetes mellitus.

The treatment for type 2 diabetes mellitus is multifactorial, meaning that it should be a combination of medication, dietary changes, and increased physical activity. She will need to check her blood glucose levels regularly, though for non-insulin dependent diabetics, there is no set guideline for how often to check or whether they should or not. Initially, it will be recommended for Mrs. R to check her blood sugar once in the morning and once before bedtime, and more often if needed until her blood sugar is stable. Her goals are an A1C of <7% (can be increased to <7.5% or even <8% if necessary), preprandial blood glucose of 80-130 mg/dL, postprandial <180 mg/dL, and bedtime level 90-150 mg/dL. Mrs. R must know that stress, illness, surgery, and dehydration are a few of the conditions that may increase her blood sugar, so she should check it more often during those times (American Diabetes Association, 2018).

Mrs. R needs to know signs and symptoms of hypoglycemia, since that is a commonly seen condition in new diabetics. Shakiness, irritability, confusion, tachycardia, and hunger are all signs and symptoms of hypoglycemia. If she feels any of these, she should take her blood sugar reading and eat or drink 15-20g of glucose, which is recommended for a reading of 70 mg/dL or less; if the reading is less than 54 mg/dL or if she is unconscious, she should use her emergency glucagon. She should recheck her blood glucose level 15 minutes after either oral glucose or glucagon injection and, based on her repeat level, take the appropriate action as detailed above. After her glucose is stable, she should eat a meal or snack to prevent another episode of hypoglycemia. She should be aware of situations where potential episodes of hypoglycemia may occur, including but not limited to fasting for tests, exercise, during sleep, or delayed meals, and it is recommended that she keep small snacks with her in case of a hypoglycemic episode (American Diabetes Association, 2018).

Foot care should be thoroughly explained, since diabetics have a high risk of peripheral neuropathy, leading to injuries to the bottoms of their feet without their realization. This can lead to infection which could eventually lead to amputation or even death if it is not caught and treated quickly. Mrs. R needs to examine her feet every day for signs of injury or skin breakdown, including toenails. If she notices injuries or ulcers, she shoul d notify the office so it can be examined and treated if necessary. She also needs to make sure that she is seeing her podiatrist regularly (American Diabetes Association, 2018).

Since diabetic retinopathy is another major complication of diabetes, Mrs. R needs to see an eye doctor regularly and report any changes in vision immediately (American Diabetes Association, 2018).

She also needs to monitor her blood pressure, since hypertension can negatively affect the cardiovascular system, for which her diabetes and hyperlipidemia already put her at risk. Even though her blood pressure today was normal, she should be aware that it needs to stay <140/90 to keep her risk of cardiovascular or renal injury lower (American Diabetes Association, 2018).


Since hyperlipidemia and diabetes commonly coexist, Mrs. R needs to understand the importance of doing what she can to lower her cholesterol levels and maintain them at appropriate levels. Diabetes and hyperlipidemia both put her at high risk of developing atherosclerotic cardiovascular disease, so it is extremely important for her to ensure that they are both controlled. Lipid control can be attained in much the same way that diabetes can be, by a combination of medications, diet, and increased physical activity. These conditions should not be controlled by medication alone; lifestyle changes should be the most important factor in managing them. Lipid goals are mostly based on LDL, which should be <70 mg/dL; these will be checked 3 months after initiating atorvastatin, every 6-12 months until normal, then every 1-2 years, unless more frequent monitoring is necessary (American Diabetes Association, 2018).


Mrs. R should be screened annually at minimum for depression, but should also be aware that signs of depression, including but not limited to worsening fatigue, appetite changes, overwhelming sadness, decreased interest in social activities, feelings of hopelessness, and sleep disturbances, should be reported to the office immediately. Since she is now having to make major lifestyle changes, she is at risk for depression, so being aware and cognizant of this can help her control it sooner (American Diabetes Association, 2018).



Metformin decreases the production of glucose from the liver. It should be taken with food in the evening and can cause nausea, diarrhea, and weight loss. While GI symptoms are common, they typically resolve with time, so Mrs. R should continue taking the medication as directed unless severe symptoms occur, such as vomiting, dehydration, or extreme weight loss. If she develops symptoms such as malaise, respiratory distress, somnolence, or severe abdominal pain, she should go to the nearest emergency department, as these can be signs of lactic acidosis, a severe adverse effect of metformin (American Diabetes Association, 2018).


As mentioned earlier, glucagon should be administered if Mrs. R’s blood glucose drops below 54 mg/dL or if she is unconscious. Her close friends and family need to be taught how to reconstitute and administer it. She should have it with her at all times and if it expires, she should throw it away in a sharps container or a puncture-proof plastic container that is labeled to indicate that it contains sharps, and obtain a new kit. The kit should be kept at room temperature, never frozen or heated, and should be administered immediately after reconstituting. When obtaining her glucagon kit from the pharmacy, she should ask for a kit that has the furthest expiration date available, so as to not have to buy one more often than necessary (American Diabetes Association, 2018).


While there is a slight risk of statin therapy increasing blood glucose levels, studies show that the benefit of lipid-lowering abilities, and ultimately the decreased risk of severe cardiovascular diseases, far outweigh the slight glucose elevations. There is a small chance that Mrs. R will experience myalgias and muscle weakness and she needs to report it if it becomes severe, as the medication may need to be temporarily stopped and a CK level obtained (Jellinger et al., 2017).


Mrs. R should be very careful and cognizant of how much acetaminophen she is taking in 24 hours and make sure that she does not take any other medications that has acetaminophen in it, such as over-the-counter cold and flu relievers (Hochberg et al., 2012). This can cause liver toxicity, which is dangerous in itself, but can also cause her to not be able to take her metformin (American Diabetes Association, 2018).


Mrs. R is obese, which can contribute to her diabetes, so she should decrease her caloric intake by at least 500cal/day to facilitate weight loss. Dietary changes are important to accomplish this and should include decreased carbohydrates, saturated and trans fats, and cholesterol; and increased n-3 fatty acids, viscous fiber, and plant stanols and sterols. This will help control her glucose levels and improve her cholesterol levels. The recommended diet for her diabetes and hyperlipidemia is the Mediterranean diet (American Diabetes Association, 2018).


As mentioned in previous sections, exercise is a large part of managing both diabetes and hyperlipidemia, and can contribute to weight loss as well, which also has a positive effect on diabetes and hyperlipidemia. It is recommended that at least 30 minutes of moderate-intensity exercise be done 4-6 times weekly, but may need to be increased to 60 minutes in order to lose weight. Depending on Mrs. R’s knee condition, she may need to make some adjustments to her exercise activities, and may need to include activities that are more gentle such as swimming or using an elliptical machine. She can also break up the activity into smaller sessions, such as 10-minute sessions spread throughout the day (Jellinger et al., 2017).


Mrs. R needs to be referred to a dietitian in order to learn exactly what types of foods she should be eating and to get an individualized diet plan that she will be more likely to adhere to (American Diabetes Association, 2018). She needs a referral to a podiatrist so she can have a specialist examining and caring for her feet, in addition to her self-exams and the exams at her primary care visits (American Diabetes Association, 2018). If she does not already have a dentist, she will need to be referred to one to ensure that her teeth are in good repair and that she is seen for regular exams, since periodontal disease is a risk of diabetes (American Diabetes Association, 2018). It is important that Mrs. R be referred to a diabetic educator so that she has someone to walk her through all the details of being diabetic and how to manage the disease. The diabetic educator can also be a great resource and contact for Mrs. R should she have any questions or issues come up, in the event that she cannot get in touch with the primary care office (American Diabetes Association, 2018). Another major risk of diabetes is diabetic retinopathy, so Mrs. R needs to be referred to an ophthalmologist if she does not already have one, so that regular exams can be done in order to detect any retinal or vision changes (American Diabetes Association, 2018).

Follow Up

Mrs. R needs to come in to be seen again in three months in order to re-evaluate her current condition and symptoms, A1C, lipids, and evaluate a spot urinary albumin-to-creatinine ratio. She will need to follow up again in three months after that to be re-evaluated again and then to determine if her condition is controlled well enough that the visits can be spread further apart or if she needs to be seen more often. Once her A1C, blood glucose levels, and lipids are well-controlled and there is no sign of organ damage, she needs to be seen annually (American Diabetes Association, 2018).

Medication Costs

For 30 pills of metformin ER 500mg, which is what Mrs. R is initially starting on, the cost is $4.00 at Walmart with no coupon required. If the dose has to be increased to the maximum of 2000mg, 120 500mg pills can be obtained at Walmart for $10.00 (GoodRx, 2018).

Glucagon kits are very expensive without insurance that covers them, ranging from about $250-$300 for one kit. If Mrs. R does not have insurance that will cover the majority of the cost, there is a coupon that can be used at multiple pharmacies that will discount it by 75%. It can be printed out, emailed, or sent via text message from (2018).

Mrs. R can get 30 10mg atorvastatin pills at Walmart for $9.00 with no coupon required. If the dose needs to be increased to the maximum of 80 mg, she can get 30 pills at Walmart for $4.00 with no coupon required (GoodRx, 2018).

For her diabetic supplies, Mrs. R can get 2 boxes of lancets, totaling 200 lancets, at Walmart for $18.38 with a GoodRx coupon (2018). She can get her glucometer at Walmart for $15.78 with no coupon required. Her test strips will be the most expensive one at $132.62 if she gets them at Walmart with a GoodRx coupon (2018). Depending on her insurance, they might cover some of these costs, but she should be prepared if it does not.

Acetaminophen can be purchased over the counter relatively inexpensively, costing approximately $7.00 for two bottles of 250 pills each (Walmart, 2018). This should last her two months, even if she is using the maximum dosage of 4000mg per day.

If Mrs. R purchases the One A Day Women’s Menopause Formula Multivitamin at Walmart, it will cost $9.58 for a count of 50, which would last her almost 2 months (Walmart, 2018).

If she goes to Walmart and pays cash for her acetaminophen, multivitamin, metformin, atorvastatin and glucometer; uses the HelpRx coupon at CVS where she can get an additional $5.00 off (2018); and uses GoodRx (2018) coupons for her test strips and lancets at Walmart, for the lowest dosages she is starting with, she would pay at the most a total of $271.36 for her first month. If she makes sure that her glucagon kit has the furthest expiration date possible, she could potentially only have to pay for it once a year. Her glucometer would only have to purchased once, unless it breaks or malfunctions, which would mean that for 11 months out of the year, she would only have to pay for the acetaminophen, multivitamin, metformin, atorvastatin, test strips, and lancets, which would average about $172.50 for one month. If her blood sugar remains stable, she could potentially not have to test her blood sugar twice a day, which would mean she would not have to buy strips and lancets as often, which will save her money.

Depending on what Mrs. R’s insurance (if she has any) will pay, her medication plan may need to be adjusted if she cannot afford what is pr escribed above. Her glucagon is not absolutely required, but is strongly recommended; so if it is too much for her to pay, she does not have to pick up the prescription, as long as she understands that she absolutely must keep snacks with her at all times to combat hypoglycemia, and she must be extremely careful and cognizant of the signs and symptoms so that she will not become so hypoglycemic that she loses consciousness (American Diabetes Association, 2018). Again, if insurance will not pay or if she does not have insurance and cannot afford all of the above, she does not have to check her blood glucose twice daily, since her fasting glucose was minimally elevated as was her A1C; so she would not have to get her prescriptions filled for the glucometer, test strips, and lancets. It is not required that she test her blood glucose levels at home; she simply will feel more in control and her medications can be adjusted better if she is aware of what her blood glucose levels are doing on a day-to-day basis (American Diabetes Association, 2018). I use GoodRx on a daily basis, not only in clinical, but in my job in the emergency department. I definitely plan to continue using it, as it is a great resource and patients are always extremely grateful for the assistance for sometimes otherwise impossibly expensive medications.


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