El Niño and La Niña

El Niño and La Niña are naturally occurring phenomena that typically occur every 3-5 years. The phenomena result from the interaction between the atmosphere and the ocean surface in the tropical Pacific, affecting the Pacific Ocean’s normal conditions. At normal conditions, trade winds blow from east to west, taking warm water in the same direction. As the warm water moves west, upwelling causes cold water from the deep to rise to the surface. El Niño and La Niña can break these normal patterns, resulting in massive global weather effects. El Niño and La Niña are Spanish names meaning “the boy” and “the girl,” respectively.

During El Niño, the trade winds weaken. Instead of warm water moving west, it is pushed back east toward South America’s west coast, causing an accumulation of humid, warm air. El Niño is associated with high air surface pressure in the tropical western Pacific and can significantly affect the weather. The warmer waters move the Pacific jet stream south from its neutral position, causing northern U.S. and Canada areas to be dryer and warmer than usual.  Convection above the warmer surface waters increases precipitation, causing increased rainfall in South America, especially Ecuador and northern Peru. Such excessive rainfall may lead to flooding, erosion, and destruction of infrastructure. El niño results in below-average rainfall in places such as India, which may lead to severe droughts. El Niño also affects marine populations. Because there is no upwelling of cold, nutrient-rich water, there is reduced phytoplankton, leading to food scarcity for the fish populations. One of the major and intense El Niños happened in 1997-1998, leading to drought conditions in Indonesia, Malaysia, and the Philippines. There were very heavy rains and severe flooding in areas such as Peru. In the United States, California experienced increased winter rainfall while the Midwest experienced record-breaking warm temperatures.

A La Niña event sometimes follows an El Niño event. During Lanina, the trade winds intensify. There is a greater push of warm water toward Asia, and upwelling increases off the coast of South America, causing more cold, nutrient-rich water that supports marine life to rise to the surface. La Niña is characterized by lower-than-normal air pressure over the western Pacific, leading to increased rainfall in areas such as Southeast Asia and Australia. Drier-than-normal conditions are observed along the west coast of tropical South America and the United States Gulf Coast as fewer rain clouds form. Cold waters in the Pacific Ocean result in a northward shift of the jet stream, leading to dry conditions in the southern United States and increased rainfall and flooding in the Pacific Northwest and Canada. In a La Niña, winter temperatures are warmer than normal in the South and cooler than normal in the North. La Niña is also known to lead to a more severe hurricane season.

ORGANIZATIONAL POLICIES AND PRACTICES TO SUPPORT HEALTHCARE ISSUES – Post an explanation of how competing needs, such as the needs of the workforce, resources, and patients, may impact the development of policy. Then, describe any specific competing needs that may impact the national healthcare issue/stressor you selected. What are the impacts, and how might policy address these competing needs? Be specific and provide examples.

How Competing Needs Impact Policy Development

     The ability to provide widespread access to health services while raising the quality of care and managing costs is a critical problem for healthcare systems worldwide. Most medical professionals are adamant about providing high-quality care (Kelly & Porr, 2018). Various factors influence the demand for of registered nurses. The detrimental effects of the current nursing practice environment on the field’s ability to attract new students and the retention of registered nurses are particularly concerning. Companies are having to adjust the policies more often than before in order to keep current nurses and try to attract new ones. These policies are made by management teams within the company in response to the needs that are verbalized by the nursing staff.

Competing Needs that impact the Nursing Shortage

     According to research in Milliken’s paper, nurses frequently feel unprepared to handle the ethical dilemmas they encounter in practice, which may lead to moral anguish and burnout. One strategy to address this issue is to guarantee that nurses have the resources necessary to handle challenging circumstances (Milliken, 2018). In order to solve issues and meet patient requirements, nurses must first be aware of any potential ethical consequences of their activities. The healthcare sector places many pressures on healthcare providers, including the difficulties of clinical work, time restraints, competing demands, a lack of control over work procedures and scheduling, and contradictory leadership responsibilities and connections (Bridgeman et al., 2018). Healthcare leaders must recognize when their staff is burning out or need additional help. Participating in policymaking by healthcare workers is nothing new. However, only some get involved due to high-stress levels and poor work-life and personal-life balance. It is vital, however, that nurses speak up and ensure that policymakers within their company hear the issues. This would be a significant factor in developing policies that would benefit nurses and all healthcare workers, leading to decreased burnout.

How can Policies Impact Competing Needs

     The issues nurses experience are misrepresented by the widespread belief that COVID-19 is to blame for their burnout and job loss. More correctly, the epidemic has brought attention to and magnified nurses’ long-standing professional difficulties. According to scientific consensus, understaffing, unfavorable workplace conditions, and the absence of solid ethical frameworks are the leading causes of nurse burnout and moral distress. Burnout and moral distress can contribute to one another’s development, although their underlying causes and effects differ. There is a consensus that burnout and moral anguish were problems caused by unfavorable working conditions long before the pandemic began (Schlak et al., 2022). Influence is the power to compel changes in beliefs, behaviors, and outcomes. One of the most significant and rewarding traits of leadership is having influence. All leaders must exercise caution when using this gift (Broome & Marshall, 2021, p. 334). Healthcare professionals must speak out about workplace issues and other challenges in order to make a positive impact on healthcare. Our legislators may create regulations that reduce nurse burnout and boost nursing retention if they actively listen to the requirements of healthcare employees. Our current employers must be made aware of these as well. Healthcare professionals have the power to improve the nation’s healthcare system. All they have to do is raise their voices.

Competing Needs Impact Policy Development

Policy development often comes with many competing needs of the organization, patient needs, financial needs, staff needs, and ethical considerations, to name a few. Nurses are often caught in the crosshairs of implementing a policy while knowing it does not align with the best needs of each patient. One persistent theme with nursing care versus policy is that the business models often need to pay more attention to the needs of the patient and nursing judgment and education in seeking the best outcomes for the organization rather than the patient (Kelly & Porr, 2018). This can lead to conflict in care teams, personal or professional, and stimulate a decline in patient care or organizational growth.

Competing Need’s Impact on Mental Health Resources

Currently, 150 million people live in an area federally designated as having a mental health provider shortage (Weiner, 2022). Several issues impact the provider shortage seen in mental health. There need to be more residency positions available to train new psychiatrists, and business models are driving patient care to be less patient-centered and more business-centered. Rural communities face challenges in recruiting providers. Additionally, nursing burnout and turnover can be high in mental health, even before COVID-19. A factor in nursing burnout is that nurses often feel unprepared to mitigate the ethical issues they face in their day-to-day practice (Milliken, 2018).

Policy’s Impact on Competing Needs

Policies can have a significant effect on patient needs. Considering mental health populations, policies must be reviewed for ethical considerations, ensuring the policy is not infringing on patients’ rights. This population can be challenging to treat, often non-compliance with treatment regimens for a variety of reasons- homelessness, lack of financial ability to afford services, lack of understanding whether that is baseline cognitive function or impacted by current disease state, physical access to services, or simply no longer taking medications because they were feeling better. This population requires much follow-up to help reach their care goals. They may also need other services that the policies fail to acknowledge. An example comes from the unit I currently work in. It is a crisis observation unit that keeps patients in a safe setting while awaiting inpatient placement. The policies did not account for the need for a social worker. So currently, we share a social worker with several of the medical floors, which means we rarely, if ever, see a social worker. It was not accounted for. It is something highly needed to be added to our policy, and now we are changing the policy to include the social workers in unit operations.

Competing Needs and Policy Development

Policy development can be a tricky feat. There are usually many stakeholders and communities that are affected by new policies and it is important to understand everyone’s needs to ensure allotted resources are divided fairly and accordingly. Many things come into play such as, Patients, providers, insurance companies, healthcare administrators and politicians (Stone, 2022, p. 20). The needs that are competing in relation to the lack of access to healthcare are the need for healthcare infrastructure and the need for quality healthcare.

Without adequate infrastructure available for behavioral health patients emergency rooms are inundated with patients who are holding for treatment facility beds and taking up valuable resources in the emergency departments for medical complaints and emergencies. Nursing staff is becoming overwhelmed with the patient loads and new facilities or processes need to be developed for nurses to prevent burnout. Without nurses speaking up for themselves and lobbying for change, administrators will continue to push their staff for monetary profits compromising patient outcomes (Kelly & Porr, 2018). Policy can address these needs by allocating funds for psychiatric facilities and behavioral health staff. New facilities need to be constructed to support the demand in certain communities. Behavioral Health urgent cares or holdings can be developed to relieve the patient load from emergency rooms resources as well as inpatient facilities being able to apply for grants to expand existing facilities to accommodate increasing demands (Atkinson et al., 2020. p. 5-6).

Nurses constantly face the challenge of providing a high standard of nursing care to patients even though their resources can be minimal at times, which leaves them feeling frustrated and without any voice as their patient’s advocate (Kelly & Porr, 2018). A national healthcare stressor for many healthcare systems is nursing shortages and burnout. These two usually go hand in hand because the shortages of nurses create more of a workload for the nurses, which then leads to burnout.

Due to the aging population, the need for healthcare services has increased. The shortage of nurses can lead to high morbidity and mortality rates as well as errors (Haddad, et al., 2022). There has been an increase in registered nurses and advanced practice nurses over the years due to the aging population and need for healthcare however, due to the increase in demand for healthcare, this can cause turnover and burnout in the healthcare providers (Broome & Marshall, 2021). The shortages we face can hinder the development of policies aimed at creating a better working environment for nurses. If the healthcare systems do not have the appropriate resources, they require for development of policies these get set aside until the need is met. How can a healthcare system put a policy into place if it doesn’t have the workforce to carry it out?

Nursing burnout and shortages are an issue across all healthcare systems today. The healthcare systems are trying to develop strategies to combat the shortages and avoid burnout in their nursing staff. The needs to combat this national healthcare issue include the need for increased workforce and resources. Healthcare systems have already begun putting recruitment efforts in place such as the use of travel/agency nurses, sign-on bonuses, and other incentives to attract more nurses to their facilities. There is also the competing need of practice authority varying from state to state. This creates roadblocks for advanced practice RNs in some states that have restrictions (Broome & Marshall, 2021). Some professional organizations support the idea of mandating a DNP for all advanced practice RNs by the year 2025 which can create more of a problem with the shortage issue solely based on the time it takes to obtain a DNP degree (Broome & Marshall, 2021). I am not so sure that policy will address these issues in a positive way unless it moves away from this requirement. If more states were to get rid of the collaborative agreement for advanced practice nurses, this type of policy change could help the shortages of providers in some states.

When it comes to registered nurse staff in healthcare systems and the shortages they face, policy changes such as the education and experience requirements that some facilities require could assist in the hiring of nurses to help the shortages they are experiencing. Some healthcare systems require you to have so many years of experience in a certain specialty in order to work there. For example, some emergency departments or labor and delivery units require nurses to have at least one year of experience in that specialty in order to be hired. If policy could change in the way of hiring more graduate nurses and training them to the specialty, it could help the shortage. Either way, there needs to be some wiggle room with these healthcare systems so this national healthcare stressor can be managed better. The nurses that are left dealing with this firsthand are getting burned out and exhausted while working short staffed.

Needs of the workforce, resources, and patients makes an impact on the development of policies. Policies are created by upper management who are responsible for keeping up to keep with changes and activities related to policy. Nursing leaders should be aware of health policy so that they can provide input to nursing management and help with the changes that would affect reforms in health care policy (Broome and Marshall, 2021).

Changes in workforce and patient load lead to changing policies with staff to patient ratio. When I first started nursing night shift nurses only could take 4 patients at night on the cardiac floor and now that policy has changed to nurses taking 6 patients per nurse. Resource policy changes as well when supply is low for certain resources such as cleaning supplies for the floor. Different products are used, or different cleaning methods are created to help with the problem.

COVID-19 lead to many changes in policy that were related to staffing and resources. Bedside nurses experienced them the most and policies were changing daily. A Korean study focused on health care policy reform due to its population being older and changes with COVID-19 changed their whole health care system due to COVID-19 affecting the older population more. They didn’t have enough nurses for the increase in patients they were experiencing and in Korean healthcare families play a big part in caring for their loved ones in the hospital. Having more family involvement lead to increased exposure in hospitals. Bedside nurses became involved politically and lead health care policy reform through civic organizations to help resolve visiting and staffing policies during COVID-19 (NamKyung, 2020).

Resource policy changed with COVID-19 due to there not being enough resources such as PPE for staff. The US Centers for Disease Control and Prevention allowed an autoclave sterilization process to be used for N95s due to the reasoning of there being a crisis capacity level. This process used a 70% ethanol treatment, and it was determined that this process did comprise the filters breathability (Grinshpun et al., 2020). Methods like this were used even with limited data because it was safer than nothing at all for frontline workers.

Healthcare is a vital field that provides citizens with healthcare and medical services. Despite its vital role, healthcare is rather a stressful working environment, and proper management of healthcare facilities is a difficult task to do. The medical staff consists of various personnel, and nurses are the most underestimated part of medical facilities. Additional ethical dilemmas for nurses during their duties are rather stressful and harm their efficiency.

In the modern healthcare system, the nursing staff plays an important role by assisting patients and monitoring their health conditions. Also, nurses act as a link between medical doctors, patients, and their families. In the modern American healthcare sector, nursing staff interacts with patients even more than professional doctorate staff. In the contemporary situation, nurses are not secondary, but additional and important medical staff. According to Milliken (2018), nurses are exposed to various ethical dilemmas that affect their overall efficiency and harm healthcare services. The key ethical issues are patient autonomy, confidentiality, allocation of resources, and enormous workload. Milliken (2018) found that current educational frameworks for nursing staff ignore ethical threats, and during real-life duties, most nurses feel unprepared to manage ethical challenges. The enormous workload is a serious problem because it has a national scale, and in the long-term run leads to professional burn-out and retirement from the profession (Kelly and Porr, 2018). Healthcare managers should do their best to avoid overload and additional work shifts for nursing staff. Undoubtedly, all medical staff understands the unstable nature of this profession and the necessity of extra shifts during emergencies, but human beings are not robots and overload leads to a lack of efficiency and mistakes.

The enormous workload of medical personnel is a very dangerous issue that leads to professional burnout, retirement from the profession, and further shortages in the medical labor market. Healthcare managers should use all their skills to avoid extra shifts that reduce overall efficiency and lead to mistakes. In the healthcare sector, mistakes could be fatal and healthcare managers should eliminate all possible risks.

Organizational Policies

The healthcare issue I chose to focus on was nurse practitioner autonomy.  While many states have adopted independent practice for mid-level providers such as PAs and NPs, others require a practice agreement with a physician.  These practice agreements usually cost money and must be renewed in a specific time frame.  The NPs must follow their state license guidelines for procedures and prescribing authority. However, ethical conflicts in the workplace are commonplace in the nursing profession due to conflicting organizational logistics and policies and quality of care (Kelly & Porr, 2018). These ethical conflicts can spread to NPs when they know they can ethically improve access to healthcare and decreases costs if they were allowed to practice independently nationwide which would allow organizations to adopt different organizational policies.

Competing or Common goals

While organizational policies might require a physician agreement, changing laws nationwide would greatly impact the costs and provider burnout in individual institutions.  For example, without the physician agreement requirement, NPs would be able to practice more independently greatly reducing the strain on the healthcare staff in the organization. Likewise, nurse practitioner labor is cheaper than physician labor which would decrease healthcare costs.  This should be seen as a common goal that by allowing NPs to practice independently, healthcare costs would be reduced.  If an organization does not provide the resources to provide quality care to save money, this can lead to ethical conflicts amongst the healthcare staff (Kelly & Porr, 2018).  However, by ensuring that NPs can practice independently, it would save healthcare institutions money and improve access to quality healthcare overall.


            Providing the best quality care possible should be the goal of every organization that has a healthcare function.  Occasionally what is ethical sometimes conflicts with organizational needs. However, ethics is at the center of everything that nurses do (Milliken, 2018). Removing practice agreements for NPs nationwide will allow greater access for patients to access quality healthcare, would help reduce healthcare costs due to various reasons, and therefore would allow for more ethical healthcare solutions.  Specifically, APRNs are poised to address social determinants of health and provide opportunities for underserved populations to access healthcare (Heath, 2022).

Competing needs that impact policy development

            In healthcare, we must have policies to help guide nurses in their specific roles, rules, and regulations of their practice and fulfill a knowledge base for the everyday care of their patients (Annesley, 2019). Policies must be realistic and obtainable, or they will never survive the healthcare environment. When developing a policy, one must consider how it could affect the healthcare workers, patients, and resources, such as the healthcare entity being about to afford the necessities to coincide with the policy.

Nurses work daily with patients at the bedside and should be involved in policy development. They know their working environments and what resources are needed to do their job effectively and can usually anticipate patients’ needs. Part of nursing is knowing the needs of patients with various socioeconomic classes in different environments, being conscientious of ethics and what is right for patients and staff members, and providing the best care for patients (Walden University, LLC, 2012).

Competing needs that impact the nursing shortage and quality of care

            Nurses can agree that nursing shortages affect the quality of care that is provided to patients. They also can usually notice that if there were more resources for staffing, for example, it could lead to a better quality of care (Suhaimi et al., 2021). Resources, such as money, obviously play a large role in nurse staffing because they must be able to pay their staff and add more positions to care for the patient numbers they are serving. There must be an incentive to attract new nurses to the entity to fill open positions, and companies must be prepared for this. Money also plays a factor in caring for the patients and having the resources needed, such as equipment and medical supplies. Lastly, patients impact the nursing need because if a facility has been low census for some time, they will not keep the same number of nurses on duty at one time and may even let some of their staff go if they are no longer needed. There must be an anticipation of what the current patient population might need; for instance, if there are more needy, heavier care patients, the entity must be able to fulfill the needs of this by providing enough care to provide for those patients.

Impacts and how they are addressed

            The impacts of the nursing shortages are causing more stress on the current nurses, causing them to want to leave the profession, creating unsafe working environments, increased errors, and patient care quality problems. Many states have investigated ways to keep and recruit more nurses, lessening requirements for licenses, modifying laws relating to the nursing scope, and paying it forward to healthcare workers through incentives (Enlund, 2022).

The government also recognizes that the quality of care of patients is of utmost importance, and the way to do that is to provide better quality that will reduce errors.  The plan should also include the recruitment and retention of nurses in healthcare entities. The standard set for nurses is that they should only have one patient in a trauma situation in places such as an ER, one patient in surgery, up to two patients in units such as L & D, tele, peds, etc., up to three patients in units such as the ER, four patients in units such as psychiatry and med surg, for example, up to five patients in SNF units, and up to six patients in units such as post-partum (Congress.gov, 2021). As nurses, we all know this is not the case, more often than not. Facilities continue to push nurses to their max performance and expect the top-notch quality to be given to patients simultaneously. Where is the tipping point where these laws or followed by facilities, or else they are fined or held liable for not abiding by them?

According to the American Nurses Association’s Code of Ethics for Nurses (2015), “The workplace must be a morally good environment to ensure ongoing safe, quality patient care and professional satisfaction for nurses and to minimize and address moral distress, strain, and dissonance” (Provision 6, p. 25). The national healthcare issue of medical, clinical, and auxiliary staff shortages in nursing homes and long-term care facilities undermines a healthy moral environment, safe practice for nurses, and quality care for residents. Kelly and Porr (2018) noted that “RNs are constantly challenged to provide quality nursing care, while resources are chipped away,” which exacerbates “frustration, exasperation, and a sense of powerlessness to change their circumstances” (Para. 2). Thus, nursing shortages, deepened by the COVID-19 pandemic, constantly compete with other needs, such as restricted budget, patient dissatisfaction, staff burnout, scarce resources, etc., and directly impact policy development on state and federal levels. According to Enlund (2022, June 20), states endorsed a variety of legislations to alleviate the nursing shortage, including “loosening licensing requirements, changing scope of practice laws, bolstering educational programs, and offering monetary incentives” (State Action section). Most states enacted licensure compact legislature “to allow various types of health professionals to provide services to patients in other states” as virtual healthcare gained more popularity during the pandemic (State Action section). Additionally, states expanded the scope of practice (SOP) for nurse practitioners (NPs), “waiving some types of practice agreement requirements to allow increased access to providers” (State Action section). On the federal level, multiple competing needs and, consequently, inadequate nursing homes performance during the peak of the pandemic prompted a complete policy revision impacting nursing homes and long-term care facilities operations. Thus, on March 1, 2022, the Biden administration revealed a comprehensive nursing home reform to ensure sufficient staffing and funds for safe and undisrupted nursing home functions. According to Edelman (2022, March 3), the reform enables “improving nurse staffing levels and holding facilities and their corporate owners accountable for the billions of dollars they receive under the Medicare and Medicaid programs” (para. 1). The reform provisions pursue such goals as to “establish a minimum nursing home staffing requirement, reduce resident room crowding, strengthen SNF value-based purchasing, reinforce safeguards against unnecessary medications and treatments” and other quality enhancing goals (para. 6).

Additionally, competing needs of the workforce can directly impact the national healthcare issue of the nursing shortage. As facilities are short in staff and desperately seeking solutions to temporarily fill in the gap in the schedule, travel nurses became increasingly popular to provide short-term relief. According to Enlund (2022, June 20), travel nurses are “employed by an independent nursing staffing agency instead of a single hospital,” travel across the country, and “provide temporary, immediate assistance to a hospital or other facility seeking short-term nurse staffing solutions” (Travel Nurses 101 section). According to American Hospital Association (2023, February 16), “data from a forthcoming Syntellis Performance Solutions/AHA report will show that travel nurse full time equivalents (FTEs) per patient day rose over 183.4% from 2019 to 2022” (p. 3). As demand for travel nurses continues to grow, the salary of travel nurses is “three to four times that of a full-time employed nurse” (Enlund, 2022 June 20, Travel Nurses 101 section). As a result, competing needs of the workforce create an imbalance in salaries and further strain healthcare facilities’ resources by operating in the circumstances of staff shortages and paying overcharged staffing agencies’ services. The states attempt to compensate for the impact of workforce competing needs on unfair pricing by applying “price-gouging law,” which prevents an “unconscionable” increase in pricing during emergency and resource scarcity situations (Enlund, 2022 June 20, Travel Nurses 101 section). For example, Minnesota and Illinois imposed limitations on staffing agencies’ pricing with a 150% wage cap “of the median wage rate over the preceding three years” (Enlund, 2022 June 20, Travel Nurses 101 section).

Developing Organizational Policies and Practices

Competing Needs Impacting Nurse Staffing Issues Nurse staffing issues are prevalent in the healthcare industry and significantly impact patient care outcomes. Two competing needs that impact nurse staffing issues are staffing shortages and financial constraints. Staffing shortages occur when nurses cannot meet patient care demands, leading to higher workloads, job dissatisfaction, and nurse burnout. Financial constraints refer to the limited resources that healthcare organizations have to allocate to nurse staffing, which may result in inadequate staffing levels, compromised patient care, and staff burnout (Costa & Friese, 2022).

The relevant policy in our organization that influences nurse staffing is the staffing ratio policy. The policy stipulates the minimum number of nurses required to attend to a specific number of patients. For instance, the policy may require a one-to-four nurse-patient ratio for intensive care units. The policy is intended to ensure patient safety, adequate staffing levels, and optimal patient outcomes.

The staffing ratio policy in our organization has ethical implications that require critical examination. First, the policy may be compromised if healthcare organizations prioritize profits over patient safety. If a healthcare organization understaffs, patients may be at risk of receiving suboptimal care, leading to adverse outcomes, which is against the ethical principle of patient-centered care. Secondly, the staffing ratio policy may infringe on nurses’ autonomy and professionalism, leading to job dissatisfaction, turnover, and burnout. Nurses may feel overworked and undervalued, leading to ethical dilemmas regarding their professional responsibilities ( Abhicharttibutra et al., 2017 ).

To balance the competing needs of resources, workers, and patients and promote ethics, the following policy or practice changes can be implemented: Increase the use of technology to support nurse staffing: Our organization can implement innovative care models, such as remote monitoring and mobile apps, that can increase nurse productivity and reduce the demand for in-person care. This approach can address the staffing shortage issue and reduce the workload on nurses, leading to improved job satisfaction, reduced burnout, and better patient outcomes.

Another practice our organization can do is to Implement a flexible staffing policy. A flexible staffing policy can allow nurses to work flexible schedules that accommodate their personal needs and preferences. This approach can reduce nurse burnout, increase job satisfaction, and improve nurse retention, leading to better patient care outcomes.

Evidence supports the effectiveness of technology and flexible staffing policies in addressing nurse staffing issues. A study by Li et al. (2021) found that remote monitoring technologies, such as telehealth and mobile apps, significantly improved patient care outcomes and reduced the workload on nurses. Another study by Yin et al. (2019) found that implementing flexible staffing policies increased nurse satisfaction and reduced job burnout, improving patient care outcomes.

Competing needs, such as staffing shortages and financial constraints, can significantly impact nurse staffing issues in healthcare organizations. To address these challenges, healthcare organizations can implement policies and practices that balance the competing needs of resources, workers, and patients while promoting ethics. Technology and flexible staffing policies can improve nurse retention, job satisfaction, and patient care outcomes. It is essential to have evidence-based resources that support policy or practice recommendations to ensure optimal outcomes for patients, healthcare providers, and healthcare organizations.

Competing needs refer to the various demands and pressures that healthcare organizations face, including those of patients, healthcare providers, and available resources. These competing needs can significantly impact the development of policies designed to address nurse staffing issues. For example, healthcare organizations may need to balance the need for adequate staffing levels to ensure quality, effective, and safe patient care while managing limited resources and financial constraints( Goldfarb et al., 2008 ).
Specific competing needs impacting nurse staffing issues may include staffing shortages, patient demand, and limited resources, including staffing and staff training funding ( Costa & Friese, 2022 ). For instance, nurse staffing ratios may be impacted by the need to manage patient demand for care, limited staff training and development resources, and staffing shortages due to increased patient acuity and nurse burnout.
Policies can address competing needs in nurse staffing by balancing the various demands and pressures of healthcare organizations, patients, and healthcare providers. Effective policies must consider the various stakeholders’ needs and prioritize their needs to ensure patient safety and optimal health outcomes ( Abhicharttibutra et al., 2017 ). For example, policies may include a balance of staffing ratios to manage patient care demands while maintaining safe staffing levels, providing incentives for staff training and development, and addressing nurse burnout through flexible scheduling and wellness programs.
In addition, policies could address the nurse shortage issue by promoting technology and innovative care models that can increase efficiency and reduce the demand for nursing staff. For example, mobile apps and remote monitoring technologies can help reduce the need for in-person care and increase the productivity of nurses.
In conclusion, competing needs are inherent in healthcare delivery and can significantly impact the development of policies designed to address nurse staffing issues. Effective policies must balance competing needs, prioritize patient safety and health outcomes, and consider the various stakeholders’ needs, including patients, healthcare providers, and available resources. Adequate nurse staffing

Competing Needs Impacts on the Development of Policy

The development of policy is very complex. One must address an issue’s economic, social, and political variables. However, there are competing needs that can impact policy development. These needs include workforce, finances, competitors, or limited resources. These competing demands impact policy development by limiting or altering the resources required to develop the policy. However, these competing needs can positively impact the development of policy by forcing one to address these competing needs and form a stronger approach that will deliver more significant outcomes (Broome & Marshall, 2021; Kelly & Porr, 2018).

Competing Needs Impacts on Nursing Shortage Policy

The nursing shortages affect direct patient care, funding, and reimbursements to healthcare organizations and the general healthcare environment in America. Many competing needs impact the nursing shortage policy development. One competing need would be the nursing workload specifically related to nurse-to-patient ratios. Many states do not have mandatory regulations to limit high nurse-to-patient ratios, leading to high nurse-to-patient ratios and increasing nurse burnout. Nurse burnout leads to other competing needs of the workforce. With nurse burnout, one has nurses leaving the profession. This impacts the development of policy for the nursing shortage by limiting the available workforce. Finally, finances are a competing need that impacts policy development for the nursing shortage. Healthcare organizations must address the nursing shortage issue while improving patient care quality and minimizing or improving financial costs. Depending on the healthcare organization’s funding and reimbursements, along with their current financial status, this could hinder what the organization could offer finically for the policy (Broome & Marshall, 2021; Buerhaus, 2021; Jones & Spiva, 2023; Pittman & Scully-Russ, 2016).

Addressing Competing Needs

One may address the competing needs with the nursing shortage policy development by first setting mandatory regulations for safe nurse-to-patient ratios. This would help improve nursing workloads and decrease nursing burnout. Also, safe nurse-to-patient ratios can improve patient care by decreasing medication errors and infection rates associated with high nurse-to-patient ratios. Next, one must listen to the nurses who left the profession related to nurse burnout and make changes to bring the nurses back into the profession. This will not be a simple fix and will take altering America’s current healthcare as a whole. Finally, healthcare organizations must perform risk assessments to analyze what can be done financially to improve the nursing shortage. The development of the nursing shortage policy will be complex. However, it is vital for the healthcare system in America ( Buerhaus, 2021; Kelly & Porr, 2018; Jones & Spiva, 2023; Pittman & Scully-Russ, 2016).

It is difficult now more than ever for hospitals to allocate resources, resources are becoming more costly and healthcare systems have budgets (Daniels, 2016). During the Covid-19 epidemic we faced a lot of shortages in supplies and resources and organizations had to allocate for that. I believe one of the deficient we have is a shortage of nurses. Due to this shortage, nurses are required to take on a larger workload and patient to nurse ratio. Policies must be development on limits to these ratios to ensure patient safety, the nurses well-being, and nurse retention. The purpose of this post is to discuss how competing needs and limited resources effect policies and how this effects high patient to nurse ratios.

           High patient to nurse ratios can decrease the survival rate for critically ill patients (Lee et al., 2017). When a nurse is assigned a workload with a high ratio, that gives the nurse less time to spend with each patient individually which can make it easy to miss errors or signs of impeding distress. Nurses carry many hats, and they need time to complete all of their tasks safely, to ensure a good patient outcome. Due to the current nursing shortage, organizations have to weigh their resources for care and one of these sacrifices is the patient to nurse ratio. But patient and nurse safety must be taken into consideration when determining how many patients a nurse can care for.

          Nurses are required to provide good quality care to their patients while working with limited resources (Kelly & Porr, 2018). Policies will address the competing needs by setting limits to patient to nurse ratios. While there are patients waiting to be cared for, this should not jeopardize the health of other patients due to unsafe workloads on nurses. There should be policies in place that put a limit on the number of patients a nurse can safely care for. There needs to be policies in place to no only increase patient safety and good outcomes, but also the safety and well-being of the nursing staff. Studies have shown that high workloads, low staffing rates, and long shifts can lead to nursing burnout (Dall’Ora et al., 2020).

Organizational Policies and Practices to Support Healthcare Issues

Allocation of resources is something that nurse leaders can be involved in within the organization at which they work. Many resources are finite, and leaders need to weigh the pros and cons of when and where they are allocated. Nurse leaders have a responsibility to think of the greater good of all involved when making decisions like these. The purpose of this discussion assignment is to explain how competing needs impact the development of policy and then describe specific needs that impact the healthcare issue selected.

Competing Needs Impacting Policy

There are many different resources that organizations have that can be allocated to different needs. One need of the workforce is appropriate staffing. This is an important need as there are laws regarding nurse to patient ratios and when there are not enough nurses, patients may be turned away for care. Organizations do not wish to ever have to do this, so there are resources in place to ensure that appropriate staffing can be obtained. One resource is money. Extra funds may be in place in some organizations to be spent on travel or registry nurses. This being said, these extra funds can only go so far when used on a short-term or temporary fix such as using these nurses. Policies should be developed so that all of the allotted money is not used up on these quick fixes. Our book mentions that nurse leaders have the gift of influence and need to practice that quality cautiously (Broome & Marshall, 2021). Some organizations have policies in place to cap the wages of travel nurses. This creates a dilemma though, if wages are capped, will nurses be less inclined to sign travel contracts (Odom-Forren, 2022). The main issue is that these short-term contract nurses are making significantly more money than the regular staff nurses at an organization. This creates a strain between coworkers that can be carried into the workplace if not careful. Organizations have many different needs but since the pandemic, the issue of travel nurses and wages has become more talked about. There should be policies in place so that this scenario does not occur.

Specific Needs for Staffing Shortages

Nurses are required to continue to work through tough times when resources are allocated elsewhere, seemingly unfair (Kelly & Porr, 2018). I selected the national healthcare issue of appropriate staffing needs and nursing shortages. One condition that impacts this issue is the lack of funds to pay nurses fair wages. One short-term solution to the issue of staffing shortages is to utilize travel and registry nurses. The problem with this is that it is a short-term and very costly solution. These nurses are paid much higher wages than regular staff nurses and then after their contract, they are gone and the unit is once again short staffed. Organizations should be focused on other solutions that will last longer over time. Policies should be made to assist in this. One solution is to retain the staff nurses that are already working there. Most organizations do not give high or frequent increases in wages which is a big reason for high nurse turnover rates. If these organizations had access to use the resources of funds previously allocated for travel or registry nurses, they may be able to offer their regular staff a wage increase or just a bonus. This way, the funds are still being allocated to the short staffed unit but it acts as an incentive for the regular staff nurses to continue coming to work. This can be considered a gamble though and any use of money resources needs to be thoroughly thought through by nurse leaders.


In conclusion, resource allocation is seen in every nursing organization. Nurse leaders are responsible for determining what areas need what resources and when. As mentioned above, there are many different scenarios and needs depending on the time and place and what is appropriate for the organization at that time. Overall, it is essential for nurse leaders to be comfortable making these decisions for the greater good.

The nursing shortage is a national healthcare issue. It has become a major stressor on the healthcare system. There is a myriad of causes for the problem, but most can agree that the shortage of nurses can lead to errors that put the patients at risk (Haddad et al., 2022). The stress caused by the shortages prompts some to take short cuts that affects the nurse’s effectiveness causing ethical dilemmas.

According to Milliken (2018), every interaction between a nurse and a patient has potential ethical impact.  It further suggests that many nurses are not aware that routine nursing tasks can have ethical repercussions. Nurses need to be taught to recognize and mitigate potential ethical dilemmas (Milliken, 2018).

Haddad et al. (2022) shows us that the aging population requires more nursing care. It also reports that approximately one-third of nursing professionals are over the age of 50 and are slated to retire in the next decade.  The shortage is compounded by a lack of faculty to teach new nurses, and organizations such as The National Academy of Medicine lobbying for a policy mandating that facilities have 80% of their nurses holding a Baccalaureate degree (Straka et al., 2019).With some organizations calling for even more advanced education in order to become a Nurse, the time needed to replace the retiring nurses is lengthened (Broome & Marshall, 2021).

Some of the competing needs that impact the issue of the nursing shortage are the fact that there is an immediate increased need for nurses due to the increased patient load caused by an aging population. There is also an urgent need to train healthcare professionals to replace the retiring nurses. One study suggests that using virtual reality can speed up and enhance training making training nurses faster and less expensive (Shorey & Ng, 2021). Policies that accept the use of new teaching technologies to teach certain skills would help alleviate the backlog on nurse education. Policies that would continue to accept ADN nurses would also reduce the educational investment needed to bring new staff onboard.

Quality healthcare should be important to everyone in the healthcare profession for more than one reason: we have two jobs, one the care we provide and two improving the system in which we work. When implementing policy, it is often done with the intent to improve standards that are already in place or for standardized guidelines. According to Mozafaripour (2022), health policies are essential to establish guidelines that benefit the patient, the organization, and the healthcare system.  But should that be the only reason? One could argue that it is rather pointless not to incorporate or consider the needs of the staff who ensures the smooth operation of an organization’s daily operations; however, some see the employees as nothing more than a business relationship and taking the employees’ emotions, feelings, and suggestions into consideration is neither essential nor worthwhile.

While many may argue that nursing shortages existed before the pandemic, there is no doubt that the pandemic has amplified the number of nurses that have exited the profession.  After the pandemic, many nurses suffered from multiple mental health challenges, countless frustration, and immense reports of burnout. Amid all this, they were still expected to offer standardized quality care with unreasonable demands with limited resources. These unrealistic demands further frustrated nurses and gave them no choice but to leave the profession. It is one thing to be dealing with being abused physically, mentally, emotionally, and verbally, but having to deal with little or no resources, inadequate compensation, an increase in demand for quality care, and not having the proper infrastructures in place to do so further forced nurses to seek less demanding jobs roles.

As noted by Kelly and Porr (2018), the excessive workload is a severe issue because of its widespread nature and long-term effects on burnout and retirement from the field.

Organizations are trying everything to cut back on spending and, simultaneously, demand an improvement in the standard of service at the expense of the nurse’s mental health and well-being. In some organizations, the nurse is the phlebotomist, the clerk, the patient care technician, the janitor, etc., while still being required to offer efficient and quality services to patients. Practices of such should be halted, and the general population should be made aware so that new guidelines for safer practices can be implemented.

Without proper security for better, safer working conditions and improvement in resources, the improvement in quality services and patient care will be at further risk. Between our growing population, and people living longer due to the advancement in healthcare and technology being used to improve the quality of life for many, the demand for more nurses is in full effect; however, due to the unsafe nurse-to-patient ratio and the increasing abuse against nurses, many nurses are moving away from the bedside. In some hospitals, nurses are forced to care for up to 10 patients, increasing medication error, mortality rate, frustration, and burnout. In a Detroit hospital, nurses recently filed a wrongful termination lawsuit after they alerted state authorities of their concerns about poor nursing staffing conditions that led to unnecessary patient death (Galea & Galea, 2022). One of the roles and responsibilities of a nurse is ethically “to do no harm,” In doing no harm, it is also the nurse’s responsibility to advocate for the patient’s needs, especially when the patient’s life is endangered. Having to deal with these unsafe practices constantly has further frustrated nurses leading to rapid turnover and nurses moving away from a once-loved role. Healthcare leaders must enforce/implement regulations that will see nurses practicing safely to improve the outcome of patients.

Since the demand for care and treatment has grown significantly, the level of frustration by our patients and their families has also increased. With this increase, the attacks against nurses have also increased, and in places such as the ER, outpatient clinics, and medical-surgical units, the nurse-to-patient ratio is excessive. Healthcare administrators consistently strive to improve the quality of care for patients; however, not implementing policies and guidelines to maintain the safety of their staff will further see a depletion of nurses moving away from the bedside.

Costa and Friese (2022) recommend that the Centers for Medicare and Medicaid Services (CMS) adopt laws to promote safe nursing care and give nurses better working conditions, appropriate compensation, and benefits to enhance patient outcomes. They also recommended that Congress fund the creation of new, safer healthcare systems and expand the testing of safety measures and procedures to improve the well-being of healthcare workers. All nurses should champion these strategies to ensure that the preservation of the profession is continuously upheld to its highest standards and not dwindled down the drain at the expense of this cooperation to save money and ensure the lives of the people we commit to serving are not treated unsafely or endangered.

Competing Needs Impacting Policy Development

The administration of a healthcare institution operates similarly to that of any other business, with the significant goals of maximizing profit, increasing patient outcomes, lessening maintenance expenses, and efficient resource use. When resources and the workforce are unavailable to satisfy these expectations that arise simultaneously and strive to be satisfied together might result in conflicting demands. As a result, there are conflicts between the distribution of resources and the setting of priorities by end users, such as nurses (Kelly & Porr, 2018). To attain the quadruple aim of patient satisfaction, affordable health care, population health, and healthcare worker satisfaction, it is morally, legally, and ethically necessary to deliver the finest patient care to all patients regardless of their background. The rising cost of healthcare, arguably due to the ongoing development of life-saving medication and healthcare technology, has made it more difficult for those who cannot afford healthcare costs to access high-quality care equally. Due to the conflicting needs of employers and employees, mistakes such as medication errors have increased, and nurses’ board licenses have been affected. The Affordable Care Act of 2010 and other healthcare laws have been implemented to eliminate the healthcare disparity brought on by the high cost of healthcare (KEN, 2022).

Competing Needs Impacting Selected National Healthcare Issue/Stressor

The National Health Council (NHC) is dedicated to encouraging the development of a society where everyone has fair access to high-quality medical care. The rising healthcare costs brought on by technical and medical innovation are one of the biggest obstacles to achieving health fairness. Health services for individuals and groups based on evidence-based professional knowledge are considered to provide quality treatment because they are more likely to result in desired health outcomes. Health services must be prompt, egalitarian, integrated, and efficient to have the desired effects of excellent healthcare (WHO, n.d.). According to the NHC (2021), dental treatment is the most common form of care individuals report delaying because of cost, with just half of US adults reporting being able to pay healthcare expenditures. Many facets of healthcare, including hearing treatments, dental work, and prescription medication expenditures, are reported to be challenging to pay for by sizable percentages of persons 65 and older. Adults without insurance, individuals of color, and people who fall below the poverty line are disproportionately impacted by healthcare expenditures. A third of persons with health insurance are concerned about paying their monthly premium, and 44% are concerned about meeting their deductible before their insurance begins to pay benefits (Montero et al., 2022). A significant portion of Americans is burdened by healthcare debt, with 41% of individuals reporting that they owe money for medical or dental expenses, including obligations to credit cards, collection agencies, family members, friends, banks, and other lenders (Montero et al., 2022). The number one concern for Americans today is how to pay for petrol and transportation expenses, which is followed by unforeseen medical expenses (NHC, 2021). Other barriers to accessing high-quality care include the inability of healthcare providers to exchange medical information due to a lack of interoperability, the staffing shortage caused by burnout, the need to hire and retain employees, and the requirement that clinicians receive training in the newest medical technology. Patient safety is crucial for the healthcare system, with increased hospital-acquired infections in 2020. These are competing needs that attract healthcare expenditures before they can be achieved. Also, healthcare inequalities the disadvantaged patient population encounters, such as racial and gender bias inequities, must be addressed (Wolters Kluwer, 2022).

The Impacts and Ways Policy Address Competing Needs

The impacts of these conflicting needs are evident when hospitals have an influx of patients in the ER with easily manageable conditions that have been exacerbated due to healthcare inaccessibility. Also, the poll shows a racial disparity where high quality is less accessible to Blacks and Hispanics, low-income earners, and underserved communities (Montero et al., 2022). The NHC Reducing HCC Initiative evaluates various suggestions for legislation to bring down healthcare prices. The NHC has recognized four major policy priority areas, and its Board of Directors, with input from its members, are reducing barriers to the development of generic and biosimilar products, expediting approval of specific generic applications, improving coverage and reimbursement requirements to expand patient access and promote value, and promoting meaningful transparency on price and cost-sharing. The NHC is dedicated to expanding access to long-term, reasonably priced, high-value care across its programs and policy initiatives. Any savings realized from reforming policies should be immediately invested in ways that would help patients and the systems that support them. Promoting value as defined by the patient must be the foundation of all initiatives to lower healthcare expenditures (NHC, 2021).

Organizational Policies and Practices to Support Healthcare Issues

In theory, a problem or a need can easily be identified and addressed with a simple solution and implementation of a policy or procedure; however, it rarely if ever works this simply, especially in health care. Competing needs of patients such as safe care and of those involved in the decision-making process as well as resources available, including money and workforce, have varying influence on what issues are addressed and how. All these needs are important to consider to ensure organizational success overall as well as success of the policy or policy change. Parkhurst et al. (2021) discuss competing interests on a much larger scale and in regard to malaria, but makes great points about how formulating health policy is not only about evaluating the evidence of what needs (i.e., patient needs and care team needs) are to be met but that many factors need to be considered in this formulation including stakeholders, power dynamics and interests, and the context of the organization itself. The formulation of policy is therefore multifaceted and complex.

Competing Needs, Policy, and APRN Practice Authority

Regarding the issue of limited scope of practice for nurse practitioners (NPs) and other APRNs, competing needs need to be considered as well. State laws and regulations determine whether NPs and other advanced practice registered nurses (APRNs) have full, reduced, or restricted scope of practice; however, facilities and organizations can further restrict scope of practice even further with their own policies (Winter et al., 2021).  In addition to policy restrictions, additional barriers to APRN full practice include lack of resources, poor relations with administration and physicians, and the profession being misunderstood and unrecognized – these barriers can also be considerations for competing needs affecting policy (Schirle et al., 2020). For instance, if the stakeholders do not value nor fully understand the skillset of APRNs and lack the additional resources to promote full practice authority of APRNs within the parameters of the law when resources are already allocated to physicians, policy change in favor of full practice authority is less likely to happen. Also competing needs to be considered, patient safety is a concern for some in relation to allowing APRNs to have full, autonomous practice authority as well as the possibility of increased costs and health care system strain (American Medical Association, AMA, n.d.; Robeznieks, 2020). These competing needs can lead to further miscommunication regarding APRN professions, the value they can bring to healthcare in general and to each specific organization, and consequently negatively impact future efforts to expand APRN practice authority. To address these competing needs, policy can make steps to expand APRN practice authority but with parameters and detailed explanations of roles of each member of the healthcare team to sponsor understanding of their role. Regarding practice authority, like Assembly Bill AB 890 that promotes full practice authority of NPs in California and was signed into law in 2020, organizational policy can make supervisory requirements for NPs and other APRNs, leading to eligibility to qualify for more autonomous practice over time and with more experience (California Board of Registered Nursing, n.d.). These changes can help build APRN relations with other organizational team members, promote patient safety, justify the use of additional resources or the reallocation of resources, and exhibit that no additional strain on the organization will result but that APRNs can be positive health care team members.

How Competing Need Impact Policy Development

Healthcare policies work within the healthcare system to shape and protect everyone and everything within the walls of the hospital. Healthcare policies address healthcare access, delivery of care, cost of care, and privacy and patients and healthcare employees. Policies within healthcare are essential as they assist with the placement of guidelines to benefit everyone within the healthcare system. Policies work to prevent error and poor communication when it comes to decisions of medicine. Examples of healthcare policies could include patient care, drugs, safety and security, and employee health (University of St. Augustine for Health Sciences, 2021). All of these compete for the need of policy development as they are all essential to a functional and safe space in healthcare.

Competing Needs that Impact the Nursing Shortage

As discussed last week, the nursing shortage is a big issue with many factors at hand. With the nursing shortage comes a lack of educators, an increased turnover rate, and unequal distribution of work. Most units are working understaffed and with high acuity patients. This causes nurses to feel unsafe in caring for patients and unsatisfied as they are doing the best they can, yet it is not enough. Nursing staff shortages lead to an increase in human errors, patient and nursing dissatisfaction, and higher mortality rates. This leads to nursing burnout, increased stress levels, and the health of the nurse is now being jeopardized (Haddad et al., 2022).

How can Policies Impact Competing Needs

Ensuring that the workload of nurses is adequate when caring for higher acuity patients will not only ensure that patient’s are safer and happier, but also assist with nursing burnout. As mentioned previously unsafe and high workloads lead to nursing job dissatisfaction and therefore nurses are more likely to leave. This increases nursing turnover and another nurse is gone. Implementing policy of patient staffing and patient acuity will assist in keeping nurses happy and patient’s safer. Adequate staffing levels can result in a decrease of mortality rates, shorter hospital stays, and improved patient and nursing outcomes (Zhavoronkov et al., 2022).

Competing Needs Impacting Policy Development

Forming and implementing new policies in healthcare can be a lengthy and arduous process. When writing policies, we must ensure that we are doing so with ethical practice in mind. Additionally, we must also consider patient care, billing, and data security (Writing Policies and Procedures in Healthcare, 2020). Policy making in healthcare is an involved process that should not be taken lightly.

Competing Needs Impacting the Nursing Shortage

The slow trickle of nurses leaving the profession or retiring has quickly become a hemorrhage that has led to the nursing shortage. Nurses are leaving the bedside or leaving nursing all together. Burnout is a strong contributor to this loss of nurses (Yang & Mason, 2022). As stated in the required media for this week, nurses and nurse practitioners are having to work double shifts to cover the gaps left by the nursing shortage (Walden University, LLC. (Producer), 2009b). This can lead to and worsen burnout. One could say that a competing need impacting the nursing shortage is the nurse’s own well-being. However, we can combat this by providing resources to nurses who are struggling with burnout.

Policy to Address Needs

Facilities should provide nurses with support during trying times. This can be in the form of EAPs (Employee Assistance Programs) run through their insurance. There should be policies in place for nurses to understand how to access these programs. The promotion of self-care for nurses is crucial. As the saying goes, “you can’t pour from an empty cup.”

Several variables contribute to the complex situation of the nursing shortage. These variables include low salaries, poor working conditions, an increasingly aging population, and a lack of nursing faculty to educate new nurses. Broome & Marshall 2021 discuss the nursing shortage and address that one of the biggest threats of having understaffed faculty is the inability to prepare new nurses in school. In 2014/15, 68,936 qualified students were turned away due to these shortages. Although increasing student enrollment will help in alleviating the shortage, other essential factors such as long-term nurse workforce growth and retention can be done by giving nurses access to a secure and encouraging work environment. Even if we fix the problem with increased faculty, we still need to retain these nurses with a better working environment.

There are several policies in place that primarily protect the health and well-being of our staff and patients. These policies are a set of rules and guidelines that help ensure that we are providing our patients with the best care possible. Unfortunately, these policies are not always followed when it comes to our staff. The development of policies regarding safe patient ratios and proper PPE hasn’t always been followed. When these policies aren’t being followed it may cause an ethical dilemma for nurses when providing the best care possible. In Walden University’s video about ethical, moral, and legal leadership, Terry Mahan Buttaro, FAANP states “The moral, legal and ethical implications of practice are all back to the value of providing the best patient care for the community and the individual patient. That is what being a healthcare provider is all about”. According to Milliken, 2018, “Ethical awareness involves recognizing the risk that nursing actions could fail to adhere to the goals of nursing, thereby violating an ethical principle”.

The nursing shortage is a global issue and will continue to be this way until several areas are improved. New policies regarding incentives and bonuses to help acquire and retain nursing faculty can help with this issue. Increasing faculty staff will help with the recruitment of new nurses, however, policymakers should have other considerations regarding pay and workforce environments. This can include tuition reimbursement, sign-on bonuses, and the ability to offer a proper work-life balance. Travel nursing has taken a lot of our core staff away due to the higher pay and more flexible schedule. Policy regarding safe patient ratios really needs to be enforced as well to help retain our nursing staff and prevent burnout.

When developing a policy, various factors and needs must be considered, including workforce needs, resources, and patients. These competing needs can impact the development of a policy in several ways.

For example, the workforce’s needs, such as ensuring adequate staffing levels and maintaining a safe working environment, may conflict with the requirements of patients, such as providing timely and efficient care. If a policy is developed to reduce staffing costs, it might increase workload and stress for the remaining staff, negatively impacting patient care and outcomes (Jun et al., 2021).

As COVID-19 cases surged in the US, healthcare systems became overwhelmed, leading to hospital beds, medical supplies, and healthcare worker shortages. This created a difficult balance between allocating resources to COVID-19 patients and those with other health conditions. It also led to many nurses and healthcare workers facing burnout. In a study completed with over 50,000 nurses, “For nurses who had considered leaving their position (n = 676 122), 43.4% identified burnout as a reason that would contribute to their decision to leave their current job (Shah et al., 2021).” 

Not only were nurses overworked and understaffed, but travel contracts for nurses soared throughout the pandemic, and many nurses were often leaving their primary jobs to join traveling agencies to make more money. That then caused some hospitals to need more nurses regarding their staffing ratios. Nurses that were required to care for more patients than they could handle safely caused increased workload and stress, which led to many of them quitting their job in healthcare altogether.

 Adequate staffing levels are necessary to meet patient needs and prevent nursing burnout, but budget constraints may limit staffing levels (Bielickj et al., 2020). It is essential to recognize that policies may have unintended consequences and that ongoing evaluation and feedback from stakeholders are necessary to ensure policies remain effective and responsive to changing needs.

Competing needs within the healthcare system happen on a daily basis. When we look at competing needs and how they may impact the development of new policies, we need to remember that balancing healthcare issues and the competing needs is an act that leaders and management cannot take lightly. Some competing needs within the healthcare setting are budgeting restraints, aging work field nurses, nurse to patient ratios and the common shortage of nurses. When healthcare facilities create new policies such as those surrounding ethics, the healthcare issue of nursing shortages and burnout come up and can cause issues with fully practicing by that new policy. The code of ethics plays a huge role in healthcare and nursing. When there is an increase in nursing shortages such as recently due to Covid-19, ethics become an issue. According to Kelly & Porr (2018), nurses have become accustomed to not speaking up when they have been told what or how to do something that they know is unethical because of possible policies and or working short staffed. When nurses or providers cut corners to get things done because they are short staffed or facilities tell them to do these things, they are put in ethical situations that can cause an increase in burnout. Milliken, (2018) referenced the same and that often times providers and nurses are prepared due to training, education or management to deal with ethical considerations and this can increase the risk of burnout and create more moral distress.

One way that healthcare facilities can help with the issues such as staff burnout and shortages is creating a policy that designates a nurse to patient ratio. While most facilities state they have ratios, these ratios are not always upheld due to staffing issues. By implementing a policy stating for instance one Registered Nurse may not have more than 5 patients per shift with the following stipulations of acuity of the patient, if there are special needs for the patient such a sitter or devices in which aid the patient with ADL’s. When the acuity of the patient is higher, having a load of 5 patients still places the patient and the staff at risk for injury, burnout, ethical dilemmas.  Congress introduced the bill S.1567 in 2021 which is the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act. This bill states that hospitals must create and submit to the Department of Health and Human Services a minimum nurse to patient ratio. This bill was introduced to help nurses maintain safe and adequate patient staff ratios. In this bill, nurses may refuse the assignment if it is above the minimum ratio. Congress (2021). This type of bill I feel is a must and while staffing is an issue, staffing may get better when nurses hear about specific policies and or bills such as staff to patient ratios. The decrease in burnout, moral distress and unethical decision making will happen because staff are finally being heard.

The physician shortage issue affects the workplace and is also a national problem. A report by the Association of American Medical Colleges highlighted a need for approximately 122,000 physicians by 2032 in the United States (Ahmed & Carmody, 2020). An organization’s policy must address the issue and guarantee quality and safe patient care. However, the organization’s resources must meet all the needs to ensure smooth operation and realization of distinct patient needs. Currently, healthcare facilities in the United States are pressured to simultaneously lower expenses and maintain quality outcomes (Akinleye et al., 2019). Therefore, various organizational needs are competing for financial resources. This discussion post outlines the competing need for drug availability and its effect on developing an organizational policy addressing physician shortage. Furthermore, the post will identify the impacts and how the policy may address the competing needs with examples.

There are various needs in the healthcare organization competing for the available financial resources. The issue of physician policy requires an organizational policy that will ensure the recruitment of an adequate workforce. Such a policy needs funding, leading to increased organizational costs (Terregino et al., 2021). The process of ensuring adequate physicians entails recruitment, training, and retaining. A new physician’s onboarding and recruitment fee is approximated at $500 000 and above annually (Terregino et al., 2021). From this perspective, the organizational policy will compete with other necessities, such as the availability of enough healthcare provisions, such as drugs. The healthcare organization must ensure that sufficient prescription drugs are in stock to enhance patient care. The facility requires much money to buy prescription medicines sold at a high price because of limited competition in the drug market (Vincent Rajkumar, 2020). At this point, the evidence confirms that drugs are a competing need for an organizational policy requiring the hiring of adequate physicians.

The purchase of drugs is vital to successful patient care. However, the high cost of prescription drugs and the need for more physicians increase the demand for financial resources. A lack of adequate funds increases the risk of compromised patient care (Kelly & Porr, 2018). A shortage of prescription drugs raises safety and patient care issues. Therefore, the healthcare organization must prioritize its procurement. On the other hand, hiring an adequate physician staff is a prerequisite. At this juncture, the healthcare organization needs a policy directing the distribution of resources to ensure all the competing needs are met to promote efficiency and quality of care. For instance, the organization may adopt a financing policy establishing the funds available for physician recruitment and prescription medicine (Tikkanen et al., 2020). Identifying money allocated for each need will reduce competition and ensure the healthcare organization has enough medicine and physicians. The physician shortage problem can be solved through an organizational policy advocating recruiting more healthcare professionals.

Healthcare organizations need to pay more attention to the problem of physician shortage. Developing an effective organizational policy depends on finding a balance between competing needs. From this discussion, it can be established that a financing policy has the potential to eliminate unnecessary competition for funding for drugs and the hiring of more physicians, and ensure all services are available to patients.

How competing needs may impact the development of a policy

In the nursing arena it appears that there are frequent times of loss of focus being on the patient, their care, and why the staff and medical facility exist and their role of the care of the patient population.   When policies are being addressed, the financial cost aspect is oftentimes the driving force behind the development of policies.  Healthcare organizations look deeply into ways to minimalize financial cost and burden, while assuring an adequate nurse staffing ratio is met. Finding the means to balance both the needs of the patient and the nurse alike has a direct impact on national healthcare issues and policy development (Patricio, 2020).

Failed policy leads directly to shortages or overages of nursing and clinical staff.  These failures not only have a fiscal effect, but the failures also have a direct impact on quality and quantity of patient care.

Specific competing needs that may impact workload

Specific competing needs that largely impact workload are the needs of both nurses and patient populations. These needs are on the forefront of national healthcare issues.  Healthcare facilities and organizations frequently seek out change and look at exploring creative ways of balancing staffing and patient ratio needs.

Again, the balance that all organizations are seeking to rectify is the balance between quality care in a safe care environment and employing qualify nursing staff that all associated costs with these servic3s are the most cost effective (Holland, 2019). Equal distribution of workload and manageability of the workload requires a balance between patient needs and nursing staff ratios.


The impacts and how policy might address these competing needs

Burnout levels are on the rise here in the U.S. and many career nurses are leaving the field for good.  These past three years in particular have been very taxing and difficult on nurses across the globe.  While many policies and procedures were brought into existence during the COVID-19 pandemic, they were simply not able to compete with the patient care crisis.

Overworked nursing staff during the pandemic, fueled by lack of policy in place to cover such a medical crisis, assisted by the daily changing needs of the COVID positive patient population, led directly to high rates of job dissatisfaction, burnout, and widespread errors. Post Covid, there have been many changes in policy in an attempt to be more prepared should another pandemic like COVID arise unexpectedly in the future.  While these policies look at the future ahead, they cannot make up for what has happened due to the fallout of COVID.

Nursing ratios must be kept in a strict guideline format and policy needs to reflect the ratio guidelines.

How Completing Needs Impact Policy Development

Competing needs are an inherent part of the policy development process, and they can significantly impact the development of healthcare policies. These competing needs can include the needs of the workforce, resources, and patients. The workforce’s needs are significant and can impact policy development as healthcare professionals require adequate resources, support, and incentives to provide high-quality patient care (Kelly & Porr, 2018). If healthcare policies fail to address the workforce’s needs, it can result in healthcare providers being overworked, stressed, and underpaid, leading to burnout and a shortage of healthcare providers. Therefore, policymakers must consider the workforce’s needs when developing healthcare policies.

The availability of resources, such as funding, technology, and infrastructure, is another critical factor impacting policy development. Healthcare policies need to be developed in a way that ensures that there is an equitable distribution of resources across different healthcare facilities and regions (Kelly & Porr, 2018). Policies that fail to consider the needs of resources can result in healthcare disparities, with some communities being underserved and lacking access to essential healthcare services.

Finally, the needs of patients are also a critical consideration when developing healthcare policies. Policies must ensure patients receive high-quality, safe, and affordable healthcare services. Policies should also address issues like access to healthcare services, patient rights, and privacy. Healthcare policies that do not prioritize the needs of patients can result in poor health outcomes, patient dissatisfaction, and increased healthcare costs.


Competing Needs that impact Access to Healthcare for Low-Income Population

Access to healthcare is a fundamental human right, yet it still needs to be discovered for many low-income populations. Several competing needs can significantly impact access to care for this vulnerable group. First and foremost, the needs of the healthcare workforce can create a shortage of healthcare providers in low-income areas. Low-income communities may need more providers as healthcare providers may prefer to work in higher-income areas with better resources and higher salaries (Khullar & Chokshi, 2018). Additionally, the need for help, such as funding and technology, can impact access to care for low-income populations. Limited financing for healthcare facilities in low-income areas can result in a lack of resources, outdated technology, and limited infrastructure, all of which can affect access to care.

Furthermore, the needs of patients can also impact access to care for low-income populations. Many low-income individuals face multiple barriers to care, including lack of transportation, limited availability of appointments, and inability to pay for necessary treatments. Policies that do not prioritize the needs of low-income patients can result in healthcare disparities and further limit access to care.

Competing needs can significantly impact access to care for low-income populations. Policymakers need to consider the needs of the healthcare workforce, resources, and patients when developing policies to address this issue. Failure to do so can lead to unintended consequences, such as increased healthcare disparities and limited access to care (Khullar & Chokshi, 2018). Policymakers must prioritize equitable access to care for all populations, regardless of socioeconomic status.


How can Policies Impact Competing Needs

Policies can have a significant impact on competing needs to access for low-income populations. Policies that prioritize equitable access to resources and services can help to reduce barriers and ensure that low-income populations have access to the resources they need. For example, policies that provide funding for affordable housing can help to address the competing needs of low-income populations by making housing more affordable and accessible (Kreuter et al., 2020). Similarly, policies that provide access to healthcare, education, and job training can help to address competing needs by providing resources and support to individuals who may otherwise struggle to access these services.

On the other hand, policies that prioritize the interests of wealthy individuals and corporations may exacerbate competing needs for low-income populations. For example, policies that prioritize tax cuts for the wealthy may reduce funding for social programs and public services, making it more difficult for low-income populations to access the resources they need (Kreuter et al., 2020).

Overall, policies that prioritize equitable access to resources and services are more likely to have a positive impact on competing needs for low-income populations, while policies that prioritize the interests of the wealthy may exacerbate these needs.


ConclusionTop of Form

In summary, policymakers need to carefully consider the needs of the workforce, resources, and patients when developing healthcare policies to promote equitable access to healthcare services. Failure to address any of these needs can have unintended consequences such as healthcare disparities, shortage of healthcare providers, and poor health outcomes. Policies that prioritize equitable access to care can help reduce these disparities and improve health outcomes for all populations, regardless of their socioeconomic status. Therefore, policymakers must balance the competing needs and develop policies that can address them to promote equitable access to healthcare services.

How Competing Needs Impact Development Policy

The aging of the baby boomer population has increased the demand for nurses in healthcare.  We also have the impact of COVID-19 on top of the demand.  Often, I read that nurses make up the largest population of the healthcare industry, yet there seems to be a problem retaining nurses (AACN, 2022).  Nursing schools are still in business and turning out new graduates continuously, but little focus is put towards keeping the new nurses employed or even in the field at all.   Policies are usually driven by a need therefore it is reasonable to say competing needs of healthcare do lead to policy development,

Competing Needs Impacting Nurse Retention

Nurses are faced with the strain of being forced to follow the business model of healthcare when we were taught to follow the treat-heal-care model in nursing school (Kelly & Porr, 2018).  The stress of trying to care for our patients in a holistic, patient-centered manor along with trying to follow the business centered policy is causing nurses to have inward resentment that causing nurses to strike out towards other coworkers and patients.  This hostility creates a negative work environment causing a problem with nursing retention organization-wide as well as profession-wide.  Pay is another competing need that is impacting nurse retention.  Nurses are finding themselves working alongside other nurses who are from a travel agency making more than double their wages.  Again, this is leading to a negative work environment as well as a negative attitude towards the nursing profession all together.  Unfortunately, the world is always going to have sickness and need for healthcare providers, that need isn’t going to change.  The focus now is how do we address the needs and develop policies to address the competing needs that seem to influence nurse retention rates.

How Policy Might Address Nurse Retention

The Nurse Practice Act (Provision 6), talks about the work environment and how nurses have an obligation to create a good work environment and how work environmental factors can lead to ethical and professional fulfillment or it can hinder ethical and professional environment (ANA, 2015).  In regards to nurses facing the strain from trying to follow the business model of the organization and their desire to provide patient-centered care, executive nursing staff has the ability to create a more positive work environment by including nurses in decision policy decisions.  Develop committees from each department within the organization and have meetings to discuss concerns and try to reach compromise that will not financially harm the organization and still allow nurses to put patient care first.  In terms of nurses harboring resentment towards outside agency staff, nursing executives can implement a policy stating before utilizing outside sources, the shifts should be offered to organization staff nurses at an incentive pay.  This will cut down on hostility towards each other and promote a better work environment.  There is no way to ever create an environment pleasing to all but it is our duty to try to be fair and reasonable.   As nurses we must remember how it feels to work short and how we need nurses, therefore, we should try to make all efforts to work together not against one another.   After all, our Nurse practice Act states “the workplace must be a morally good environment to ensure ongoing safe, quality patient care and professional satisfaction for nurses and to minimize and address moral distress, strain, and dissonance” (ANA, 2015).  This is a must if the profession wants to retain nurses.

Competing needs can be a huge stressor in the workforce. To be able to provide the best care for patient’s proper resources are a necessity. The healthcare issue/stressor that I picked was that of the opioid epidemic and overdoses that occur due to opiate dependency. Resources that would be needed for this subject would be proper educational material for patient’s and providers that help address signs and symptoms of dependency, which can hopefully lead to a decrease in overdoses and addiction rates. Education on different forms of pain management that steer away from opioids.” The National Institute on Drug Abuse (NIDA) has developed tools, as part of its NIDAMED initiative, to educate health care professionals about how to identify and treat patients with opioid use disorders. The materials include continuing medical education (CME), screening and assessment tools, and opioid prescribing resources” (“Improving opioid prescribing,” 2022). By providing these educational materials and additional resources providers and patients can look at different avenues for pain management, become more aware of when opioid dependency is starting to occur and can address what pain levels require opiates and which would be better managed with other medications. The issue with making a policy regarding this topic would be determining how you can label pain in a universal manner in which all patients can benefit from the policy being made. We never want to under treat pain and we want to make sure that the medication being given is appropriate for the type of pain a patient is feeling. Pain tends to be a person dependent which can make it more difficult to create a policy that would apply to all patients. The competing needs can be difficult for many reasons but lack of resources would be the main factor. The facility you work for may not have the budget or ability to allow for extra staff to provide these resources. Which can lead to patient’s falling through the cracks and being provided opiates to address pain when something else may be better suited for the patient. If a policy is created showing that additional resources are needed for the overall benefit and better outcome for the patient, additional funds may be allocated, allowing for safer medication practices.

Healthcare is an evolving field. Aging workforces and populations, technological advances, growing demands for care, and regulatory constraints are all barriers to adequate treatment being provided (McNally 2018). Providing high quality healthcare is influenced majorly by the workforce so policies and procedures in place are key to delivering efficient healthcare, rather than attempting to make policies in crisis situations (McNally 2018).

When psychiatric nurses are exposed to workplace violence repeatedly with inadequate debriefing and follow-up, nurses can experience PTSD, burnout, turnover, decreased quality of care, and higher nurse-patient ratios related to short staffing (Dean et al. 2021).

Healthcare has accepted that there is a risk for violence in the workplace, especially working with high-risk populations, but that doesn’t mean it should be expected. A zero-tolerance policy should be in place, meaning that administrators will react to any complaints of verbal, physical, and sexual abuse promptly (Emergency Nurses Association). Although a zero-tolerance policy can’t stop every threat, special training should be offered to staff on how to handle aggressive situations, crisis teams should be present at facilities to immediately intervene in dangerous situations, and facilities should be inspected frequently to minimize risk factors of violence (Emergency Nurses Association). Evidence-based practice is the best way to implement policies to help avoid situations from arising.

Post a description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Which social determinant(s) most affects this health issue? Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.

Nursing Retention

In the field of nursing we often face heavy workloads, mentally exhausting, physically exhausting, long hours, high stress,  and working short staffed on a frequent basis.  Now add a national pandemic to intensify the highly stressful occupation in the last 3 years and one can see how nursing retention is an even bigger problem.  Nursing retention focuses on preventing turnover and keeping nurses in the field (Tang & Hudson, 2019).  Nursing burnout and shortage are two of the biggest factors that lead to nursing retention problems.  One factor to be considered in retaining nurses is that the profession and organizational leaders place emphasis on employee well-being.  Employee well-being can be broken down in five areas: Purpose, financial, social, physical, and community well-being (Jacobs et al., 2018).  I’ve recently started a new job working for the federal government at a VA hospital, this has been a big change from the private sector hospital I worked at for 16 years.  The private sector hospital faced major issues with nurse retention.  Nurses who had worked there for years such as myself were leaving due to working stressful jobs with inadequate staffing, poor benefits, lower pay than other hospitals or healthcare sectors, and generally not feeling valued.  Now, I’m working in a federal employment sector where the pay is the well above average, benefits are superb, respect for staff is required, workload is divided fairly in a manor relevant to your level of education, and you are paid based on your years of experience.  With all of those perks to working a federal job, there is still a big problem with nurse retention at the VA.

Social Determinants

One common social determinant that leads to nurses wanting to leave the profession is the mental and physical strain on a nurse.  COVID-19 increased the physical and mental demand of the nursing profession.  In an article written by Butler & Johnson (2020), four social determinants were narrowed down to: Family concerns (childcare, moving, non-job illness, and others); Economic (pay and benefits); Stress (job stress, job illness, other job dissatisfaction, nurse job dissatisfaction, and lay-off concerns); and Other (travel, another occupation, and school).  After COVID hit in early 2020, all of these social determinants were even more affected and caused an even higher rate of nursing job turnover and a mass exodus in the nursing profession.  A survey released by Elsevier in 2022 reveals a prediction that 75% of healthcare workers will leave the healthcare profession by 2025 (Bruisie, 2022).  Nurses make up the biggest population of healthcare workers so if this prediction comes true, healthcare will be in for another transformation and crisis.

My Workplace Retention Strategies

The VA has done some restructuring to improve nurse retention.  The organization has adapted to the Theory of Complex Adaptive Systems which recognizes the need for an organization to adapt to change which leads to new and creative solutions to problems within the system (Broome & Marshall, 2021).  The VA recently owned up to the fact that they were one of the lowest paying organizations in healthcare, nurses received a huge raise in salary as high as 24%.  Registered nurses are given an $8000 sign on bonus to be distributed in 4 payments over a year.  After 1 year of employment, the VA offers the Education Debt Reduction Program (EDRP) which pays up to $200,000 of  student loans.  The benefits such as medical, dental, and vision insurances are offered at great rates and provide excellent coverage with a variety of choices.  Retirement is one of the best on the market matching 5% of employee contribution and paying $.50 on the dollar after 5%.  Paid time for 13 federal holidays as well as earning 12 hours of leave time every 2 weeks.  Last but not least,  nurses get 5 weeks of paid vacation from the start of their career at the VA.  Just to show how good this is to me, my former employer I gave 16 years of my career to matched 3% max on retirement, after 16 years working I was up to 4 weeks vacation I had to pay for using my PTO which I also had to use to cover sick time and days we were closed for holidays.  Progress is being maJade but the VA along with all other healthcare sectors have a long way to go and must stay current with benefit and pay incentives to improve nurse retention rates.  Along with pay and benefits, employee well-being must be given high regard as well to promote a healthy work environment.

One huge healthcare issue that we are all facing today is nursing burnout and shortages. There has been an increase in registered nurses and advanced practice nurses over the years due to the aging population and need for healthcare however, due to the increase in demand for healthcare, this can cause turnover and burnout in the healthcare providers (Broome & Marshall, 2021). One study has shown that physicians and nurse practitioners working together to meet the increased demand of patient care is aimed at preventing burnout  and improving access to and quality of care (Norful, de Jacq, & Carlino, 2018). The supply of physicians over the years has decreased which has not helped the demand of healthcare services needed. The longer medical education needed for physicians contributes to the shorter supply which is where advanced practice nurses can alleviate this constraint since their training is shorter (Auerbach, Staiger, & Buerhaus, 2018).

The shortages and staff burnout has caused many issues within healthcare. Just in the emergency department that I work for, the shortage of nurses we experience is causing us work fatigue and burnout. This has a direct impact on nurse retention. Nurses are leaving the high stress setting of the emergency department to work for a lower stress job. There are times I am taking care of intensive care patients plus emergency care, such as cardiac arrests. This causes nurses to question the care they provide and if is high quality because of the needs of these patients. It also makes them question if their license is at risk.

Social determinants of health such as underserved areas is impacted by the shortage of nurses and providers. A culturally diverse nursing staff can help with more competent care of minorities. However, this cannot be accomplished if there is a shortage of staff. We currently have four nurses on staff in the community emergency department that I work for who are Spanish. The Spanish population in this particular area is high so it is important to have staff that know the culture and language for better patient care. Patients with this ethnic background would be more trusting of healthcare staff that have this culture knowledge and experience (Broome & Marshall, 2021).

The healthcare system I work for is attempting to respond to the shortage to end nursing burnout and turnover. They have hired a nursing recruitment agency that is offering sign-on bonuses in order to attract more nurses. They also have offered overtime bonuses to help with the day-to-day operations and have travel nurses working as well. When it comes to the shortage of providers like physicians and advanced practice nurses, they have been using locum tenens (temporary providers) and float providers within the healthcare system. The float providers bounce from hospital to hospital within the healthcare system. Although there are a couple ways they are trying to assist with the shortage to avoid burnout in staff, it seems these measures aren’t really helping. Some staff work the overtime to help however, we are still losing nurses because they are tired and want a lower stress job.

Lack of Mental Health Resources

Lack of access to mental health resources is a problem that is getting worse. The Covid-19 pandemic put a significant strain on an already strained healthcare system, making providers and organizations do more with less, some even having to close their doors permanently. In April 2020, of the surveyed community mental health facilities, two-thirds stated that due to the current financial climate, they believed they could only keep operating for a maximum of three months (Majlessi, 2020). Organizations had to make significant staff cuts, decreasing their revenue while trying to curtail overhead costs. While it did help decrease the costs associated with daily operations, it also decreased the organization’s capability to service more patients and therefore bring in more income.

The pandemic did bring some innovation to providing healthcare for the medical community. Telehealth was more widely accessible, allowing for expanded services in rural and urban areas. Currently, 150 million Americans live in a federally designated mental health provider shortage area (Weiner, 2022). This problem has been a persistent issue even before the pandemic. Telehealth services can cover these areas, but that is not always an accessible or appropriate solution for all patients.

In Iowa, a state ranked dead last in the country in access to mental health, only two beds are available for every 100,000 people (Carpenter, 2023). This creates backlogs in ER and outlying facilities holding patients waiting for an inpatient bed. Access is impacted by social determinants of race, ability to pay, insurance, and location.

Workplace Response

The unit I currently work in came about as a response to many mental health patients waiting in the Emergency Room (ER) for days, waiting for a bed. This decreased our ER’s ability to see and treat patients as rooms were full of holding patients. As a result, one of our nurse leaders created a crisis observation unit to hold medically cleared psychiatric patients awaiting an inpatient bed. This unit is for adults only, with the possibility of opening a pediatric hold unit. This unit is staffed by psychiatric nurses that can adequately meet these patients’ needs. It also provides the patients more freedom- they have their own room and bathroom, and have access to a common room and complimentary therapy, if desired, rather than waiting in one room for however long it takes to find placement for them. Our psychiatric providers oversee these patients and coordinate care with outside facilities. We have a liaison on-site during the week from a local inpatient hospital to assist with placement in their facility and a telehealth service over the weekend that assists with placement. This unit is open to five beds currently, with plans to expand to twelve beds.

Nurse Practitioner Autonomy

One major healthcare issue we are facing today is a provider shortage. With an ever-aging population, many estimates show that in order to meet the demand for primary care providers there will need to be an additional 52,00 primary care physicians by 2025 (Poghosyan et al., 2018). Primary care provider shortages have caused many states to remove the need for practice agreements between NPs and physicians.  One such state is NY after passing the Nurse Practitioner Modernization Act which would enable NPs to practice without written agreements after 3,600 hours of experience (Poghosyan et al., 2018). Getting society, organizations, and physicians to realize that NPs can be valuable independent providers, especially in primary care, is a national healthcare issue. Likewise, another possible model to decrease strain on primary care is the co-management of patients between NPs and physicians (Norful et al., 2018).  One study showed that this model can alleviate burnout, improve patient quality, and decrease individual workload (Norful et al., 2018).

Current Workplace

            Currently, I work in a correctional setting that hires FNPs, Adult NPs, and PAs as mid-level providers.  Working in a correctional setting we are constantly short-staffed in the medical department including providers and nurses. In my place of work, mid-level providers can treat and provide autonomous care however require a physician to cosign on some prescriptions such as opiates and some psychiatric medications.  Nurse practitioners can also perform simple bedside procedures such as I&Ds, suturing, stapling, and toenail removals.  Recently, the agency I work for also started to hire PMHNPs at medical centers due to the psychiatric provider shortage.  In order to attempt to recruit and retain more providers, the agency I work for has also offered generous 25% recruitment and retention bonuses along with paid moves. While there is room for improvement, the agency I work for has gone through great strides to improve mid-level provider autonomy.


            A study was performed at the VA comparing patient outcomes between patients assigned to an NP versus M.D. in various clinical settings (Liu et al., 2020). The study found that patients assigned to NPs were less likely to use primary care and specialty care services and incurred fewer hospitalizations (Liu et al., 2020).  Likewise, the clinical outcomes, diagnostic workups, and costs were not a significant difference between NPs and MDs (Liu et al., 2020). This shows that NPs can and should be trusted to provide patient care independently since they provide the same or better outcomes compared to MDs in some circumstances.  While some states have allowed NPs to practice autonomously, others still require physician collaboration which puts unnecessary strain on an already strained healthcare system.

Workplace violence can occur physically, sexually, mentally, and through neglect. Violence can include beatings, shootings, rapes, threats, intimidation, harassment, and being cursed at/shouted at (Baker and Alshdefat 2020). Although workplace violence in healthcare is a largely arising issue, nurses working in psychiatric facilities are 20 times more likely to be assaulted than any other field (Baker and Alshdefat 2020). It’s reported that approximately 68/1000 psychiatric nurses are assaulted by patients whereas approximately 21/1000 nurses in other fields report workplace violence (Baker and Alshdefat 2020).

Long term complications of being a victim of workplace violence includes anxiety, post-traumatic stress disorder (PTSD), decreased productivity, increased burnout, death, and fear of returning to career but the continuous exposure to violence tends to lead nurses to feel that it’s just an accepted part of their job (Baker and Alshdefat 2020). Short staffing, lack of security, inadequate training, and uncoordinated treatment interventions play a huge role in increasing the risk of workplace violence occurring (Baker and Alshdefat 2020).

Social determinates of workplace violence include patients suffering with untreated mental health disorders, active substance abuse issues, inability to cope with situational crises, access to weapons (such a scissors or metal cans), and their own PTSD from history of violence. Worker risk factors include age, years of experience, gender (women are most likely affected), and absence of training in violent situations (Gillespie et al.).

A couple of months ago I left my job of nearly 3 years at a psychiatric hospital. I loved my job and what I did but the lack of support from management and lack of training for new hires was being physically dangerous. Within a one-year span I was held at gunpoint in the parking lot, spit on, punched, had a printer and desk chair thrown at me, almost received stitches from being hit and scratched, and was kicked in the face due to a new employee not being educated on proper hold techniques. Our facility had no security and an outdated security camera system that never worked, and they had no intentions on changing any of the flaws. During our handle with care training for new hires to learn how to safely do holds, seclusion, and restraints since covid the training was verbal and not hands on. It’s important to understand the steps of things you’re doing to prevent injury to staff and patients before a situation arises.

One of the most in-demand professions nowadays is registered nursing. They offer care in every area associated with health care, including hospitals, doctor’s offices, outpatient care facilities, skilled nursing facilities, behavioral health settings, the home, schools, universities, jails, and workplaces owned and operated by private parties. In addition to being essential patient care providers, nurses play a significant part in addressing health outcomes disparities and enhancing the general well-being of the population (Zhavoronkova et al., 2022).

Nurses have started leaving the healthcare setting in droves, especially since the increased demands placed on them during the pandemic. Nurses have to take on increased patient loads which can adversely affect the rest of the patients they are caring for. These high staffing ratios are a surefire prescription for failure, as anyone who has worked at the bedside can attest. If nurses are given too many patients, they cannot give the best care. Some patients might not get all the required components of evidence-based care, and some requirements might need to be met. It is a system failure, not the nurse’s responsibility that this circumstance exists (Bourgault, 2022).

Some of the social determinants affecting our nursing shortage and burn out are the aging nursing workforce population, increased health demands due to an older population requiring increased care, higher hospital censuses, and greater acuity of the patients. Another major factor is the lack of nursing students that are graduating. Several nursing programs in the United States struggle to build facilities to accommodate qualified nursing candidates. Over 90,000 suitable undergraduate and graduate nursing students were turned away from schools in 2021, according to the AACN’s report 2021-2022 Enrollment and Graduations in Bachelor and Graduate Programs in Nursing. These rejections were due to a need for clinical education sites, classroom space restrictions, and staff (Tamata & Mohammadnezhad, 2022).

Academic Progression in Nursing supported initiatives on two fronts: initiatives that remove barriers that prevent nursing students from earning their BSN, such as support for collaborations between universities and community colleges to enable smooth progression from the associate’s degree (AD) to the baccalaureate; and employment-focused collaborations between schools and healthcare facilities that give students practical experience, encourage greater use of the BSN and create employment opportunities (Gerardi et al., 2018, p. 43).

I currently work in Hospice. We do not have a standard patient-to-nurse ratio. As a whole corporation, they have seen the increased demands on nursing staff and have allotted more nurses to be hired. However, appropriate candidates are hard to find, and few apply. A way our main branch is handling the nursing shortage that we are going through right now is that our director of operations has started to assist with patient admissions and on-call schedules. Our office is working together and being transparent about our difficulties and burnout. This was discussed in Pittman’s article. It was noted how important this was to establish this change (Pittman & Scully-Russ, 2016). Our director of operations is a great leader and checks with the staff daily to see how she can help.

Another significant concern that our director has noticed is taking on new patients that it would take longer than an hour for a nurse to get to. She is looking at how far the patient lives from our main office, and if it is not feasible to provide the proper care to the patient, we send that patient to a different hospice company and ensure they can provide the adequate care required for this patient. Our director is putting her staff first and not the financial bottom line.

In conclusion, the nursing shortage is not a new issue. However, it is now more pronounced as nurses put boundaries into place and expect more from their employers. As healthcare evolves and demands increase, nurses will continue to speak up and advocate for themselves and their patients. The best way to positively affect the nursing shortage and burnout is to listen to what the nurses and health care professionals are saying.  There is not one fix all for this solution. It is gonna have to be tackled company by company throughout the world.

Despite nursing shortages being an issue for many decades in many countries, the global health crisis has impacted the profession significantly. Since the Pandemic, nurses have been exacerbated by its impact. Many nurses were left suffering from mental and psychological exhaustion, frustration, and loss of passion for the love of patient care; these symptoms left many nurses that were highly qualified, skilled, and with years of experience in the profession exiting their roles to venture into different opportunities that were less demanding and stressful. Haines (2022) reported that the proportion of nurses in the profession that are between the ages of 25 and 34 is the largest, but between May 2020 and May 2021, their numbers plummeted by 5.2%, while the second largest proportion of nurses in the age group between 35 and 44 plunged by an even greater 7.4%. Also, the aging population and the need for healthcare have increased the demand for registered and advanced practice nurses over the years; however, the increased demand for healthcare has led to caregiver burnout and turnover (Broome & Marshall, 2021). While many may have theorized that the current problem lies with the number of staff enrolled in the profession being on the frontline, it can be quickly concluded that the actual problem is simply the number of qualified nurses that no longer have the zeal and passion for providing patient care.

I work in the ICU, where my current state and concern for my license are at an all-time high. The impact of nurse shortages has seen nurses practicing unsafely as the nurse-to-patient ratio in a critical setting is unsafe and has caused poor patient outcomes and increased patient stay due to poor nursing practices. Due to the nurse shortages, nurses having to work longer hours further distort their nursing judgment, leading to an increased medication error, increased workplace hostility among staff, and an unsafe working environment. Decreased patient satisfaction is also a significant concern in my work setting because patients have to wait longer for services, e.g., pain medication, thus increasing their suffering. The healthcare setting I am affiliated with was once a magnet institution, which meant the level of nursing services provided was second to none; however, since the satisfaction rate has plummeted drastically due to nursing staff shortages, they no longer hold that status. Hospital-acquired infection such as Catheters-associated Urinary Tract Infection (CAUTI) has also increased due to poor management, e.g., Foley cares every 8hrs not being done, Central line-associated Bloodstream Infection (CLABSI) and Ventilator-associated Pneumonia (VAP) is also on the rise because of nurse shortages.

According to Haddad et al., 2022, nursing continues to face shortages due to a lack of potential educators, high turnover, and inequitable workforce distribution. Some of the social determinants that have been impacting the nursing shortages are burnout; this is so due to nurses having to work longer working hours to help cushion staff shortages in some facilities, e.g., in some institution, after working a 12hr shift, nurses are mandated to work an extra 4hrs because the facility is short-staffed. Technological advancement has seen people live longer due to new and improved ways to treat many illnesses.  Haddad et al. (2022) postulated that as the population ages, the need for health services increases, and currently, the United States has the highest number of Americans over the age of 65 than any other time in history, with statistics indicating that for 2029, the last of the baby boomer generation will reach retirement age, resulting in a 73% increase in Americans 65 years of age and older, 41 million in 2011 compared to 71 million in 2019. As the baby boom generation reaches retirement age, the population is aging, resulting in a greater need for health services. Another social determinant that has affected nurse shortages is violence in healthcare.  Verbal, physical, and psychological abuse are some of the hostility nurses face daily at the bedside leading to many nurses resigning as caregivers.  According to the World Health Organization (WHO), “between 8 and 38% of nurses suffer from healthcare violence at some point in their career” (Kafle et al., 2022). Because of how common violence and abuse against nurses have become, it has not only led nurses to exit their role in the profession, but its impact has decreased productivity and patient outcomes.

Dr. Brenda Freshman has alluded to the notion that to address future challenges in healthcare, the most crucial thing leaders can do is develop cultural competency, the ability to take multiple perspectives, and a greater understanding of the whole system of the organization (Walden University, 2015).  To help alleviate this issue, my healthcare facility has tried to hire outside recruiters with attractive and competitive pay packages that attract travel nurses to sign a contract for 13-26 weeks and work a 48hr work week. The organization has also hosted job fairs to lure in recent graduates and nurses interested in working for an attractive compensation package with an enormous sign-on bonus for up to three years. Further measures taken by the facility to combat nurse shortages include the implementation of up staffing and mandatory on-calls. To retain their current staff, they have been considering retention bonuses that will help to prevent their highly trained and qualified nurses from resigning. Another effort by the organization to address nurse shortages is the impending introduction of remote nurses, who will support bedside nurses and give them greater flexibility in providing better care for all patients. Finally, more grants and scholarships are introduced for nurses to continue their education, which has seen many nurses capitalize on this opportunity to help boost their morale, which benefits the organization in the long run.

The Healthcare system has suffered immensely since covid, and the aftermath has left many healthcare workers struggling to continue their work at the bedside. The demand for healthcare services has caused more stress to nurses, and as such, despite measures implemented, nurses are still abandoning their roles for jobs that have less stress and demands.

Review of Current Healthcare Issues

Depending on who you ask, answers will vary significantly on what is thought to be the most significant issue facing healthcare today. As nurses, it is important to stay up to date on these national issues so that understanding and implementation can be translated into the workplace. The purpose of this discussion post is to select one current national healthcare issue to reflect on and to think about how it is addressed in the workplace setting.

Nursing Shortages and/or Appropriate Staffing

In America, the total number of working registered nurses is about four million (Baker, 2022). Historically, there have rarely ever been enough nurses to act as a supply for the demand of services needed. Recently, with the COVID-19 pandemic, the supply of registered nurses has decreased while the demand has significantly increased. This is due to many reasons. Some nurses have gotten ill from the pandemic and have not been able to return to work while others have chosen to retire to avoid being surrounded by COVID. Another reason includes burnout and turnover from this increased demand (Broome & Marshall, 2021). When there are not enough nurses available to be scheduled on a unit, organizations are forced to use short-term solutions to provide appropriate care. Some of these short-term solutions include the use of agencies to supply travel nurses as well as bonuses for those already on the payroll (Chervoni-Knapp, 2022). These are considered short-term solutions as they ultimately are not sustainable for organizations to be involved in for a long period of time (Chervoni-Knapp, 2022). Organizations are faced with this tough choice as the alternative of not enough nursing staff would mean that fewer patients are cared for and less money is made for the company. This could result in entire organizations having to shut down which then would lead to significantly fewer beds available for those who are sick. As you can see, there is no perfect solution for this problem and most organizations are trying their best just to get by.

Workplace Impact

I have worked at an inpatient psychiatric facility since 2019. It has been an interesting experience to work before COVID, during COVID, and now, while COVID is decreasing. Before COVID, the unit where I worked was always appropriately staffed, if not overstaffed, on each shift. I remember being canceled every so often as we consistently had more than enough nurses to care for the patients. During COVID, there seemed to never be a day that enough nurses were working. My workplace utilized travel nurses and registry agencies to maintain adequate license-to-patient ratios. A downside to this short-term solution is that for one, these nurses cost a greater amount of money than regular staff nurses do due to the demand as well as these nurses are not familiar with the unit or the company procedures and need time to learn. These downsides created an upset in the unit where I worked. Now, since COVID has been decreasing, my unit has not needed to use travel nurses or agencies to staff it appropriately. We still are not always fully staffed, but accommodations have been made. One is that the organization offers bonuses to staff to come in on their day off if the unit is short. Another is that if another unit has extra staff, they will be floated to my unit for the day to help out. This has been working enough for the past few months. I hope to see soon where the unit starts becoming adequately staffed again.


In conclusion, national nursing and healthcare issues are prevalent throughout America. Every nurse and organization will have an opinion on what they believe is the most significant issue. This being said, the issue of nursing shortages and struggles with appropriate staffing has been endured by most due to the COVID-19 pandemic. Overall, nurses should be educated and aware of these issues so that complete understanding and change can occur.

As many of us pursuing degrees as advanced practiced registered nurses (APRNs) know, despite receiving an expansive education to provide care to patients, the state that we choose to practice in, its laws and regulations, will affect to what capacity we are allowed to practice and utilize the skills we have learned (American Association of Nurse Practitioners, AANP, 2022). Although strides to expand scope of practice for APRNs have evolved over the years, there are still limitations. These limitations are problematic because of shortages in healthcare professionals, particularly advanced practitioners. As Poghosyan et al. (2018) discusses, for example, that more than 50,000 physicians will be needed by 2025 to meet the demand for primary care but the number of physicians are decreasing while the number of nurse practitioners (NPs) that could potentially fill these gaps are increasing. Health care disparities and inequalities are not new topics, but in this world of Covid-19, these disparities and inequalities, the social determinants affecting them, and the resulting patient outcomes have been highlighted and emphasized (Heath, 2020). Heath (2020) continues to state that health inequalities are rooted in the social determinants of health because they can limit an individual’s ability to achieve optimal health and wellness.

For this issue, the social determinant most involved in this topic is health care access and quality, specifically access to time effective and “high-quality health care services,” because limiting the nurse practitioner’s ability to practice to the full extent of their education and knowledge limits how they can be adequately used in every community to contribute to the availability of health care services to the members of those communities (U.S. Department of Health and Human Services, HHS, n.d.). Nurse practitioners can play an important role in addressing this issue not only because of the increased numbers of nurse practitioners in the workforce but also because of the nursing approach founded in holistic patient care, building a connection with patients, and practicing with compassion and empathy (Heath, 2020). Expanding nurse practitioner scope of practice regulations can allow them to work to their full potential, fill in gaps in care that physicians are unable to, and provide care to the millions in communities with limited access to primary care or other care. For example, the ten states with the most flexible nurse practitioner scope of practice laws and regulations have some of the best overall health outcomes while the ten states with the worst overall health outcomes have the strictest laws and regulations regarding nurse practitioner scope of practice (Heath, 2020). Broome and Marshall (2021) also discuss how APRNs are a resource that should be utilized fully by referencing a study in which “the addition of nurse practitioners (NPs) to an inpatient care team at a single site demonstrated enhanced revenue through gross collections and cost efficiency, reduced overall lengths of stay, and standardized practices to improve quality of care” (p. 71).

As a travel nurse, I see the workings of many different facilities and how functioning with limited staffing versus adequate staffing can affect team communication, timely patient care, and patient outcomes. The lack of more autonomous APRNs in the inpatient setting, from my experience, leads to longer wait times for patients and bedside nurses to hear from the care team about issues that arise and to participate in care team rounds that require the physician to be present. Of course, bedside nurses can call, page, or message the physician, resident, intern, or even the physician assistant if applicable but typically nurse practitioners are not utilized as a functioning, decision-making part of the team which would be valuable. For example, I have had patients complain about feeling neglected by their physician because no one was able to round with them for a day/a few days or that no one from the care team came to see them until late in the day because the physician and team of residents and physician assistants were busy with other patients and tasks. A nurse practitioner may have been helpful to fill these gaps. Also, because nursing education is grounded in a holistic approach at every level, their input may provide a different perspective to the care approach and decision-making that may improve patient-provider relations and patient outcomes. Again, as a travel nurse, I do not have much insight into organizational changes or initiatives because of the limited amount of time I spend at each facility, however, at the current facility I work at in California I can honestly say that I have not heard of any initiatives to alleviate this issue during huddles or unit meetings. I cannot recall interacting with a nurse practitioner at this facility at all. From what I have heard from staff members, this Kaiser facility does not utilize nurse practitioners at all or very rarely. This may be a consequence of California state law and/or specific Kaiser policies in this region. This facility could greatly benefit from utilizing nurse practitioners from my experience as I have had the pleasure of working with APRNs in my home state of Pennsylvania; they serve as an invaluable resource and bedside nurses and physicians alike relied on their expertise greatly. As Poghosyan et al. (2018) reports, many physicians believe that nurse practitioners are competent members of the care team that can expand the capacities of health care practices and help meet the increased demand for quality patient care.

National Healthcare Issue/Stressor – The High Cost of Health Care

Healthcare expense in the United States is among the highest in the world compared to other developed nations. The US spent 4.3 trillion dollars on healthcare in 2021, or around $12,900 per person, according to Peter G. Peterson Foundation (2023), compared to other first-world countries that only charge around half as much for healthcare per person. Healthcare expenses have risen over the past several decades relative to the size of the economy, from 5% of GDP in 1960 to 18% in 2021 (Peter G. Peterson Foundation, 2023). The rising aging population and healthcare costs are the two most significant drivers. The proportion of Americans aged 65 and older has increased considerably (Broome & Marshall, 2021). Americans over 65 spend more on healthcare than any other age group because of age-acquired illnesses. The cost of healthcare services frequently increases more quickly than the cost of other goods and services. The Consumer Price Index (CPI) for medical care has increased by 3.4 percent annually.
The introduction of cutting-edge, innovative healthcare technology that results in better but more expensive services and products; organizational waste in the insurer and provider payment systems may be brought on by the complexity of the American healthcare system; and hospital mergers may bring about a lack of competition and a monopoly that attracts high prices are a few additional potential causes for the rise in healthcare costs (Peter G. Peterson Foundation, 2023). One-fourth of people report delaying or skipping care due to cost, making costs a significant barrier to access. High healthcare costs sometimes prevent people from getting essential care or finishing their medications. They have missed doses, cut pills in half, or not finished prescriptions in the last year, with more significant percentages among those with lower incomes (Montero et al., 2022).

Impact on Work Setting

The hospital had noted a tendency in some patients who could not pay for care when they first sought medical attention and later learned they had severe illnesses due to delaying or skipping medical visits for routine checkups, therapy, or rehabilitation following surgery or a treatment, aftercare, or an inpatient stay. As a result, of the high cost of medical treatment, patients’ health deteriorated, and undiagnosed or untreated medical conditions developed worsening symptoms, necessitating additional, more expensive therapies that would only worsen the initial problem causing these patients to be admitted to the hospital (Experian Health, 2022). There are more patients with serious issues who, if appropriately managed as outpatients, may have avoided admissions to emergency room (ER) services for medication-related diseases that escalated because they missed doctor appointments. It often results in a needless ER admission, which raises medical expenses since ER treatments are generally expensive (Rakshit et al., 2023). As a result of unpaid medical bills, calls to patients to inform them about outstanding debts for at least 120 days before pursuing extreme steps have increased. Invoices are subsequently forwarded to a collection agency when all available payment alternatives have been offered to the patients and have yet to be taken advantage of have been seen. Patients with medical debt hospitalized for stress and high blood pressure are becoming more common in this hospital (Rakshit et al., 2023). Due to the high cost, it is found that some patients are thinking about switching providers and moving to a location with lower costs. When patients fail to appear for their appointments, it jeopardizes the quality of medical services. It affects resource efficiency, resulting in a loss of projected income in services, interfering with medical processes, and wasting time and resources.

Social Determinant

The effects of high healthcare costs are felt most acutely by those without insurance, those of color, and those with lower or no incomes who lack healthcare resources to obtain health insurance or pay for expensive procedures and prescription drugs. Some people claim that they cannot afford specific forms of therapy and delay or skip receiving medical care due to the cost (Montero et al., 2022). Individuals who reside in rural areas, belong to specific racial and ethnic groups, are physically disabled, or are members of specific communities are more likely to struggle financially to pay for expensive healthcare. Institutional racism and discrimination lead to disparities in social and economic opportunities and resources. The resources necessary to ensure a high quality of life, such as healthcare programs like Medicare and Medicaid, are typically inaccessible to those in disadvantaged areas. Unfulfilled social needs, environmental factors, and barriers to seeking medical care, such as high expenses, all contribute to worse health outcomes. Poverty can limit access to educational and career opportunities and widen the wealth gap, creating a vicious cycle of poverty and the inability to pay for adequate healthcare. The risk that an individual would experience poverty as an adult rises due to childhood poverty, which feeds poor generational cycles (H HS, n.d.). People without access to quality education throughout their lives are more likely to find themselves in difficult financial situations, making it more challenging to afford quality healthcare. The likelihood of finding higher-paying occupations with fewer safety dangers increases with education. More educated people ultimately have more significant financial resources to pay for and receive high-quality healthcare.

Health System Work Setting Response

Being a non-profit hospital, the healthcare system where I work provides treatment for those in need, regardless of their financial situation or state of health. No matter what medical challenges a patient may encounter, they can obtain the best care possible because of their financial support and other measures they have put in place to help pay for medical bills. The hospital’s billing office telephone number allows patients with financial difficulties to call and discuss options like a payment plan or financial aid. These services for financial support consist of fair and standardized billing and collection procedures, such as Charity Care, financial aid policies, and a standardized application procedure. Once a patient is eligible, their Charity Care programs are utilized to pay all or a portion of the hospital charge. There is also a payment arrangement with zero interest and extended payment plan choices for patients who owe medical bills to pay off their debt affordably. This hospital provides a minimum monthly payment of $25 for 36 months. This enables people with high medical costs to stay compliant with their medical care and has a positive societal impact (Parkview Health, n.d.). This hospital prevents surprise medical expenditures by providing patients with realistic pricing projections. Clear and precise estimates are provided to equip patients better to arrange their finances and make treatment decisions. The estimates are provided to patients through an easy-to-use self-service website (Parkview Health, n.d.). Despite budgetary limitations, this hospital also provides emergency care. It is one of 12 grant recipients countrywide who must get money to develop its Medication Assisted Treatment (MAT) clinic program, with aims to treat drug addiction disorders, notably opioid misuse disorder, by offering free medicine, counseling, and behavior therapy to patients who would not otherwise be able to pay for their prescription medications (Parkview Health, n.d.). Employee discount offers a variety of healthcare goods and services to its employees and beneficiaries. Also, this hospital employs social workers and medical professionals who inform patients of outside resources they might use for assistance. With case management, patients may set up Medicare and Medicaid programs. They have pharmacy discount cards available and provide information about healthcare facilities like Matthew 25 Health and Care, a gospel-inspired medical facility. They offer high-quality medical and psychiatric services free of cost to low-income, uninsured adults, bringing joy to the most vulnerable in the neighborhood by treating them with kindness and dignity despite their socioeconomic status or religious views (Matthew 25 Health and Care, n.d.).

Healthcare Issue/Stressor-Nursing Shortages and Quality of Care

            Every day, nurses are expected to do their job and do it to the best of their ability. I currently work in a clinic setting, and we are adding more and more clinics. Each nurse has clinics they are specifically assigned to. But what happens when they keep adding more and more, and we only are allowed a certain number of employees? Well, I can tell you that we will have to work those clinics and care for those patients. The biggest question that comes to mind, though with that, is how thin can staff be stretched? We run into issues such as insufficient time to room patients and get a full health history appropriately. So then, what are we missing that we should be aware of. That, for example, leads to quality-of-care issues. As a patient, I know I’m not the only critical patient that day of my visit, but I know I’d like to feel like they are dedicated enough to learn and know my whole story, problems, etc., to develop a plan of care. The example listed above is only one example of how nurses are shorted and overworked many times, and in turn it lacks on the patient care end and providing quality care simply because they do not have the time.

Many reasons have caused staff shortages, but today, one can think that the COVID-19 pandemic did not help the situation. Any nurse that worked through it probably wanted to run away from it. Most healthcare entities had difficulty staffing their facilities during the pandemic, especially in rural communities. Nurses being short staffed causes increased mortality rates, length of stays and hospital readmissions, patient safety problems, errors, lack of quality of care, and wait times (Norwich University Online, 2020). The nursing field continues to experience exhaustion and burnout. The nursing turnover nationally ranges from 8.8-37%  (Haddad et al., 2022).

Social Determinants

            Social determinants of healthcare are the patient’s financial situation, their level of education, employment status, work and home conditions, ability to get food, age-appropriate development, social situation, and affordability and accessibility to quality of care (World Health Organization, 2018). When speaking of quality care, all the social determinants of care can be quality factors. Specifically in our clinic, financials are a bit problem, especially when it comes to getting medications that are prescribed. Thinking back to a specific example of a patient not being able to afford simple over the counter medications for a colonoscopy. We then had to send in the MiraLAX and Bisacodyl through insurance because they could not pay for them through food stamps. Many of the patients with low socio-economic status’ do not receive the preventative care they need until major health problems arise, and that is when we see them more in the clinic in one or more department. This is, in turn increases patient loads because of the many appointments that they have in the clinic or even some patients we have come in for daily or even twice daily antibiotic infusions, which we must work our other patients around. Again, going back to only so many staff nurses, being shorthanded, affecting the quality of care, and needing time to care for each patient appropriately.


            Our clinic setting has taken a team approach in this staffing issues. We stay central to our clinics to maintain continuum of care, a positive aspect of quality of care. We have had to learn new clinics to ensure their patient load is appropriately cared for. In our downtime, we get into the inbox and promptly respond to patient calls, refills, and results notes. Hopefully, we will also add a specific nurse that can take care of prior authorizations, med refills, result notes, patient notification, etc,. That way the rest of the nurses can focus on patient care. We also have a manager that genuinely cares about quality care and how the clinic runs. She also assists in getting PRN help when needed as well. Many aspects make up quality patient care, and just because we are short staffed and they are adding more and more clinics does not mean that we cannot provide the best care around. I would compare our approach to the core competencies of teamwork, values, responsibility, knowing our clear roles, and communicating with one another (Broome & Marshall, 2021).

National Healthcare Issue/Stressor

The national healthcare issue/stressor I have chosen is COVID-19 and personal protective equipment. Any change in a work setting comes with pushback. In healthcare change is inevitable and learning how to cope with change while delivering effective care is necessary for healthcare professionals (Broome & Marshall, 2021). COVID-19 was a change that was unexpected and led to massive changes in a short amount of time. Hospitals and healthcare facilities were not prepared for a pandemic and PPE was in high demand. COVID-19 caused stress for healthcare workers due to lack of resources, unsafe working conditions, long working hours, stress of exposure, and PPE that was uncomfortable and hard to work with (Evcili & Demirel, 2022).

Impact on Work Setting

I currently work in a peri-op setting and before COVID we were only required to wear PPE when the patient had a known respiratory illness or if was required due to a different isolation reason such as C-Diff. Due to COVID, we now always wear masks in pre-op and PACU. When COVID was at its peak, we had to always wear N95s and protective eyewear. Our health care system still requires staff and patients to wear a mask. Many people have pushed back and have left to other systems in the state who do not require staff to wear masks.

Social Determinants

Social determinants that have been affected due to COVID and PPE are working conditions and medical care. COVID has made working conditions stressful for healthcare workers and being in PPE 12 plus hours a day is very uncomfortable. PPE and COVID at its peak, affected the care patients received because nurses had to learn how to reprioritize their work and provide tasks for many patients at a time. COVID-19 has led to missed nursing care and leads to longer lengths of stay for patients and higher rates of readmission (Khrais et al., 2023).

Health System Work Setting Response

COVID has affected all healthcare workers in some way. Healthcare is still recovering from it. There has been recent talk in my healthcare system that masks will not be required anymore due to push back from patients/staff. Our organization currently does not require them in a non-clinical setting. I will be interested to read if other healthcare systems still require them in other states from all of you!

Staff Shortage in Long-Term Care Facilities

The national issue of nursing and primary care provider shortages constantly impacts work in my healthcare settings of long-term care and rehabilitation facility within the ProMedica healthcare organization. Ricketts and Fraher (2013) noted that the nursing shortages pattern resembles a sinewave prompting policy development that “stimulates rapid growth leading to surpluses” (p. 1876). Periera and Bowers (2021) confirmed that “the nursing supply between 2014 and 2030 is expected to exceed demand, with a projected surplus of 293,800 RNs by 2030” (p. 83). Despite these projections, the skilled nursing facility (SNF) where I work constantly experiences workforce shortages in nursing assistants, nurses, and primary care providers. The nurse-patient ratio of one-to-thirty instead of one-to-twenty became the new normal, inevitably resulting in diminished quality of patient care, patient dissatisfaction, and staff burnout. The continuous effort of Human Resources to hire new employees does not have much effect on adequate staffing either due to high turnover rates. According to Periera and Bowers (2021), “turnover of nurses within healthcare organizations is common, with 20% of nurses leaving their job within the first year of employment” (p. 84). Therefore, to maintain sufficient staffing and uninterrupted work of the facility, reorganizational strategies should be implemented beyond simply hiring new employees.

According to Walden University (2018), the Triple Aim of healthcare, which is increasing access to healthcare, improving clinical outcomes, and reducing the cost of healthcare delivery, was converted to Quadruple Aim with added focus on environmental effects that include work life and provider experience improvement (Walden University, 2018, 1:15; Periera & Bowers, 2021, p. 69). Hence, one of the reorganizational strategies and health system work setting response to the healthcare issue of staff shortages would be enhancing employees’ well-being and experience. Jacobs et al. (2018) noted that “making well-being an organizational strategy could be a way to improve employees’ lives while achieving organizational outcomes” (p. 232). The authors overviewed Anne Arundel Medical Center’s approach to enhancing employees’ well-being, including educational opportunities, career development, social, financial, and physical expansion, and assuring community support (pp. 236-237). ProMedica healthcare organization also provides diverse programs to support employees in their daily work life, particularly during hardship times. Thus, ProMedica launched Employee Assistance Program (EAP) that offers mental health counseling, stress management, substance abuse consultation, solution support, and is open for employees 24 hours via telehealth, phone, or in-person counseling (ProMedica, 2023). Additionally, ProMedica ensures employees’ wellness via 24/7 telehealth support for adverse health conditions, unemployment protection, and family/parental support.

Another reorganizational strategy and health system work setting response to staff shortages would be engaging the nurse practitioners (NP) workforce to support primary care providers. Norful et al. (2018) noted that one of the reorganizational models “includes having more than one primary care professional comanaging the same patient and sharing the workload responsibilities or care management tasks” (p. 250). The authors noted, however, that current legislation and organizational policy restrict nurse practitioners’ authority leading to a “physician-led hierarchical infrastructure in which the physician has the final decision-making authority” (p. 252). The authors further collaborated that perceived NP lack of authority can be mitigated by NP-physician shared philosophy of care, mutual respect and trust, and effective communication, which, in turn, will be beneficial “to meet demand of patient care” and alleviate “individual provider workload” (p. 253). Lovink et al. (2017) confirmed that the collaborative work model of NPs and physicians and even the substitution of elderly care physicians (ECPs) by NPs, physician assistants (PA), or registered nurses (RN) is possible if NPs, PAs, and RNs are supported by management and physicians, “collaborating with the ECP based on trust, [and] sharing the same views with the ECP on good resident care” (p. 9). The SNF where I work is at the beginning of adopting this model. With only four primary care physicians for a 200-bed facility, organizational management attempts to assign certain patients to third-party organization nurse practitioners who work discordantly with the facility’s permanent physicians and nursing staff. More efforts should be made to advance the education of already employed RNs to NPs and promote collaborative work with primary care physicians in the facility.

Finally, working synergistically with educational underprices and providing a launching base for new nursing assistances and nurses can serve as an additional reorganizational strategy and health system work setting response to the healthcare issue of staff shortages. According to Jean (2022), such innovative approaches as “training new technologies, […] providing a ‘flexible workforce,’ [ensuring] personalized educational opportunities, […] or providing tailored educational opportunities” are effective ways to address healthcare personnel shortages (Using Innovation to Address the Nursing Shortage section). The author pointed out that the nurse residency programs effectively combine learning opportunities for nurse novices and fill in the gap of nursing staff shortage (Using Innovation to Address the Nursing Shortage section). For example, the SNF where I work effectively uses its settings as an educational platform to prepare nurses and nursing assistances. Many students who graduated from local community colleges decide to apply for a job and continue working in an already familiar environment.

Therefore, searching for working model reorganizational strategies, such as enhancing workforce well-being, promoting a collaborative approach of NPs, RNs, and physicians to centered patient care, and enhancing educational opportunities in both ways offering tuition reimbursement programs and serving as an educational practice site, is an effective way to recruit new healthcare team members and retain the already existing workforce.

The challenge of training nurses has been a national healthcare issue in the healthcare industry. Having well-trained nurses is essential to ensuring patients’ highest quality of care. It contributes to ensuring that nurses have the information and abilities needed to effectively carry out their tasks and care for patients in line with accepted standards of practice. Efficient and effective clinical training for nurses is required to ensure that healthcare is provided efficiently (Will et al., 2019). Although the lack of enough skills for nurses is particularly pertinent in the rapidly changing technology environment and increasing complexity of care delivery, this issue must be addressed (Ricketts et al., 2013). This issue can potentially impact my work setting as it could lead to making mistakes in delivering medical care, resulting in poor patient outcomes, incorrect diagnoses, incorrect medications, or even missed symptoms that can have serious health consequences.

In my work setting, we have responded to this issue in several ways. First, our organization has provided ongoing training and workshops for nurses. This training focuses on the role of nurses and the importance of collaboration and communication. We have also implemented an electronic health record (EHR) system to help streamline the workflow and reduce the burden on nurses. The (EHR) system has improved the quality of care, lowered costs, and improved productivity by making care more efficient and effective (Negro-Calduch et al., 2021). Finally, we have implemented several initiatives to increase nurses’ satisfaction, such as flexible scheduling, mentoring programs, and educational opportunities. In conclusion, this challenge of training nurses must include regular workshops and conferences, implementing an EHR system, and improving nurses’ satisfaction. Our firm is working to guarantee that healthcare is delivered effectively and efficiently through these ways.

Review of Current Healthcare Issues

             Nurses make up the largest section of healthcare professionals and according to the US Bureau of Labor Statistics, the need for nurses is expected to grow from 2020-2030 (Haddad et al., 2022). Possible causes of the current nursing shortage include, lack of educators and high turnover rate. With the aging of the baby boomer generation, there will be an increase need of care for the elderly, as their health progresses. Another factor that lead to our current nursing shortage is the Covid-19 virus, this virus increased the demands for nurses and the volume of patients being seen (Turale & Nantsupawat, 2021). The purpose of this discussion post is to discuss the national nursing shortage and how it affects my workplace.

Nursing Shortage Impact on Emergency Department

             In the emergency department we see critically ill patients every day, and it is our job to triage and appropriately place the patient where they need to go. This can be challenging when there is an increase in volume of patients in the department and a shortage of nurses to care for them. Nursing shortages in the emergency room increase the door to discharge length of stay and increase the number of patients that leave before being seen (Ramsey et al., 2018). Some social determinants affecting the nursing shortage are stress from increased workload, and negative effects on mental health. Another determinant is the Covid-19 virus and nurses fear of infection and possibly death (Turale & Nantsupawat, 2021).

Workplace Response to Nursing Shortage

             My workplace has made many efforts to increase nurse retention, hire more nurses, and decrease nurse workload. My workplace is offering nurses a ten thousand dollar sign on bonus in exchange the nurse has to stay at my organization for two years. The first half of the bonus is given after their first ninety days and the other half after one year. For their current employees they are giving them yearly raises, annual incentive bonuses, and a bonus for extra shifts worked. To help decrease the nurses work load the emergency department has hired medics to help with tasks like, IV insertion and triage. Lastly, to eliminate unsafe nurse to patient ratios, they hired travel nurses to fill in holes in the schedule. In conclusion, with my employer taking these steps to improve the nursing shortage, we have already seen an improvement in the department.

The national healthcare issue and stressor I selected for analysis is the nursing shortage. When we dissect the healthcare team in the hospital setting, the majority of these professionals are nurses, who play a crucial role in healthcare. Since the pandemic hit in 2020, the nursing shortage has been growing and continues to be a huge concern. The US Bureau of Labor Statistics projects that more than 275,000 additional nurses are needed from 2020 to 2030 (Haddad et al., 2022).

I currently work in the emergency department of a small rural hospital and the nursing shortage has affected us tremendously. We have a total of 22 beds which includes two code/trauma/treatment rooms. One of these rooms is designated for the providers, and two are for storage. So, we technically have 17 rooms for patients in total. As of last August, our MOSU unit closed due to the nursing shortage, so the ER also rooms observation and admitted patients. The staffing for our shifts is one charge nurse, two nurses, one provider, and three days a week one HUC. To give a better idea of how stressful this can be I will provide an example. Last week we had a total of nine admits which left us with eight beds total for ER patients. Keep in mind, this means each nurse has three holds and must also take care of the patients that come into the ER.

With that being said, we have recently been informed that all but two of our doctors will be leaving. The number of patients the providers had to see was already high and the fact that we have to house the holds makes it even worse. These providers are stressed out and could have had some relief with a midlevel provider.  The number of NPs and PAs is growing rapidly, in part because of shorter training times for such providers as compared with physicians and fewer institutional constraints on expanding educational capacity (Auerbach et al., 2018). The nurses in the emergency department are burned out and really need more help too. You would think the hospital would offer some kind of incentive for working under these conditions, but they don’t.  Cecilia K. Wooden from the Walden University (2015) video states that velocity and vitality are important aspects of balancing work-life balance. She states that the workload we encounter causes stress, and we need to balance that with utilizing employee wellness programs to avoid burnout.

Social determinants that affect this healthcare issue are nursing burnout, location, and the low pay offered at this hospital. In this hospital, ER nurses are also practicing as floor nurses and most have never done that which can be stressful and pose a risk for the patient. This hospital is also over an hour away from the city and most people don’t want to make the drive there. The company needs to increase the pay to make up for the drive these nurses would have to make, and they don’t. As stated above, they also don’t have any kind of employee incentive programs for anything. Nursing burnout is very high here due to all of this. According to Jacobs et al., 2018 “Engaged employees who feel cared for by their employer through initiatives like our WellBeing programs positively influence an organization’s performance”.

The admin and nursing director haven’t done much to try and help alleviate these problems. The most they have done is place an ad online to their facebook page to advertise job openings. They haven’t even offered anything to the providers that are leaving. The quadruple-aim study includes provider satisfaction, and this hospital does not follow this aim at all.  In an effort to address these aims, healthcare leaders must identify new priorities not only for healthcare delivery but to improve the work life of the members of the healthcare team (Broom & Marshall, 2021).

Healthcare Issue/Stressor and Impact on Work Setting

Lack of access to healthcare has always been an issue healthcare organizations have been combatting for years. Before the pandemic, there was a multitude of social determinants that created barriers to access to health care. The pandemic, however, was clearly the most significant determinant that destroyed access to healthcare exponentially compared to the determinants that were already an issue previously. This impacted the work setting because there was an increased demand for emergency services since many patients needed help to follow up with primary care providers or specialists. My hospital stopped elective procedures from having rooms for critical patients with life-or-death necessities. Staffing shortages became an issue, and we began to notice decreased patient and worker satisfaction due to higher nurse-to-patient ratios and increasing demand for nurses and doctors. Despite the significant increase in demand for medical services, the supply of medical professionals is not growing fast enough to keep up with the demand. Physicians need to outsource their work, new technologies are being developed and more duties are falling on APRNs and clinicians that are not physicians (Auerbach et al., 2018, p.2358-2360).

Social Determinants Affecting this Healthcare Issue

Covid-19 was the primary determinant preventing access to healthcare, and facilities had to pivot with their technology to remain current and competitive. However, before covid-19, there were other determinants facilities were already taking actions to reorganize processes to improve outreach and services to the sickest patients. . Income and poverty restricted access to those individuals who were struggling to afford services or medication and could also limit access to transportation to healthcare facilities. Low education levels affected access due to illiteracy which sometimes delayed seeking healthcare services until problems progressed. Location and proximity to services hamper access and have always been an issue if patients travel 1-2 hours to see their providers. As you can see, the Roe vs. Wade situation currently limits access to reproductive services for women. There have always been social determinants that need to be combatted to improve access for our population with a focus on minority groups and the underserved long before covid-19 turned off all the lights. Systems need to be altered at times which sometimes means certain tasks need to be outsourced and loosely controlled or remain in house and tightly controlled by the faculty. Creativity and flexibility in new processes is key to be able to adapt effectively (Pittman & Scully-Russ, 2016, p. 2-3).

How Work Setting has Responded to this Healthcare Issue

In combatting these social determinants leadership needs to get creative and evolve with the times to ensure their business will continue to grow through the difficult times. New systems need to be developed to meet ever changing needs of the community in challenging times of change (Broome & Marshall, 2021, p. 35-36). My facility has increased access to telehealth services after discharge to monitor patients and ensure they remain proactive in their mental health and stay engaged in their care. Low-cost or free services are sometimes granted to low-income individuals and families who have difficulty paying for assistance but have critical needs for access to remaining focused and stable in the community. Telehealth has become the forefront of the next generation of healthcare, improving access to millions of people living in rural areas or hours away from the nearest provider.

Nursing Shortage

National healthcare issues directly affect how a healthcare organization functions. One national healthcare issue directly impacting the healthcare organization where I work is nursing shortages. Nurses are a vital part of healthcare. From 2020 to 2021, the supply of registered nurses (RNs) decreased by more than 100,000, creating an additional strain on an already suffering healthcare system following the COVID-19 pandemic. Factors that contribute to the nursing shortages are nurse burnout, an aging workforce reaching retirement age, family obligations, a lack of nursing educators, and an aging population with chronic diseases. Nurse shortages affect direct patient care by creating high nurse-to-patient ratios, thus leading to increased medication errors, infection rates, higher morbidity and mortality rates, and increased nurse burnout. Also, nurse shortages affect direct patient care by limiting the number of hospital beds available to care for patients. A healthcare organization needs a nurse to care for its patients. The nursing shortage will leave hospitals with empty rooms due to limited nursing staff available. This causes hospitals to diverge patients to other hospitals and can decrease funding and reimbursements (American Association of Colleges of Nursing, n.d.; Broome & Marshall, 2021; Buerhaus, 2021; Jones & Spiva, 2023).

Impact of Nursing Shortage

The healthcare issue of the nursing shortage directly impacts my workplace healthcare organization by decreasing the beds available in the emergency department. Currently, I work in a rural healthcare organization. The closest level-one trauma center is over one hour, with limited ambulance services available. My healthcare organization is a critical access point for this rural area. The nursing shortages have decreased half the emergency department’s nursing staff, causing the healthcare organization to close over half the number of beds available. Thus, causing a delay in patient care and limiting the services available to the community (American Association of Colleges of Nursing, n.d.).

Social Determinants of Health

The social determinants of health most affected by the healthcare issue of nursing shortage are Health Care Access and Quality. The limited number of nurses available to care for patients and the financial strain that the nursing shortages had applied to healthcare organizations have decreased patient access to healthcare, especially in rural and low-income areas. Also, nursing shortages have affected the quality of patient care by causing higher nurse-to-patient ratios, thus leading to increased medication errors, infection rates, and morbidity and mortality rates (American Association of Colleges of Nursing, n.d.; Broome & Marshall, 2021; Buerhaus, 2021).

Responding to the Nursing Shortage

My healthcare organization has yet to succeed in responding to the nursing shortage. The only action they had implemented was a sign-on bonus with a one-year contract. However, their pay does not compete with other larger healthcare organizations in the surrounding areas. The administration is currently discussing and holding meetings with nursing staff and providers to form an action plan to retain and recruit nurses.

Nursing Shortage
Description of the National Healthcare Issue/Stressor
The selected national healthcare issue or stressor is nursing shortages. A problem that hinders the proper dispensation of overall healthcare services. An issue of nursing shortages is where the nurses are fewer compared to the patient. The need for more nurses causes a strain on the existing nurses as they are expected to attend to more patients (Pittman & Scully-Russ, 2016). The demand and supply of nurses must be increased to cater to the population’s growing needs.
The identified healthcare issue has impacted my work setting. There have been complaints regarding poor working conditions, which have caused a decrease in overall nursing turnover. In this regard, nurses within my work setting have raised objections to significant amounts of work and few human resources to attend to the needs of patients. According to Hosseini et al. (2022), it is challenging to maintain nurses within an organisation when the working conditions could be better.
However, my organisation’s work system has made attempts to respond to the identified healthcare issues. One strategy employed in mitigating the identified problem is adopting a recruitment program. This strategy entails acquiring new talents who fit the organisational goals and requirements. The healthcare system has also attempted to develop a unique corporate culture that aims at empowering the existing nurses in a manner that will leave them feeling appreciated and motivated to carry out their delegated duties. These measures have proven significant in mitigating the identified issue and achieving patient safety and positive outcomes in care delivery.

The national healthcare stressor I’ve selected is the growing nursing shortage. I think it’s safe to say that we all feel the weight of this stressor daily in our working lives. Many facilities, including my own, are constantly working short-staffed. We have an aging population with increasing complexities in healthcare needs and a decreasing supply of current and future nurses (Morris, 2022). In my state of Virginia, there’s only 10-12 nurses per 1,000 residents (Nurse Journal, 2020). This is dangerous for our patients and for us as nurses. Patients may not receive adequate care and nurses are at risk of losing their licenses due to unsafe practices and high ratios.

The main social determinant affecting this issue is geographic location. Many nurses are moving to hiring paying areas, leaving lower paying areas without adequate staff. Thus, leading to the rise in reliance on travel nurses and per diem staff. Contract hires are wonderful resources to use in times of need, however, it is so important to have a strong core staff to keep units up and running efficiently.

My facility has tried to combat this by hiring new graduates to practice in high levels of care and by taking advantage of travel and per diem employees. The practice of using travel and per diem employees is expected to rise to combat the nursing shortage overall (Green, 2023). New graduates can do well in higher levels of care IF they have adequate orientation. Unfortunately, due to the nursing shortage, many new graduates are being pressured to come off of orientation early. This can be detrimental to both the nurse and their patients. I would like to see my facility offer incentives for new hires and for current staff, as this is something that is currently lacking.

War on Women’s Health:

On June 24, 2022, Rowe v. Wade was overturned by the Supreme Court, leaving it up to each state to decide whether the practice of abortions would be legal or not in their condition. This impacted our healthcare system, especially regarding women’s health, nationwide.

Restrictive abortion regulations in states can limit access to safe and legal abortion services. This can increase unsafe abortions, resulting in serious health complications and even death. Abortion regulations can also impact reproductive health outcomes, including unintended pregnancies, maternal mortality, and morbidity. This makes healthcare providers uneasy when it comes to providing care for these patients without being put at risk for legal and regulatory barriers to providing abortion services, which can limit their ability to provide the full range of reproductive healthcare services (Harris, 2022).

In the state of Ohio, which is the state I reside and practice as a Registered Nurse, abortion laws are more strict. According to (Field et al., 2022), “Ohio abortion regulations limit ob-gyns’ ability to provide comprehensive reproductive health care, creating ethical dilemmas for these physicians as they attempt to care for their patients. As Ohio’s abortion laws increase in number and restrictiveness, they further undermine obstetric and gynecologic ethical practice guidelines.” This can also impact the ability of healthcare providers to provide evidence-based care, which can impact health outcomes. The healthcare organization where I currently work often has to refer patients to other clinics in states where access to safe abortions is available to them when they need one.

Abortion regulations can also impact social determinants of health, such as access to education and employment opportunities, and can perpetuate social and economic inequalities (Carroll, 2022). These regulations can disproportionately affect low-income women, women of color, and those living in rural areas, who may have limited access to healthcare services and may be more vulnerable to the negative impacts of restrictive abortion policies (Redd et al., 2022). Women unable to obtain abortions may be forced to continue pregnancies unprepared, impacting their ability to work, attend school, and care for their families.

How can the health profession address the needs of the many where there are only a few? The healthcare profession has faced a multitude of factors keeping up with the demand of the census. Ranging from meeting the population’s medical needs in rural areas or providing primary care to the overall census due to the shortage of physicians. Physician shortage may be due to extended training time vs. acute need for primary care and a lack of medical school capacity. In addition, the limited accredited residency position(Auerbach et al., 2018). In addition, the aging population of physicians shows that within the next decade, more than 2 out of every five practicing physicians will be over 65(Jubbal, 2022). The Association of American Medical Colleges projects the physician population will only increase by 0.5%-1% per year between 2016 and 2030(Auerbach et al., 2018, para. 2). However, researchers believe in offsetting the slow growth of the physician population, the number of physician assistants and nurse practitioners will continue to sour in development by 6.8% and 4.3% annually. Therefore, Nps and PAs contribute more than two-thirds (67.3%) of all practitioners between 2016 and 2030(Auerbach et al., 2018, para. 6).

Nurse practitioners are equipped with the education and capability to fulfill the gap between the need for clinicians and providing high-quality cost-affected care to the population in need. Some of the duties of a nurse practitioner are to assess and perform physical examinations, order and analyze cost-efficient diagnostic tests, consult fellow health professionals to aid in the treatment of the patient, prescribe the appropriate medications, and follow up on the individual’s status to reduce readmission and improve the patient outcome.

NPs consistently demonstrate similar or better outcomes than their physician colleagues across various health indicators(Buerhaus et al., 2015). However, “the increasing number of Nps alone will not address the deficiencies in primary care delivery because many policy and practice setting barriers affect Nps’ ability to offer services at the full range of their educational preparation and competencies” (Broone & Marshall, 2021, p. 77). Currently, 28 states out of 50 have limitations on the scope of practice for nurse practitioners mandating signatures for care to be signed by physicians.

Currently, I reside in Virginia. Virginia has a limited scope of practice for nurse practitioners. However, nurse practitioners and physicians provide comanagement upon treatment to patients, but the physicians have the final say in the direction of care management. I like this format from a new nurse practitioner aspect, but after becoming comfortable in my role. I want more autonomy.

Nursing shortages and staffing concerns have been and continue to be major issues in healthcare. There are myriad reasons for staffing shortages in the nursing field. The aging workforce is seeing many more nurses retire than become new nurses. The nurses that remain want more time with their families. An increase in violence in the workplace, job dissatisfaction, and burnout are also some of the factors that lead to the lack of a nursing force worldwide (Haddad et al., 2022). One study suggests that by 2035 there will be a shortage of over twelve million nurses (Marć et al., 2018). More nurses are working in non-hospital settings such as Home Care, community health, and outpatient settings (Palumbo et al., 2017). This shift in locations of medical care is one of the contributing factors in the decline of hospital staff.

Nursing shortages are affecting all nursing fields, even the areas where the above study indicated the shift is helping. In my particular home care agency, we are currently looking for nursing staff for patient care. Despite offering more than the national average salary (Marć et al., 2018) we are unable to find qualified candidates. Due to the lack of appropriately qualified applicants, we are forced to make decisions between overextending our staff or curtailing patient interactions. Our agency has attempted to mitigate the stressors involved with nursing by implementing set hours of operation, focusing on employee wellbeing, increased training, and placing our nurses in the community where they live (Jacobs et al., 2018).

As I said earlier, there are many factors that play into the nursing shortage. Some of the determinants are a lack of educators to teach nurses, the regionality of the field, nurses retiring, more people needing care as the population ages, and an uptick in violence against healthcare workers (Haddad et al., 2022).

Nurses are critical to the makeup of healthcare. As times continue to change the profession of nursing continues to face shortages as a result of a lack of education, an increasingly high turnover rate, and an unequal workforce distribution. Nurse burn out rates are increasing tremendously. Many times, nurses are finding that once they start their profession in healthcare, they then decide the career is not for them. The national average rates in the United States for turnover have increased from 8.8% to 37.0% (Haddad, et al., 2022).

I work as a labor and delivery nurse in a small community hospital. It is incredibly evident within my hospital; nursing burn out is real. Being that I work in a small hospital, it seems that more and more hats get added to our heads. Overtime, this creates hardships for nurses. Nurses feel they cannot care for the patient the way the patient should be cared for because of all the extra jobs being added to their already overflowing plate.

Social determinants of health (SDOH) are what impacts individuals’ health and well-being. Included within SDOH are economic stability, good quality and access to education, access to quality healthcare, access to opportunity of physical activity and nutritious foods, and safe housing (U.S. Department of Health and Human Services, n.d.).

The social determinants that most affect this health issue would be the determinants of physical and mental health. Healthcare professionals experience emotional exhaustion and a lack of confidence when physical and mental health is at stake. Addressing these social determinants of health can help by combating the healthcare burnout issue. (Heath, 2019).

My hospital has recently implemented sign on bonuses and retention bonuses to help with nursing burnout and nursing shortages amongst the hospital. The has helped because those who decided to sign must commit to a two-year contract. The hospital also worked to put together a serenity room for staff to use. These things have helped, but there is still a lot of other changes that need to be made in order to assist with this healthcare issue.

Burnout and work-related stress

One national healthcare issue/stressor affecting my work setting is the nursing shortage, lack of supporting staff, and sudden changes that have led to burnout and work-related stress. Nurse burnout impacts patient healthcare outcomes and contributes to a poor work environment (Lajiness, 2022). I work at a military medical center, and most of the time, changes come down the pipe without the opinions of the staff involved. In 2020, when covid pandemic hit the world and affected the healthcare system, my ward was changed to be the designated covid unit. The ward was a locked unit, with no warnings and no training on the expectations of things to come. In 2022, when the war in Afghanistan was over, and the military base was closed, the injured Afghanis when brought to our hospital, and the unit was shot down again. Once more, we cared for patients who spoke no English, did not want women to touch them, and seemed hostile toward us. These two events created a lot of workplace-related stress and burnout. Leadership made all the decisions, and we had no say in whether we could support this mission. At the same time, most of the military staff were deployed to different states where the covid numbers were rising. So we were short-staffed and dealing with these changes. According to Hetzel-Riggin et al. (2020), one factor that affects the nursing shortage is an unfavorable and declining work environment which leads to job dissatisfaction. Nurses started looking for jobs in the outpatient environment where changes are predictable. According to Hetzel-Riggin et al. (2020), five different types of burnout symptoms can be observed: physical (such as sleep disturbances, headaches, and gastrointestinal problems), emotional (such as irritability, depression), behavioral (such as poor work performance, increased absenteeism), interpersonal (such as withdrawal from others), and attitudinal (such as callousness, dehumanization of clients/patients). One staff member retired, and two others left. Losing staff members with the skills set and experience is devastating and often leads to low-quality care and poor patient satisfaction.

Social Determinant

The social determinant mostly affecting this health issue is employee well-being. Jacobs et al. (2018) suggested that the work environment significantly impacts employee well-being, and employees with poor well-being were less engaged and more pessimistic about the workplace. The morale was very low amongst the staff. There was no trust in leadership, especially after we lost a staff member during the pandemic.

After our concerns were brought to the leadership and we had a unit meeting, the following changes were made;

  • Our ward was removed from the list for any sudden changes without conversing with the staff.
  • A quiet room with a massage chair was provided for us where we could go there to center ourselves.
  • The lunchroom always had healthy snacks and fruits.
  • Hospital-wide for civilians with at least one year with the federal government tuition assistance from $6000 to $8000 annually.
  • Staff is allowed to use the gym and swimming environment during working hours if staffing is appropriate.

There is still work to do, but employee satisfaction has improved for now, and we celebrate each other. Patient satisfaction has improved; our unit has won the daisy ward twice.

Health Insurance and Low-Income Population

One national healthcare issue that can affect family clinics is the lack of access to affordable healthcare services for low-income families. Many families who cannot afford private health insurance or out-of-pocket medical expenses rely on public healthcare programs like Medicaid and CHIP (Cha & Cohen, 2022). However, these programs may have limited coverage or may not cover certain services, leaving families with limited options for healthcare. This can strain family clinics, which often serve low-income populations and may be reimbursed at lower rates for Medicaid and other public insurance programs. Family clinics may need help providing the necessary care and services to these patients while balancing their financial needs.

The shortage of primary care physicians in certain areas can also affect family clinics, as they may need help to recruit and retain qualified healthcare providers. This can limit the availability of healthcare services for families in those areas and strain existing staff. Addressing these healthcare issues and improving access to affordable, quality care is crucial for supporting family clinics and ensuring all families have access to the care they need (Cha & Cohen, 2022).

Social Determinants

A lack of access to affordable healthcare services can affect several social determinants. To name a few,

  • Health outcomes: Lack of access to affordable healthcare services can lead to poor health outcomes, including increased rates of preventable diseases, chronic conditions, and premature death.
  • Economic stability: When individuals cannot access affordable healthcare services, they may face high medical bills, leading to financial instability and bankruptcy.
  • Education: Lack of access to affordable healthcare services can impact education, leading to increased absenteeism and decreased academic performance.
  • Employment: When individuals cannot access affordable healthcare services, they may miss work due to illness or injury, leading to decreased job productivity and loss of income.
  • Social and community context: Lack of access to affordable healthcare services can impact social and community context by leading to increased stress and decreased social support, which can negatively impact mental health.
  • Physical environment: Lack of access to affordable healthcare services can impact the physical environment by increasing exposure to environmental hazards and decreasing access to safe and healthy living conditions.
  • (Artiga & Hinton, 2018).

The lack of access to affordable healthcare services can significantly negatively impact individual health and social and economic well-being.


Affected Workplace

Limited access to healthcare for low-income individuals can affect family health clinics in several ways. Family health clinics that serve low-income populations may experience an increase in demand for services as individuals who lack access to other healthcare options seek care. This can put a strain on clinic resources, including staff and funding. Many clinics need financial stability because of providing care to low-income patients who are uninsured or underinsured. These patients may need help paying for services or may be covered by public insurance programs that reimburse at lower rates, resulting in financial challenges for the clinic. Not only does it affect the clinic, but limited access to healthcare in low-income communities can also lead to challenges in recruiting and retaining qualified healthcare providers. Family health clinics may struggle to attract providers due to lower salaries or lack of resources, making it difficult to provide consistent patient care. Lastly, when low-income individuals cannot access necessary healthcare services, it can lead to adverse health outcomes for individuals and families. Family health clinics may see patients with more advanced or chronic health conditions because of delayed care, which can be more difficult and expensive to treat.

Healthcare for low-income individuals can significantly impact family health clinics, affecting demand, financial stability, staffing, and health outcomes. It is essential to address healthcare disparities and improve access to care to support the health and well-being of families and communities.

The scope of healthcare delivery extends beyond disease treatment to include preventative care, routine checkups, and emergency care. Accessibility, shortages of medical professionals, antiquated equipment, and other problems all contribute to our country’s trouble in providing medical care to its citizens. Low quality of service and poor health outcomes, longer wait times to obtain care, harm to the institution’s image, a loss of patient trust, and a lack of accreditation are all direct results of healthcare delivery problems. (Broome & Marshall, 2021).

The organization has hired several APRNs to enhance service delivery in the face of physician shortages in primary care outpatient settings (APRNs). In Maryland, advanced practice registered nurses (APRNs) have the authority to conduct patient assessments, order and interpret diagnostic tests, make medical diagnoses, and launch and oversee treatment plans independently. They can also write prescriptions for drugs and treatments. These rules provide APRNs complete independence in the workplace and serve as a means of speeding up healthcare delivery. Healthcare delivery may be enhanced by resolving the problem of patient access to services. Integration of telemedicine services is one way to achieve this goal. In response to the COVID-19 pandemic, numerous healthcare facilities have used telemedicine, which has helped APRNs with triage services and improved high-risk patients’ access to regular treatment. Moreover, it has assisted persons with mental health conditions to maintain access to the necessary therapy services. Most importantly, it has allowed people with mental health issues to keep accessing the treatment they need via therapy (Smith et al., 2020).

Hence, the organization has hired nurse informaticists who have developed tools to improve healthcare delivery. According to Darvish et al. (2014), the new wave of technology has allowed new communication channels between doctors and their patients. Nurse informaticists utilize their knowledge to improve patients’ health, develop better healthcare systems, and make their jobs easier. A nurse informaticist develops software that facilitates electronic communication between nurses and other care team members, as well as between nurses and patients.

Across the United States, there are many different healthcare issues that can affect workplace settings. One workplace setting issue or stressor that many are facing is nursing shortages and burnout. There has always been a need for nurses and a shortage, however since Covid-19 has come into play, the shortage/burnout has become more of an issue. With Covid-19 nurses are expected to work more days, longer hours and patient/nurse ratio has gone up. There are not enough nursing students that are passing school and able to join the workforce. Another part of this is nurses are leaving the field all together due to the constant stressors. I work in the clinic, however we see a shortage in nursing in the clinical setting as well. Within my rural facility, nurses are being pushed to do the job of 2-3 nurses during clinic hours while also maintaining patient safety. “The nursing profession continues to face shortages due to a lack of potential educators, high turnover, and inequitable workforce distribution” (Haddad, et al, 2022).

With a nursing shortage/burnout there is no one social determinate that is affected. All of healthcare and patients are affected by nursing shortages. With that said, one social determinate that is affected are psych/mental health patients. This field is already a low retention rate area to work and since the pandemic this number has increased. According to the American Psychiatric Nurses Association 2019, “More than 75 percent of all U.S. counties have a shortage of any type of mental health worker and 96 percent of all counties have an unmet need for mental health prescribers.” Since this, it has continued to become more of an issue.

Within my facility, they have had multiple different attempts in helping with nursing burnout/shortages. One of which is large retention bonuses. These bonuses are given in payments across two years. Our current largest bonus is $25,000 spread across the 2 years and I believe to be twice a year. The longer the staff is with the more money they receive. While this is a nice thing to have, it is hard to still work through the hard times of working shorthanded. Floor nurses are being called in on their days off and end up working 4+ 12 hour days instead of working their scheduled 3 days. Another way the facility is attempting to keep nurses is offering tuition assistance to go back to school. Once staff sign up for tuition assistance, they are signed in for one year after graduation or they must pay all the money back. Nurses are encouraged more and more to continue on with their education and more facilities are wanting BSN nurses vs RN’s. My current facility has specific colleges they help pay for and according to Gerardi, Farmer & Hoffman, 2018, “…employment-focused partnerships between schools and health care facilities that provide students with practice experience, promote greater use of the BSN, and create employment opportunities.” This is a great way to encourage nurses to continue on in their education and retain employees as well.

The nursing shortage is real and it is here to stay. With the increase in demand for nurses, nurses being unable to pass schooling or finding qualified schools to attend, the nursing shortage is here to stay. Because of nursing shortages, nurses are being put in unsafe situations not only physically and mentally for them but also the patients in which they see/treat. “Patient outcomes are affected by staffing shortages. High nurse-to-patient ratios can lead to medication errors and higher morbidity and mortality rates” (Morris, 2022).

The national healthcare issue I chose to analyze was that of opioid addiction. This issue directly impacts the care of every single patient I see. Throughout the pandemic we started using more opioids to treat pain in our patients whether covid positive or just being seen for every day issues. Not only is dependency a huge issue with opioids but the number of overdoses has increased rapidly throughout the years.” More than 932,000 people have died since 1999 from a drug overdose.1 Nearly 75% of drug overdose deaths in 2020 involved an opioid (“Data overview,” 2022). This directly affects my work setting for many reasons, we must make sure that the proper medications are being given to patients, in proper doses and that we don’t overmedicate or use medications the patient may not truly need. Social determinants that are seen with opioid use include but are not limited to, a person’s income, a person’s housing stability or living situations in general, education regarding the use and addictive properties of opioids (“Social Determinants of Opioid Use among Patients in Rural Primary Care Settings,” n.d.). As far as addressing this crisis in the healthcare setting, more physicians are less likely to prescribe opioids for generalized pain and prefer to use a multimodality form of pain control. This includes using heat and ice, using creams to address pain, lidocaine patches, alternating Tylenol and ibuprofen. While there are certainly situations in which opioids are needed a deeper look is being taken before just prescribing and giving these medications especially with patients who have previous abuse histories.

In the field of Women’s Health, particularly Labor & Delivery, Antepartum and Postpartum care, the national standards of care and patient ratios are provided by AWHONN, Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN, 2022).  These standards of care, which include safe practice guidelines for patient to nurse ratio, are updated on a frequent basis.

Most large hospitals and teaching facilities adhere very well with patient:nurse ratios as set forth in the AWHONN guidelines, however there are exceptions when acuity and lack of staffing require the ratios to be tilted and the patient/nurse ratio to be overextended.  The Women’s Health Departments in smaller, more rural hospitals tend to not adhere to these guidelines, oftentimes causing very unsafe staffing ratios and place an overbearing load on nurses within their Women’s Health units.

Unit policies are created within each facility, sometimes policies are set forth by upper management that have never staffed the unit or understand how these guidelines are there to protect both patient and caregiver.  However on the other end of the spectrum there are hospitals that have policy makers that are all clinical staff.  The policies set forth by both nurse managers, attending physicians, and nursing staff are most often policies that are easy to follow, understand and provide the best patient care guidelines (ACOG, 2022).

Within each of the departments making up the Women’s Health Unit, both management and nurses often times participate in the leadership role and participate closely with policy and procedure.  Both in writing policy and preparing the procedural flow, nurses transition into a leadership role. According to Boome, “leadership is the ability to guide others, whether they are colleagues, peers, clients, or patients, toward desired outcomes” (Broome, 2021).  The role of the nurse is multifaceted, as with the policy and proceedure at different hospitals and facilities across the country,  As participants in the policy and procedure arena nurses take on the role as a transformational leader, where as nurse leaders one can influence others by changing the understanding of others, to what is important in the care of patients, family, staff (Broome, 2021).

Changing policy and procedure is a process. It is not just one thing, it consists of many characteristics and is an evolving process.  As nurse leaders we can participate in these changes, use our knowledge of national guidelines and governances to assist in exceptional results within our hospitals and facilities.



Scenario 1: Polycystic Ovarian Syndrome (PCOS)

A 29-year-old female presents to the clinic with a complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 11 years of age. She began to develop dark, coarse facial hair when she was 13 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg.m2. Moderate hirsutism without virilization noted.  Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management.  


1.     What is the pathogenesis of PCOS? 

Your Answer:

Ovulation irregularity, elevated testosterone levels, and polycystic ovaries are all symptoms of Request Unlock Polycystic Ovary Syndrome (PCOS), which has a genetic basis. Alterations in luteinizing hormone (LH) activity, insulin resistance, and a probable propensity for hyperandrogenism have all been implicated in the pathophysiology of polycystic ovary syndrome. Hyperandrogenism may be exacerbated by insulin resistance, according to one idea. According to this theory, insulin resistance increases androgen production in the adrenal glands and ovaries, increasing sex hormone-binding globulin synthesis. As a result, hyperandrogenism manifests itself physically, and menstrual irregularity becomes a common symptom. The hyperandrogenic condition is characteristic of PCOS; however, glucose intolerance or insulin resistance and hyperinsulinemia often accompany and considerably amplify the hyperandrogenic state.

Scenario 1: Polycystic Ovarian Syndrome (PCOS)

A 29-year-old female presents to the clinic with a complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 11 years of age. She began to develop dark, coarse facial hair when she was 13 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg.m2. Moderate hirsutism without virilization noted.  Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management.  


How does PCOS affect a woman’s fertility or infertility? 

Your Answer:

PCOS is the most common reason for female infertility. Infertility leads to a lack of ovulation, abnormal follicle development, and Request Unlock decreased androgen production. Follicles on the ovaries may not develop, preventing ovulation even if testosterone levels are normal. Infrequent ovulation and menstruation may result from hormonal imbalance. Essential to the development of PCOS is a hyperandrogenic condition. Follicle growth is affected by elevated androgen levels, whereas follicle loss is prevented by insulin’s ability to inhibit apoptosis. Ovarian follicle development is not functioning correctly. Anovulation is a self-perpetuating condition that starts with inappropriate gonadotropin production.

Scenario 2: Pelvic Inflammatory Disease (PID)

A 30-year-old female comes to the clinic with a complaint of abdominal pain, foul smelling vaginal discharge, and fever and chills for the past 5 days. She denies nausea, vomiting, or difficulties with bowels. Last bowel movement this morning and was normal for her. Nothing has helped with the pain despite taking ibuprofen 200 mg orally several times a day. She describes the pain as sharp and localizes the pain to her lower abdomen. Past medical history noncontributory. GYN/Social history + for having had unprotected sex while at a fraternity party. Physical exam: thin, Ill appearing anxious looking white female who is moving around on the exam table and unable to find a comfortable position. Temperature 101.6F orally, pulse 120, respirations 22 and regular. Review of systems negative except for chief complaint. Focused assessment of abdomen demonstrated moderate pain to palpation left and right lower quadrants. Upper quadrants soft and non-tender. Bowel sounds diminished in bilateral lower quadrants. Pelvic exam demonstrated + adnexal tenderness, + cervical motion tenderness and copious amounts of greenish thick secretions. The APRN diagnoses the patient as having pelvic inflammatory disease (PID).  


1.     What is the pathophysiology of PID? 

Your Answer:

Inflammation of the peritoneal cavity, uterus, fallopian tubes, ovaries, and other reproductive organs is the Request Unlock hallmark of severe pelvic inflammatory disease (PID). For PID to develop, an infection must first establish itself, and then the normal vaginal microbiota must fail. Other bacteria may cause PID if the vaginal pH changes and the cervix’s mucus loses its integrity, although gonorrhea and chlamydia are the most prevalent causes. When the cervix is damaged, the inflammatory process that leads to edema, blockage, or necrosis in the uterus and fallopian tubes might begin. Both chlamydia and gonorrhea germs may move to the abdominal cavity, where they can multiply by rupturing cell membranes and causing inflammation and damage.

Scenario 3: Syphilis

A 37-year-old male comes to the clinic with a complaint of a “sore on my penis” that has been there for 5 days. He says it burns and leaked a little fluid. He denies any other symptoms. Past medical history noncontributory. 

SH: Bartender and he states he often “hooks up” with some of the patrons, both male and female after work. He does not always use condoms.

PE: WNL except for a lesion on the lateral side of the penis adjacent to the glans. The area is indurated with a small round raised lesion. The APRN orders laboratory tests, but feels the patient has syphilis.  


1.     What are the 4 stages of syphilis 

Your Answer:

The clinical signs of syphilis may be broken down into four distinct phases. In the first, or primary, phase, bacteria replicate in the Request Unlock epithelium, leading to the development of chancre and ultimately draining into lymph nodes, where they elicit an adaptive immune response. In the second phase, the immune system fights against the infection and eliminates the chancres once pathogens have invaded the body systemically. After the secondary stage is the latent phase; during this time, the infected person will show no outward signs of the disease but will still be contagious to others if they engage in sexual activity. The tertiary phase is characterized by severe systemic signs of the illness resulting in death. Destructive skin, bone, and soft tissue lesions, as well as cardiovascular problems such as aneurysms, heart valve dysfunction, and heart failure, are among these signs. Damage to the nervous system is also a possibility.

Scenario 1: Acute Lymphoblastic Leukemia (ALL)

An 11-year-old boy is brought to the clinic by his parents who states that the boy has not been eating and listless. The mother also notes that he has been easily bruising without trauma as he says he is too tired to go out and play. He says his bones hurt sometimes. Mother states the child has had intermittent fevers that respond to acetaminophen. 

Maternal history negative for pre, intra, or post-partum problems.

PMH: Negative. Easily reached developmental milestones. 

PE: reveals a thin, very pale child who has bruises on his arms and legs in no particular pattern.

LABS: CBC revealed Hemoglobin of 6.9/dl, hematocrit of 19%, and platelet count of 80,000/mm3. The CMP demonstrated a blood urea nitrogen (BUN) of 34m g/dl and creatinine of 2.9 mg/dl.

DIAGNOSIS: acute leukemia and renal failure and immediately refers the patient to the Emergency Room where a pediatric hematologist has been consulted and is waiting for the boy and his parents.

CONFIRMED DX: acute lymphoblastic leukemia (ALL) was made after extensive testing.  


1.     Explain what ALL is?  

Your Answer:

Acute lymphoblastic leukemia (ALL) is the most frequent form of cancer in Request Unlock children and young adults. Lymphoblasts, which are precursors to adult white blood cells, are overproduced. While the precise origin of cancer remains a mystery, several factors—including one’s genetic makeup—have been linked to its development. When another genetic defect is present, such as Down syndrome, leukemia is more common. The progression of ALS varies considerably among regions. The incidence of ALL is more remarkable in developing nations with higher socioeconomic status. This has not been fully grasped yet. The most typical presentation of ALL in the clinic occurs rapidly, often within days to weeks. Depression in the bone marrow is linked to these symptoms. Anemia, thrombocytopenia, and infection-related fever are all potential causes of exhaustion. The mouth, the throat, the lungs, the lower intestines, the kidneys, and even the skin may all get infected. Gram-negative bacilli cause most infections. Another typical sign is bleeding.

Scenario 1: Acute Lymphoblastic Leukemia (ALL)

An 11-year-old boy is brought to the clinic by his parents who states that the boy has not been eating and listless. The mother also notes that he has been easily bruising without trauma as he says he is too tired to go out and play. He says his bones hurt sometimes. Mother states the child has had intermittent fevers that respond to acetaminophen. 

Maternal history negative for pre, intra, or post-partum problems.

PMH: Negative. Easily reached developmental milestones. 

PE: reveals a thin, very pale child who has bruises on his arms and legs in no particular pattern.

LABS: CBC revealed Hemoglobin of 6.9/dl, hematocrit of 19%, and platelet count of 80,000/mm3. The CMP demonstrated a blood urea nitrogen (BUN) of 34m g/dl and creatinine of 2.9 mg/dl.

DIAGNOSIS: acute leukemia and renal failure and immediately refers the patient to the Emergency Room where a pediatric hematologist has been consulted and is waiting for the boy and his parents.

CONFIRMED DX: acute lymphoblastic leukemia (ALL) was made after extensive testing.  



1.     Why does ARF occur in some patients with ALL? 

Your Answer:

Prerenal acute kidney damage, acute tubular necrosis, renovascular disease, obstruction, glomerulonephritis, and Request Unlock parenchymal invasion of tumor cells are all factors that may lead to renal injury in ALL. Renal failure is a rare presenting symptom in ALL and is regarded to be a poor prognostic signal even though renal involvement is widespread in ALL. If leukemic infiltrates are bilateral and diffuse, mainly if they include the cortical area, it may significantly compromise renal function. Acute renal failure is a common complication of the chemotherapy regimen used to treat individuals with acute leukemia, which results in tumor lysis syndrome. Acute uric acid and calcium phosphate nephropathy are caused by tumor lysis syndrome. In volume depletion, prerenal AKI is leukemia’s most prevalent kind of kidney damage. The infiltration rate is proportional to the stage and grade of the illness; hence a kidney biopsy is often indicated when infiltration is suspected since it may provide predictive information about the malignancy.

Scenario 2: Sickle Cell Disease (SCD)

A 15-year-old male with known sickle cell disease (SCD) present to the ER in sickle cell crisis. The patient is crying with pain and states this is the third acute episode he has had in the last 10-months. Both parents are present and appear very anxious and teary eyed. A diagnosis of acute sickle cell crisis was made. 


1.     Explain the pathophysiology of acute SCD crisis. Why is pain the predominate feature of acute crises?  

Your Answer:

One hundred thousand persons in the United States are affected with sickle cell disease (SCD), an autosomal-recessive hereditary condition. Mutations in the Request Unlock beta-globin chain of hemoglobin are responsible for sickle cell disease. The mutation has the unusual feature of polymerizing in the absence of oxygen, which causes the red blood cells to adopt a sickle form under specific circumstances. Sickling of red blood cells is exacerbated by low oxygen tension, which damages cell membranes and lessens the flexibility of the cell, all of which contribute to sickle cell disorders. Pain is frequent and may worsen by extreme heat or cold, intense activity, or a lack of oxygen. In this instance, the hypothetical patient had a ten-month sickle cell crisis with accompanying discomfort.

Scenario 2: Sickle Cell Disease (SCD)

A 15-year-old male with known sickle cell disease (SCD) present to the ER in sickle cell crisis. The patient is crying with pain and states this is the third acute episode he has had in the last 10-months. Both parents are present and appear very anxious and teary eyed. A diagnosis of acute sickle cell crisis was made. 


1.     Discuss the genetic basis for SCD.

Your Answer:

Due to a single base pair point mutation in the -globin gene, the amino acid valine is replaced by glutamic acid in the Request Unlock – globin chain in individuals with sickle cell disease (SCD), a clonal condition. A person with SCD has two copies of the gene responsible for producing hemoglobin (-globin). In humans, chromosome 11 is home to the -globin gene. Hemoglobin S is an aberrant form of the hemoglobin molecule resulting from beta-globin (HBB) gene mutations in sickle cell disease.

Scenario 3: Hemophilia

8-month infant is brought into the office due to a swollen right knee and excessive bruising. The parents have noticed bruising about a month ago but thought the bruising was due to the attempts to crawl. They became concerned when the baby woke up with a swollen knee. Infant up to date on all immunizations, has not had any medical problems since birth and has met all developmental milestones. 

FH: negative for any history of bleeding disorders or other major genetic diseases. 

PE: within normal limits except for obvious bruising on the extremities and right knee. Knee is swollen but no warmth appreciated. Range of motion of knee limited due to the swelling.

DIAGNOSIS: hemophilia A.    


1.     What is the pathophysiology of Hemophilia 

Your Answer:

Whether inherited or acquired via spontaneous mutation, a lack of functional plasma clotting factor Request Unlock VIII (FVIII) is the root cause of hemophilia A, an X-linked, recessive condition. For hereditary cases already challenging to treat, the appearance of inhibitory alloantibodies to FVIII is a significant additional obstacle. Hemophilia A is seldom developed when autoantibodies target factor VIII.


Scenario 1: Schizophrenia

A 22-year-old female student was brought to her college student health department by her boyfriend. He was concerned about the changes in her behavior. The boyfriend noted that she has been hearing voices, and seeing things that are not there. She also thinks that there are people that want to harm her. She told her family that she cannot finish college as the voices told her to quit because she is “dumb”.  The boyfriend relates episodes of unexpected rage and crying.

PMH:  noncontributory

FH: positive for a first cousin who “had mental problems”.

SH: Denies current drug abuse but states he smoked marijuana every day during junior and senior years of high school. Admits to drinking heavily on weekends at various fraternity houses.

PE: thin, anxious disheveled female who, during conversations, stops talking, tilts her head and appears to be listening to something. There is poor eye contact and conversation is disjointed. 

DIAGOSIS: schizophrenia.  


1.     What are known characteristics of schizophrenia and relate those to this patient.  

Your Answer:

Hallucinations are one of the positive symptoms of schizophrenia, and they may take many forms, including Request Unlock auditory, olfactory, somatic-tactile, visual, and voice commenting or chatting. Delusions, such as the illusion of control, the hallucination of mind reading, the delusion of reference, the delusion of grandiosity, guilt, persecuting thoughts, somatic thought broadcasting, thought insertion and thought withdrawal, are also good signs. Aggression and agitation, changes in personal hygiene, a narrow worldview, and dysfunctional social and sexual interactions are all symptoms of a mental health illness. 

The patient in this situation is 22 years old, which is consistent with the typical age of onset for schizophrenia (late teens to early twenties). The condition runs in the family of mental disorders for which there is a family history. Both visual and auditory hallucinations are plaguing the learner. Additionally, she is acting paranoid, agitated, and strangely. The patient appears disoriented and cannot care for themselves or maintain eye contact.

Scenario 1: Schizophrenia

A 22-year-old female student was brought to her college student health department by her boyfriend. He was concerned about the changes in her behavior. The boyfriend noted that she has been hearing voices, and seeing things that are not there. She also thinks that there are people that want to harm her. She told her family that she cannot finish college as the voices told her to quit because she is “dumb”.  The boyfriend relates episodes of unexpected rage and crying.

PMH:  noncontributory

FH: positive for a first cousin who “had mental problems”.

SH: Denies current drug abuse but states he smoked marijuana every day during junior and senior years of high school. Admits to drinking heavily on weekends at various fraternity houses.

PE: thin, anxious disheveled female who, during conversations, stops talking, tilts her head and appears to be listening to something. There is poor eye contact and conversation is disjointed. 

DIAGOSIS: schizophrenia.  


1.     Genetics are sometimes attached to schizophrenia explain this.

Your Answer:

Several factors contribute to the genetic link between schizophrenia and its onset. This is a genetic illness that runs in families. Compared to mendelian disorders, in which mutations Request Unlock  in a single gene are thought to be responsible for disease development, schizophrenia is a complex disorder involving multiple genes on multiple chromosomes. Someone can possess a disease gene without experiencing the sickness itself. Alterations in normal brain architecture and functions may also be caused by environmental variables that counteract the effects of genetic programming. Brain structure anomalies in schizophrenia have been uncovered using cutting-edge neuroimaging techniques. Possible novel gene associations could be uncovered through studies of protein interaction.

Scenario 1: Schizophrenia

A 22-year-old female student was brought to her college student health department by her boyfriend. He was concerned about the changes in her behavior. The boyfriend noted that she has been hearing voices, and seeing things that are not there. She also thinks that there are people that want to harm her. She told her family that she cannot finish college as the voices told her to quit because she is “dumb”.  The boyfriend relates episodes of unexpected rage and crying.

PMH:  noncontributory

FH: positive for a first cousin who “had mental problems”.

SH: Denies current drug abuse but states he smoked marijuana every day during junior and senior years of high school. Admits to drinking heavily on weekends at various fraternity houses.

PE: thin, anxious disheveled female who, during conversations, stops talking, tilts her head and appears to be listening to something. There is poor eye contact and conversation is disjointed. 

DIAGOSIS: schizophrenia.  


What roles do neurotransmitters play in the development of schizophrenia?

Your Answer:

It was long thought that abnormally high levels of the neurotransmitter dopamine in the brain caused the start of Request Unlock schizophrenia, providing more evidence that neurotransmitters play a role in the disorder’s development. Schizophrenia, according to the current dopamine theory, results from various changes to the brain’s dopamine circuits. Reduced dopaminergic neurotransmission in the mesocortical dopamine pathway has been linked to the unpleasant symptoms and cognitive impairments seen in schizophrenia. The excitatory neurotransmitter glutamate and its effects on the N-methyl-d-aspartate (NMDA) receptor subtype are also linked to schizophrenia.

Scenario 1: Schizophrenia

A 22-year-old female student was brought to her college student health department by her boyfriend. He was concerned about the changes in her behavior. The boyfriend noted that she has been hearing voices, and seeing things that are not there. She also thinks that there are people that want to harm her. She told her family that she cannot finish college as the voices told her to quit because she is “dumb”.  The boyfriend relates episodes of unexpected rage and crying.

PMH:  noncontributory

FH: positive for a first cousin who “had mental problems”.

SH: Denies current drug abuse but states he smoked marijuana every day during junior and senior years of high school. Admits to drinking heavily on weekends at various fraternity houses.

PE: thin, anxious disheveled female who, during conversations, stops talking, tilts her head and appears to be listening to something. There is poor eye contact and conversation is disjointed. 

DIAGOSIS: schizophrenia.  


Explain what structural abnormalities are seen in people with schizophrenia.

Your Answer:

Enlargement of the lateral and third ventricles and frontocortical fissures and Request Unlock sulci are among the structural abnormalities in persons with schizophrenia. The cognitive deficits and unpleasant feelings seen in some people with schizophrenia who also have cerebral ventricular enlargement make them resistant to therapy. The thalamus and temporal lobes are commonly found to be smaller in size. Another recurrent result is a reduction in hippocampal volume in the formative years. People with schizophrenia experience a rapid loss of hippocampal volume after age 50. Reduced amygdala volume, aberrant amygdala projections, and altered amygdala connections have all been associated with schizophrenia. The temporal lobes, somatosensory cortex, motor cortex, and dorsolateral prefrontal cortex all experience gradual loss of cortical gray matter in teenagers. Researchers think that alterations in the dorsolateral prefrontal cortex (DLPFC) have a role in developing negative symptomatology in schizophrenia.

Scenario 2: Bipolar Disorder

A 44-year-old female  came to the clinic today brought in by her husband. He notes that she has been with various states of depression and irritability over the past 3 months with extreme fatigue, has lost 20 pounds and has insomnia. He has come home from work to find his wife sitting in front of the TV and not moving for hours. In the past few days, she suddenly has become very hyperactive, has been talking incessantly, has been easily distracted and seems to “flit from one thing to another.”. She hasn’t slept in 3 days. The wife went on an excessive shopping spree for new clothes that resulted in their credit card being denied for exceeding the line of credit. The wife is unable to sit in the exam room and is currently pacing the hallway muttering to herself and is reluctant to talk with or be examined the ARNP. Physical observation shows agitated movements, rapid fire speech, and hyperactivity. 

DIAGNOSIS: bipolar type 2 disorder. 


1.     How does genetics play in the development of bipolar 2 disorders?  

Your Answer: Request Unlock

Those who have a first-degree relative with bipolar disorder are more likely to acquire the disease themselves, highlighting the role that genetics plays in the onset of manic-depressive illness. There’s a strong genetic link there. Research into the defective gene or genes responsible for this significant heritability of mood disorders has gained momentum. Those with a first-degree relative who also has the illness have a higher probability of acquiring it.


Scenario 1: Gout

A 68-year-old obese male presents to the clinic with a 3-day history of fever with chills, and Lt. great toe pain that has gotten progressively worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. 

HPI: hypertension treated with Lisinopril/HCTZ .

SH: Denies smoking. Drinking: “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. 

PE:  remarkable for a temp of 100.2, pulse 106, respirations 20 and BP 158/92. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 15,000 mm3 and uric acid 9.0 mg/dl.

Diagnoses the patient with acute gout.


Explain the pathophysiology of gout.

Your Answer:

Hyperuricemia, the condition that causes gout, is the body’s inflammatory reaction to an excess of uric acid in the blood. When uric acid levels in the blood rise over around 6.8 mg/dl, Request Unlock a crystallized, insoluble precipitate is formed and deposited into connective tissue all throughout the body. Purine metabolism and renal function are connected to how the body responds to uric acid buildup. Overproduction of uric acid, a byproduct of purine nucleotide breakdown, is thought to contribute to the high purine synthesis rates seen in gout patients. His gout results from his age, his gender, and the fact that he consumes a decent quantity of red wine each week. Gout was diagnosed based on his VS and examination of his great toe and his blood uric acid level of 9.0mg/dl.

Scenario 1: Gout

A 68-year-old obese male presents to the clinic with a 3-day history of fever with chills, and Lt. great toe pain that has gotten progressively worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. 

HPI: hypertension treated with Lisinopril/HCTZ .

SH: Denies smoking. Drinking: “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. 

PE:  remarkable for a temp of 100.2, pulse 106, respirations 20 and BP 158/92. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 15,000 mm3 and uric acid 9.0 mg/dl.

Diagnoses the patient with acute gout.


Explain why a patient with gout is more likely to develop renal calculi.

Your Answer:

Renal stones occur much more often in those who have primary gout. Urate excretion by the kidneys is hindered in persons with Request Unlock primary gout, even though the kidneys eliminate most of the uric acid in the body. Acute nephropathy may be caused by monosodium urate crystals that deposit within the renal tubules and the slow rate at which the kidneys excrete urate in people with primary gout, a metabolic disorder. Renal stones may develop in the renal tubules, pelvis, or ureters, leading to blockage and potentially life-threatening acute renal failure.

Scenario 2: Osteoporosis

A 78-year-old female was out walking her small dog when her dog suddenly tried to chase a  rabbit and made her fall. She attempted to try and break her fall by putting her hand out and she landed on her outstretched hand. She immediately felt severe pain in her right wrist and noticed her wrist looked deformed. Her neighbor saw the fall and brought the woman to the local ER for evaluation. Radiographs revealed a Colles’ fracture (distal radius with dorsal displacement of fragments) as well as radiographic evidence of osteoporosis. A closed reduction of the fracture was successful, and she was placed in a posterior splint with ace bandage wrap and instructed to see an orthopedist for follow up.  


Discuss what is osteoporosis and how does it develop pathologically? 

Your Answer:

In humans, osteoporosis affects more bones than any other illness. Fractures are likely due to inadequate bone minerals, lower bone strength, and compromised structure. Three basic types of bone cells contribute to bone development, maintenance, and breakdown. In ideal conditions, osteoblasts—immature bone cells—allow the bone Request Unlock  to develop and be laid down. Osteocytes are the cells that continually renew bone as part of the body’s natural regenerative process. The osteoblasts make bone regrowth possible thanks to the osteoclasts’ removal of old bone cells. Bone resorption is the job of cells called osteoclasts. As we age, we lose bone far more than we gain it. Around the time we hit 30, we’ve reached our maximal bone mass or bone density. Primary and secondary osteoporosis are the two forms of the disease. The most prevalent kind of osteoporosis, primary osteoporosis, is a hormone-mediated form in which falling estrogen or testosterone levels speed up bone loss. Osteoporosis in women is a progressive disease that starts before menopause and progresses more quickly in the early years following. Furthermore, white people are disproportionately affected by this condition.

Scenario 3: Rheumatoid Arthritis

A 48-year-old woman presents with a five-month history of generalized joint pain, stiffness, and swelling, especially in her hands. She states that these symptoms have made it difficult to grasp objects and has made caring for her grandchildren problematic. She admits to increased fatigue, but she thought it was due to her stressful job.

FH: Grandmothers had “crippling” arthritis. 

PE: remarkable for bilateral ulnar deviation of her hands as well as soft, boggy proximal interphalangeal joints. The metatarsals of both of her feet also exhibited swelling and warmth. 

Diagnosis: rheumatoid arthritis.


The pt. had various symptoms, explain how these factors are associated with RA and what is the difference between RA and OA? 

Your Answer:

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that may affect many body parts, mainly the Request Unlock joints. Antibodies against self-antigens and inflammatory cytokines, particularly pro-inflammatory CD4+ T cells, mediate symptoms. TNF and Interleukin-1 encourage synovial cells to release protease that destroys hyaline cartilage, and many inflammatory cells are implicated. Joint swelling and bone or tissue fusion are symptoms of rheumatoid arthritis. The most prevalent sites of joint damage are fingers, toes, wrists, elbows, ankles, and knees. The patient’s feet and hands are both affected by RA. RA, an inflammatory disease, destroys joint tissue, whereas bone is lost due to osteoarthritis. Osteoarthritis (OA) is articular cartilage degeneration in a specific body area. An earlier injury or infection may have damaged the normal cartilage, resulting in secondary OA. The prevalence of primary OA increases dramatically beyond age 65, and there is a clear association between obesity and the development of OA. Osteoarthritis (OA) as a noninflammatory disease process

Scenario5: Multiple Sclerosis (MS)

A 28-year-old obese, female presents today with complaints for several weeks of vision problems (blurry) and difficulty with concentration and focusing. She is an administrative para-legal for a law firm and notes her symptoms have become worse over the course of the addition of more attorneys and demands for work. Today, she noticed that her symptoms were worse and were accompanied by some fine tremors in her hands. She has been having difficulty concentrating and has difficulty voiding. She went to the optometrist who recommended reading glasses with small prism to correct double vision. She admits to some weakness as well. No other complaints of fevers, chills, URI or UTI

PMH: non-contributory

PE: CN-IV palsy. The fundoscopic exam reveals edema of right optic nerve causing optic neuritis. Positive nystagmus on positional maneuvers. There are left visual field deficits. There was short term memory loss with listing of familiar objects.

DIAGNOSIS: multiple sclerosis (MS).


Describe what is MS and how did it cause the above patient’s symptoms?

Your Answer:

Degeneration of central nervous system (CNS) myelin, scarring, and axonal loss characterize Multiple Sclerosis (MS), a chronic inflammatory illness. MS is triggered by Request Unlock an autoimmune reaction to self or microbial antigens in those genetically predisposed to the disease. Her first symptoms of multiple sclerosis, such as a sudden decline in her eyesight, are typical of an acute neurological event. Diffuse central nervous system involvement may manifest via various symptoms, including paresthesia’s affecting the face, trunk, or limbs, weakness, vision abnormalities, and urinary difficulties. Regular exercise, quitting smoking, and avoiding overwork, excessive weariness, and heat exposure are all recommended for MS management.


Scenario 1: Syndrome of Antidiuretic Hormone (SIADH)

A 77-year-old female was brought to the clinic by her daughter who stated that her mother had become slightly confused over the past several days. She had been stumbling at home and had fallen twice but was able to walk with some difficulty. She had no other obvious problems and had been eating and drinking. The daughter became concerned when she forgot her daughter’s name, so she thought she better bring her to the clinic.  

HPI: Type II diabetes mellitus (DM) with peripheral neuropathy x 30 years. Emphysema. Situational depression after death of spouse 6-months ago 

SHFH: – non contributary except for 40 pack/year history tobacco use.  

Meds: Metformin 1000 mg po BID, ASA 81 mg po qam, escitalopram (Lexapro) 5 mg po q am started 2 months ago 

Labs-CBC WNL; Chem 7- Glucose-102 mg/dl, BUN 16 mg/dl, Creatinine 1.1 mg/dl, Na+116 mmol/L, 

K+4.2 mmol/L, CO237 m mol/L, Cl97 mmol/L.  

The APRN refers the patient to the ED and called endocrinology for a consult for diagnosis and management of syndrome of inappropriate antidiuretic hormone (SIADH). 


1.     Define SIADH and identify any patient characteristics that may have contributed to the development of SIADH 

Your Answer:

An overabundance of the hormone antidiuretic causes a condition known as the syndrome of inappropriate Request Unlock antidiuretic hormone (SIADH). (ADH). The hypothalamus in the brain secretes ADH, which is then stored and released by the pituitary gland. ADH regulates the body’s water balance by releasing excess and storing essential fluids. Due to water retention, electrolyte levels drop when ADH is increased. Hyponatremia, or low salt levels, is a severe consequence of SIADH that may lead to cramps, nausea, vomiting, disorientation, seizures, and death. Hydrocephalus, Guillain-Barre syndrome, multiple sclerosis, AIDS, Rocky Mountain spotted fever, lung cancer, gastrointestinal cancer, genitourinary cancer, lymphoma, sarcoma, asthma, lung infections, cystic fibrosis, medications, anesthesia, hereditary factors, and sarcoidosis are all potential causes of SIADH. Hypoglycemic medicines, antidepressants, antipsychotics, opioids, general anesthetics, chemotherapeutic agents, nonsteroidal anti-inflammatory drugs (NSAIDs), and synthetic ADH are only some of the pharmaceuticals that might trigger SIADH. Our patient’s COPD puts her at risk of developing SIADH. Lexapro, metformin, and ASA are all potential triggers for SIADH, all of which our patient is now taking.

Scenario 2: Type 1 Diabetes

A 14-year-old girl is brought to the pediatrician’s office by his parents who are concerned about their daughter’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with her school activities. She had been seemingly healthy until about 4 months ago when her parents started noticing these symptoms. She admits to sleeping more and gets tired very easily. 

PMH: noncontributory.


FH:- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process 

SH: denies alcohol, tobacco or illicit drug use. Not sexually active. 

Labs: random glucose 244 mg/dl.  

DIAGNOSIS: Diabetes Mellitus type 1 and refers to an endocrinologist for further work up and management plan.  


1.     Explain the pathophysiology of the three P’s for (polyuria, polydipsia, polyphagia)” with the given diagnosis of Type I DM.

Your Answer:

Polyuria is the excessive production of urine. A high blood sugar level has a diuretic effect due to its Request Unlock osmotic nature. Glycosuria occurs when the kidneys’ glomeruli filter more glucose than the renal tubules can reabsorb, leading to excessive water loss. 

Polydipsia is a condition characterized by excessive thirst. Intracellular dehydration and hypothalamus stimulation of thirst come from the body’s cells being osmotically drawn to the higher concentration of glucose present in the blood.

Polyphagia is intense or uncontrollable hunger. Cellular deprivation, caused by the breakdown of stored carbs, lipids, and protein, leads to an increase in appetite.

Scenario 2: Type 1 Diabetes

A 14-year-old girl is brought to the pediatrician’s office by his parents who are concerned about their daughter’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with her school activities. She had been seemingly healthy until about 4 months ago when her parents started noticing these symptoms. She admits to sleeping more and gets tired very easily. 

PMH: noncontributory.


FH:- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process 

SH: denies alcohol, tobacco or illicit drug use. Not sexually active. 

Labs: random glucose 244 mg/dl.  

DIAGNOSIS: Diabetes Mellitus type 1 and refers to an endocrinologist for further work up and management plan.  


1.    Explain the genetics relationship and how this and the environment can contribute to Type I DM.


Your Answer:

Autoimmune polyendocrine insufficiency patients’ sera included Request Unlock islet cell autoantibodies (ICAs). Beta cells, which secrete insulin, generate autoantigens that then travel through the body’s circulatory and lymphatic systems. Autoantigen is then presented by antigen-presenting cells after being processed. Type 1 DM is thought to result from a complex interplay between genetic predisposition and environmental factors, although the precise nature of this connection is unclear. Viruses, air pollution, stress, immunizations, microbial ecology, family density, and cow’s milk proteins are all examples of environmental variables. Hyperglycemia, increased thirst and urination, weariness, and a family history of the disease are also present.

Scenario 3: Type II DM

A 55-year-old male presents with complaints of polyuria, polydipsia, polyphagia, and weight loss. He also noted that his feet on the bottom are feeling “strange” “like ants crawling on them” and noted his vision is blurry sometimes. He has increased an increased appetite, but still losing weight. He also complains of “swelling” and enlargement of his abdomen.  

PMH: HTN – well controlled with medications. He has mixed hyperlipidemia, and central abdominal obesity. Physical exam unremarkable except for decreased filament test both feet. Random glucose in office 333 mg/dl.

Diagnosis: Type II DM and prescribes oral medication to control the glucose level and also referred the patient to a dietician for dietary teaching. 


1.     How would you describe the pathophysiology of Type II DM?  

Your Answer:

Insulin resistance, poor control of hepatic glucose generation, and the decline in B-cell activity that ultimately leads to Request Unlock B-cell failure are the hallmarks of type II diabetes. The failure of insulin-sensitive tissues to properly react to insulin and faulty insulin release by pancreatic B-cells constitute type 2 diabetes.
 In order to maintain a steady blood sugar level, the molecular processes involved in insulin production, storage, and secretion, as well as its detection, are strictly controlled. A metabolic imbalance, and hence the illness, may originate from a malfunction in any of the systems involved. Hyperglycemia, a consequence of insulin resistance, insufficient insulin secretion, and excessive or incorrect glucagon production, characterizes type 2 diabetes mellitus, a constellation of dysfunctions. It’s often linked to being overweight.

Scenario 4: Hypothyroidism

A patient  walked into your  clinic today with the following complaints: Weight gain (15 pounds), however has a decreased appetite with extreme fatigue,  cold intolerance, dry skin, hair loss, and falls asleep watching television. The patient also tearfulness with depression, and with an unknown cause and has noted she is more forgetful.  She does have blurry vision.

PMH: Non-contributory.

Vitals: Temp 96.4˚F, pulse 58 and regular, BP 106/92,  12 respirations. Dull facial expression with coarse facial features. Periorbital puffiness noted.

Diagnosis: hypothyroidism.


What causes hypothyroidism?

Your Answer:

The inability of the thyroid gland to produce enough Request Unlock thyroid hormone (TH) is the root cause of hypothyroidism. Due to a lack of thyroid function, TH synthesis drops and TSH and TRH are secreted at higher levels in those with primary hypothyroidism. Thyroiditis, surgical or radioactive therapy for hyperthyroidism that results in thyroid tissue loss, drug side effects, and endemic iodine shortage are the most prevalent causes. Congenital abnormalities in the pituitary or thyroid glands may cause the condition in newborns and young children.


Scenario 1: Peptic Ulcer

A 65-year-old female comes to the clinic with a complaint of abdominal pain in the epigastric area. The pain has been persistent for two weeks.  The pain described as burning, non-radiating and worse after meals. Denies N&V, weight loss or obvious bleeding. She admits to frequent belching with bloating.  

PMH:  seasonal allergies with Chronic Sinusitis, positive for osteoarthritis, 

Meds: Claritin 10 mg po daily, ibuprofen 400-600 mg po prn pain 

Family Hx-non contributary  

Social history: Separated recently pending divorce; stressful situation with trying to manage two homes. Works as a Legal Assistant at a local law firm. She has 35 PPY of smoking, drinks 1-2 glasses of wine a day, and 6-7 cups of coffee per day. She denies illicit drug use, vaping or unprotected sexual encounters.  

Breath test in the office revealed + urease. 

The healthcare provider suspects the client has peptic ulcer disease.


1.     Explain what contributed to the development from this patient’s history of PUD?

Your Answer:

The excessive release of gastric acid and the resulting breakdown of the stomach’s protective mucosal Request Unlock barrier are the root causes of peptic ulcer disease, manifesting as inflammation and ulceration of the mucosal lining. Duodenal, stomach, and stress ulcers are the three kinds of ulcers. H. pylori infection and long-term usage of NSAIDS have been linked to ulcers in the duodenum and stomach. The patient’s positive urease result suggested they were infected with H. pylori, which raised their likelihood of developing PUD. PUD risk factors include the patient’s history of using NSAIDs, the patient’s age, the patient’s current smoking status, the patient’s current drinking status (more than one or two glasses of wine per day), and the patient’s current psychological stress levels. The interaction of NSAIDs and H. Pylori may influence peptic ulcer pathogenesis. Coffee and alcohol cause more acid to be produced, eroding the mucosal lining and promoting more inflammation. Nicotine reduces stomach mucosal prostaglandin production, making the mucosa more prone to ulceration.

Scenario 1: Peptic Ulcer

A 65-year-old female comes to the clinic with a complaint of abdominal pain in the epigastric area. The pain has been persistent for two weeks.  The pain described as burning, non-radiating and worse after meals. Denies N&V, weight loss or obvious bleeding. She admits to frequent belching with bloating.  

PMH:  seasonal allergies with Chronic Sinusitis, positive for osteoarthritis, 

Meds: Claritin 10 mg po daily, ibuprofen 400-600 mg po prn pain 

Family Hx-non contributary  

Social history: Separated recently pending divorce; stressful situation with trying to manage two homes. Works as a Legal Assistant at a local law firm. She has 35 PPY of smoking, drinks 1-2 glasses of wine a day, and 6-7 cups of coffee per day. She denies illicit drug use, vaping or unprotected sexual encounters.  

Breath test in the office revealed + urease. 

The healthcare provider suspects the client has peptic ulcer disease.


1.     What is the pathophysiology of PUD/ formation of peptic ulcers? 

In peptic ulcer disease, the protective mucosal barrier of the stomach is compromised, leading to inflammation and ulceration of the Request Unlock mucosa. Due to PUD risk factors, duodenal acid, and pepsin concentrations can breach the mucosal barrier and produce ulcers. The duodenal acid environment is ideal for the growth of H. pylori. Disruption of the gastrointestinal (GI) tract’s inner lining due to gastric acid production or pepsin causes PUD. It penetrates the stomach epithelium down to the muscularis propria layer. It often affects the stomach and the first part of the duodenum. It is well-documented that H. pylori colonizes the stomach mucosa and causes inflammation there. Acidity and stomach metaplasia are facilitated by H. pylori’s interference with bicarbonate production.

Scenario 2: Gastroesophageal Reflux Disease (GERD)

A 44-year-old morbidly obese female comes to the clinic complaining of  “burning in my chest and a funny taste in my mouth”. The symptoms have been present for years but patient states she had been treating the symptoms with antacid tablets which helped until the last 4 or 5 weeks. She never saw a healthcare provider for that. She says the symptoms get worse at night when she is lying down and has had to sleep with 2 pillows. She says she has started coughing at night which has been interfering with her sleep. She denies palpitations, shortness of breath, or nausea. 

PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m2

FH:non contributary   

Medications: Lisinopril 10 mg po qd, Bentyl 10 mg po, ibuprofen 800 mg po q 6 hr prn 

SH: 20 PPY of smoking, ETOH rarely, denies vaping    

Diagnoses: Gastroesophageal reflux disease (GERD). 



1.     If the client asks what causes GERD how would you explain this as a provider? 

Your Answer:

The symptoms of GERD are caused by acid from the stomach traveling back up into Request Unlock the esophagus. The hallmark of pyrosis is a burning feeling below the breastbone, which most people call heartburn. In someone who has just eaten, this may be accompanied by regurgitation. Some drugs (calcium channel blockers), a hiatal hernia, and obesity may all cause the lower esophageal sphincter (LES) to relax, allowing stomach contents to enter the lower esophagus and potentially cause inflammation and erosion of the esophagus.

Scenario 3: Upper GI Bleed

A 64-year-old male presents the clinic with complaints of passing dark, tarry, stools. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some mid epigastric pain for several weeks and has been taking OTC antacids. The most likely diagnosis is upper GI bleed which won’t be confirmed until further endoscopic procedures are performed.


1.     What are the variables here that contribute to an upper GI bleed? 

Your Answer:

Explicit, bright red bleeding in emesis or black, granular digested blood (often known as Request Unlock “coffee grounds”) in the stool are telltale signs of bleeding in the esophagus, stomach, or duodenum, all parts of the upper gastrointestinal (GI) tract. Drugs (nonsteroidal anti-inflammatory medicines [NSAIDs]), aspirin, selective serotonin reuptake inhibitors, antiplatelet and anticoagulant medications, malignancy, arteriovenous malformations, and peptic ulcers may all contribute to the development of upper gastrointestinal bleeding.

Scenario 4: Diverticulitis

A 54-year-old schoolteacher is seeing your today for complaints of passing bright red blood when she had a bowel movement this morning. She stated the first episode occurred last week. The episode today was accompanied by nausea, sweating, and weakness. She states she has had some LLQ pain for several weeks but described it as “coming and going”. She says she has had a fever and abdominal cramps that have worsened this morning.

Diagnosis is lower GI bleed secondary to diverticulitis.


1.     What can cause diverticulitis in the lower GI tract? 

Your Answer:

Herniations of the mucosa, or Request Unlock saclike protrusions of mucosa through the muscular layers of the colon wall, are what we call diverticula. Infection of the diverticula is the root cause of diverticulitis. If undigested food or feces becomes lodged in one of the pouches, it might lead to an infection. The feces bacteria may then proliferate and spread, leading to an illness. Fever, leukocytosis, and lower left quadrant discomfort manifest when diverticula become inflamed or abscesses form.


Scenario 1: Myocardial Infarction

CC: “I woke up this morning at 6 a.m. with numbness in my left arm and pain in my chest. It feels tight right here (mid-sternal).” “My dad had a heart attack when he was 56-years-old and I am scared because I am 56-years-old.” 

HPI: Patient is a 56-year-old Caucasian male who presents to Express Hospital  Emergency Department with a chief complaint of chest pain that radiates down his left arm. He states this started this morning and has been getting worse, pointing to the mid-sternal area, “it feels like an elephant is sitting on my chest and having a hard time breathing”. He rates the pain as 9/10. Nothing has made the pain better or worse. He denies any previous episode of chest pain. Denies nausea, or lightheadedness. Nitroglycerin 0.4 mg tablet sublingual x 1 which decreased pain to 7/10.

Lipid panel reveals Total Cholesterol 424 mg/dl, high density lipoprotein (HDL) 26 mg/dl, Low Density Lipoprotein (LDL) 166 mg/dl, Triglycerides 702 mg/dl, Very Low-Density Lipoprotein (VLDL) 64 mg/dl

His diagnosis is an acute inferior wall myocardial infarction.


Which cholesterol is considered the “good” cholesterol and what does it do?

High-Density Lipoprotein (HDL) is referred to as “good” cholesterol, as it Request Unlock removes excess cholesterol buildups in they body cells and transfers it to the liver for elimination. By doing so, it prevents cardiovascular diseases such as heart attacks and strokes, when cholesterol levels are optimal. HDL protects against atherosclerotic cardiovascular disease by preventing plaque buildup in the arteries, maintaining endothelial functions, reduces the risk of atherosclerotic cardiovascular disease, and protecting against the reverse transport of cholesterol from the tissue to the liver, where it is excreted. HDL prevents LDL from being oxidized, boosting its anti-inflammatory and anti-thrombotic effects. 

Scenario 1: Myocardial Infarction

CC: “I woke up this morning at 6 a.m. with numbness in my left arm and pain in my chest. It feels tight right here (mid-sternal).” “My dad had a heart attack when he was 56-years-old and I am scared because I am 56-years-old.” 

HPI: Patient is a 56-year-old Caucasian male who presents to Express Hospital  Emergency Department with a chief complaint of chest pain that radiates down his left arm. He states this started this morning and has been getting worse, pointing to the mid-sternal area, “it feels like an elephant is sitting on my chest and having a hard time breathing”. He rates the pain as 9/10. Nothing has made the pain better or worse. He denies any previous episode of chest pain. Denies nausea, or lightheadedness. Nitroglycerin 0.4 mg tablet sublingual x 1 which decreased pain to 7/10.

Lipid panel reveals Total Cholesterol 424 mg/dl, high density lipoprotein (HDL) 26 mg/dl, Low Density Lipoprotein (LDL) 166 mg/dl, Triglycerides 702 mg/dl, Very Low-Density Lipoprotein (VLDL) 64 mg/dl

His diagnosis is an acute inferior wall myocardial infarction.


1.     How does inflammation contribute to the development of atherosclerosis?

Your Answer:

Myocardial infraction is almost often caused by Request Unlock atherosclerosis, which is an inflammatory disease. Mitochondrial damage is caused by inflammation in the heart muscle, increases free radical production, which further activates the chronic inflammatory cascade. Since plaque development erodes the artery wall, inflammation is a leading cause of aneurysms. Damage to the wounded heart may be exacerbated by an inadequate or exaggerated response to the inflammation, which causes harmful remodeling. 

Scenario 2: Pleural Friction Rub

A 35-year-old female with a positive history of systemic lupus erythematosus (SLE) presents to the Emergency Room (ER) with complaints of sharp retrosternal chest pain that worsens with deep breathing or lying down. She reports a 5-day history of low-grade fever, listlessness and says she feels like she had the flu. Physical exam reveals tachycardia and a pleural friction rub. She was diagnosed with acute pericarditis.


1.     Because of the result of a pleural friction rub, what does the APRN recognize?

Your Answer:

The APRN is aware that a roughening of the usually smooth surfaces of the Request Unlock visceral and parietal pleura, as it is often seen with inflammation of the pericardium related to the pericarditis or pericardial effusion, is responsible for the pleural friction “rub” that is audible upon auscultation of the lung, towards the op of the chest and the left sternal border. Patients presenting with autoimmune illness, malignant pleural disease, pleurisy from a secondary virus or pancreatitis, or pleurisy as a result of pneumonia or a pulmonary embolisms are at a very high risk for this type of syndrome. Pleural effusion, pleuritis, and serositis are conditions that may lead to a pleural friction rub. 

Scenario 4: Deep Venous Thrombosis (DVT)

A 81-year-old obese female patient who 48 hours post-op left total hip replacement. The patient has had severe nausea and vomiting and has been unable to go to physical therapy. Her mucus membranes are dry. The patient says the skin on her left leg is too tight. Exam reveals a swollen, tense, and red colored calf. The patient has a duplex ultrasound which reveals the presence of a deep venous thrombosis (DVT).


1.     Given the history of the patient explain what contributed to the development of a deep venous thrombosis (DVT)

Your Answer:

There are many contributions to the development to the deep venous thrombosis (DVT) after the surgery. First, Request Unlock venous stasis, which is caused by factors such as old age, obesity, and the inability to move around during the physical therapy. Secondly, she exhibits signs of hypercoagulability, which would indicate that her blood has an increased propensity to thrombosis, protein, and particles that may promote platelets to cling to the vessel wall and clump together, creating blood clots. Lastly, the vessel walls get damaged due to an endothelial injury, which would result in inflammation and fibrosis. The patient currently is experiencing the onset of Virchow’s triad, which includes damage and the development of a thrombosis. 

Scenario 5:  COPD

A 66-year-old female with a 50 pack/year history of cigarette smoking had a CT scan and was diagnosed with emphysema.  He asks if this means he has chronic obstructive pulmonary disease (COPD).


1.     There is a clear relationship between emphysema and COPD, explain the pathophysiology of emphysema and the relationship to COPD.

Your Answer:

COPD is a progressive lung disease that causes lung harm due to many pathogenic mechanisms inside the Request Unlock lung. Damage to the lungs from emphysema is permanent because of the inflammatory and destructive process that occur as a result of maternal smoking or secondhand exposure. These include oxidative stress, inflammation, apoptosis, autophagy, and protease-antiprotease imbalance, which affect alveolar maintenance. Emphysema pathophysiology is characterized by substantial ventilation/perfusion mismatch due to the loss of alveoli, resulting in reduced surface area of gas exchange. The alveolar are also damaged due to the elastin breakdown inside the septa. Progressive damage from inflammatory oxidative stress is triggered by neutrophils, macrophages, and lymphocytes migrating to the lungs after prolonged exposure to the irritants. Individuals with chronic obstructive lung disease and emphysema often suffer from pulmonary infections, which are accompanied by production of large volume of sputum.  

Alteration in Cellular Processes: A 27-year-old patient with a history of substance abuse is found unresponsive by emergency medical services (EMS) after being called by the patient’s roommate. The roommate states that he does not know how long the patient had been lying there. Patient received naloxone in the field and has become responsive. He complains of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L.

The Role of Genetics

This patient has a history of substance abuse which could be a concluding factor to the sudden loss of consciousness and other symptoms exhibited by him. Considering the fact that the patient received naloxone in the field and became responsive proves that he has been consuming opioids, either injectable or oral, in large quantities. Compliant of burning pain over his hip and forearm shows that he is suffering from rhabdomyolysis, a complex condition caused by injured or damaged skeletal muscles. This condition can result from a traumatic or non-traumatic causes which in this case, drug abuse is one of the non-traumatic contributing factor to the development of rhabdomyolysis in this patient. Due to the disruption in the integrity of skeletal muscles, rhabdomyolysis leads to the release of intracellular muscle proteins including myoglobin, creatine kinase and electrolytes into the blood stream which could be a life threatening condition. (Torres et al, 2015). The role of genetics in the development of rhabdomyolysis could be an inherited neuromuscular disorder. The genetic predisposition of rhabdomyolysis include muscular dystrophies, metabolic muscle disorder, mitochondrial disorder, and intramuscular calcium release and excitation-contraction coupling. (Scalco et al, 2015).

Presenting with Specific Symptoms

The symptom of burning pain over his left hip and forearm experienced by the patient is as a result of the muscle injury incurred while taking opioids in large quantities leading to necrosis and tissue damage. Cell injury and death result when the body has been exposed to “toxic chemicals, infections, physical trauma, and hypoxia”. (McCance & Huether 2019). The abnormal EKG reading and elevated serum potassium levels are due to the release of calcium and potassium from damaged muscles into the blood stream which could not be cleared by the kidney. (Torres et al, 2015). Additionally, the symptom of unresponsiveness was caused by opioid overdose.

Physiological Response and Cells involved in this Process

The physiological response to the stimulus in this scenario is the quick return of responsiveness after the patient received naloxone which is a reversal agent for opioid overdose. Naloxone, an opioid antagonist, attaches to opioid receptors, reverses and block the effect of other opioids. Also, it restore normal breathing to persons whose respiration has been slowed or stopped due to opioid overdose. (NIDA 2022, January 11). The cells to which naloxone binds in this process is called the mu-opioid receptors. As a mu-receptor antagonist, naloxone works within two minutes when administered intravenously and last between 60 to 90 minutes. (Edinoff et al, 2021).

Genetics and Environment

Genetics and the environment are another characteristics that will change the response as it is a contributing factor to why most individuals who abuse drugs are opioid dependent while others are not. The risk for someone becoming a drug addict can be dependent on their genes and the environment. Their are individuals with the single polymorphism gene that protect them from becoming dependent on opioid. The environment and lifestyle affects an individual’s vulnerability to drug use and addiction. (Wang et al, 2019).


First, it should be mentioned that we do not know how long the patient was unconscious and what this patient overdosed on. Naloxone (Narcan) was used as treatment of choice, which caused patient to regain consciousness. Narcan can quickly reverse an opioid overdose. It is an opioid antagonist. As a result, it binds to opioid receptors, blocking and reversing the effects of other opioids (Naloxone Drug Facts, 2022). However, it is important to note that single Narcan application may not be enough as we are not aware of substance and amount taken.

Second, patient presents with necrotic tissue over left great trochanter as well as the forearm. Necrotic tissue is cause by decries oxygenated blood to body parts. It may be caused by many things including injury, cold, or chemicals.  Pt could have potentially fallen as a result of overdose, which could have caused rhabdomyolysis. Rhabdomyolysis is the breakdown of damaged muscle that leads to the leaking of the contents of muscle cells into the blood, which may harm organs. Potassium plays a major role in regulating the skeletal muscle blood flow (Buttner, & Buns, 2022). In the information provided patient presents with increased K+ level at 6.9 mEq/L, which is a contributing factor of rhabdomyolysis. Rhabdomyolysis is usually associated with hyperkalemia due to renal failure. Aside from that muscle breakdown could be indicated by muscle protein creatine kinase (CK) levels in blood, which we were not provided with (Rhabdomyolysis, 2023). 

Third, patient presents with abnormal EKG results involving prolonged PR interval and peaked T waves. Elevated serum K+ can cause EKG abnormalities. An elevated serum potassium level (> 5.2 mmol/L) is referred to as hyperkaliemia. EKG alterations typically do not appear until hyperkalemia has reached a significant level (6.0 mmol/L). An increase in T wave amplitude is the first sign of hyperkalemia (Buttner, & Buns, 2022).

In case of genetics, information was never provided if this patient belongs to a certain race. It is known that this patient is a potential 27 year old male. Genetically speaking, it can be assumed that heredity plays a part in one’s future. For example, it may be possible to predict whether a person would develop an addiction to substances by counting the amount of a certain type of dopamine receptor known as D2. It responds to the presence of dopamine. If one is lacking this gene the compulsion to consume will be increased (Price, 2018).

In terms of gender the difference comes with age and weight. This will determine dosage and potential amount of treatment required. Older people tend to respond slower compared to younger people. In terms of wight dosage might be adjusted to prevent Narcan rebound effect. The body only retains the effects of Narcan for 30 to 90 minutes. If a powerful opioid is present in the body, it is possible for a person to continue to feel the effects of an overdose even after naloxone wears off or to require additional doses (Naloxone Drug Facts, 2022). Environment plays a big role in addiction treatment as well.

Necrosis is the typical type of cell death with severe cell swelling and breakdown of organelles. (Jog & Caricchio, 2014). The patient had gangrenous necrosis based on the patient history of substance abuse and symptoms. Since the patient’s history of substance abuse contributed to hypoxia, a lack of oxygen supply, ATP production was decreased. This type of tissue necrosis results from a severe hypoxic injury due to blockage or arteriosclerosis.

Genetics is the study of genes and heredity traits. Genes influence all aspects of the body’s structure and function, so any error in one of the genes can lead to a recognizable genetic disease (McCance & Huether, 2019). Genetics plays a role in the disease to determine if the patient carries specific disease-causing mutations (McCance & Huether, 2019). In the case of the patient in the scenario, the necrotic tissue could result from genetic mutation or the use of substance abuse by the patient. The DNA must replicate itself accurately during cell division to preserve genetic code for subsequent generations.

The patient presents with the symptoms because of the release of bradykinins, obstruction, and pressure. Dead cell causes a burning sensation and pain. Also, the fluid shift has changed due to cell necrosis. Potassium is the primary intracellular electrolyte and is highly regulated due to its role in neuromuscular function (McCance & Huether, 2019). The cell hypoxia leads to hyperkalemia by diminishing the efficiency of cell membrane active transport causing a change in cell membrane permeability, leading to the escape of potassium to ECF (McCance & Huether, 2019). The EKG reading of prolonged PR interval and peaked T wave occurs due to hyperkalemia.

Cells involved are the endoplasmic reticulum and mitochondria, the plasma membrane rupture, and the cell lysis. The physiological response to the stimulus in the scenario is EKG result and burning pain. One problem that causes necrosis is the use of chemical agents, such as substance abuse (Khalid, n.d.). The patient had burning pain due to the necrotic tissue, and research shows that lack of oxygen causes necrosis (Khalid, n.d.). When tissue has a problem, it affects the transport of electrolytes across the cell, resulting in electrolyte imbalance. The Prolong PR and peaked T were caused due to hyperkaliemia. In the scenario provided, whether the patient is male or female was not cleared. However, based on research evidence, males are more likely to develop necrosis than females (Ortona et al., 2014).

The role genetics plays in the disease.

Normal serum potassium level ranges from 3.5 mEq/L to 5.5 mEq/L. There is no difference in potassium level between females and males. Serum potassium level more than 5.5 mEq/L is considered more than normal and it is referred as hyperkalemia (Jain, Ong & Warnock, 2013). There is always need to rapidly treat such a condition given that a potassium level more than 6.5mEq/L result in high mortality rate and morbidity, which means it should be treated as an emergency (Jain, Ong & Warnock, 2013). The patient may be suffering from hyperkalemic period paralysis which is amplified by taking of drugs. Drugs such as opioids can increase chances of hyperkalemic episodes. Hyperkalemic periodic paralysis is associated with changes in SCN4A gene. This is an inherited condition which results in increase in serum potassium levels.

Why the patient is presenting with the specific symptoms described.

The symptoms of hyperkalemic periodic paralysis can begin from childhood and may continue to adulthood. The condition is associated with muscle weakness during the episode of high potassium levels in the blood. As a result of the muscle weakness, the patient would be lying on one side of the body for a long time. This caused the ED to show large amount of necrotic tissue. Large amount of necrotic tissues involves cutting off of blood supply to a certain area of the body, resulting in death of the tissues. Similarly, an increase of serum potassium above 6.5 mEq/L leads to prolonged PR interval (Parham et al., 2006). This is given that it leads to a longer action potential.

The physiologic response to the stimulus presented in the scenario and why you think this response occurred.

Naloxone is used for treatment of opioid overdose (NIDA, 2022). The different opioids include fentanyl, heroin, morphine, and oxycodone. Individuals who have signs of opioid overdoes are given naloxone. In case the patient was suspected of an opioid overdose, naloxone reverses and blocks the effect that opioids have on the body.

The cells that are involved in this process.

Cells involved in naloxone action include µ-opioid receptor. These receptors control a variety of physiological functions. Such functions include mood, memory, motivation, temperature and respiration. Opioids such as fentanyl and morphine are used to treat severe pain due to the fact that these drugs target these receptors.

How another characteristic (e.g., gender, genetics) would change your response.

Other causes of hyperkalemia would be kidney diseases which impacts the function of the kidney. Kidneys are involved in balancing serum potassium levels. The kidney usually works to filter potassium and ensure it is balanced in the body (Hollander-Rodriguez & Calvert, 2006). If the functioning of kidney is not good, it will not be able to remove excess potassium in the body. People with kidney diseases and who take diets with high potassium will likely suffer hyperkalemia

The main root of diagnosis for this patient is substance abuse. There are many factors both genetic and environmental that put someone at risk for developing substance use abuse. According to the NIHs, National Institute on Drug Abuse, NIDA, half of a persons risk of being an alcohol, nicotine or tobacco user depends on his or her genetic makeup. Besides for genetic factors, environmental factors such as social circles, financial bracket and emotional trauma can put someone at greater risk for developing substance abuse (NIDA, 2019).

The selected patient scenario seems to be describing an individual who has experienced an opioid overdose. As a result of the overdose the patient was found by EMS in an unresponsive state. Naloxone, a reversal agent for opioids was administered, causing the patient to gain consciousness (CDC, 2023). Upon becoming responsive, it seems the patient was experiencing tremendous pain radiating over his left hip and forearm. Based on the given information, it seems that the patient was experiencing this pain before and perhaps as a result took pain medications. Deeming the patients history of abusive patterns, I would deduce that the patient was overmedicating on some opioids to reduce his pre existing pain.

Often times as a result of substance abuse, a condition called rhabdomyolysis can occur ( F, Fernandez, et al. 2019). Rhabdomyolysis, along with necrosis is what I would attribute to the intense pain felt over his left hip and forearm. Rhabdomyolysis, is a life threatening condition that is caused by injury to the skeletal muscles, in this case the injury being the substance abuse (CDC,2023).The abuse substance impairs the skeletal muscles ability to produce or use ATP or it causes an increase in the ATP demand that exceeds the bodies ATP production ability. As a result the muscle tissue breaks down rapidly releasing intracellular muscle components into the bloodstream. This can lead to electrolyte imbalances, kidney disorders and other dysregulations in the body. In this situation, as a result of the muscle breakdown, there is a shift in the K+ and Na+ gradients. The increase in intracellular Ca+ due to the muscle breakdown causes an electrolyte shift in the membrane, often causing increased  potassium in the blood, also known as hyperkalemia. The increased potassium level of 6.9 this patient is experiencing has caused the peaked T waves due to the gradient shift. The increased potassium causes increased excitability in the electrical conduction of the heart, causing the peaked T waves as well as the prolonged PR interval seen on the EKG reading (Mckance & Heuther, 2019).

Being that the patient was found unconscious and had a period of time with potential hypoxia to all extremities and a potential infection prior to the overdose, the necrosis, and essentially tissue death found over the greater trochanter and forearm is not surprising. Oftentimes following an episode of opioid overdose, a person is driven into respiratory depression, which causes a decrease in oxygenation leading to hypoxia which can in turn cause necrosis to parts of the body (Alyssa, 2022).

Had the patient been of older age, with multiple comorbidities I am certain my assessment and interpretation of this case would be different. The older the person is , the more sensitive their body becomes to drug metabolization. As a result an older patient may have worse adverse effects from an overdose than a 27 year old individual and they may be affected from a lower “overdose” than someone who is of younger age. Additionally, having comorbidities can cause the overdose symptoms to be exacerbated or may lead to additional complications (Public citizen, 2019).

In regards to this post about the 27-year-old patient,  I believe that he is suffering from rhabdomyolysis. The description of this patient having substance abuse and then being found on the floor after many many hours fits with this diagnosis . His elevated potassium level is also a sign of rhabdomyolysis. When reading an article on the National Kidney Foundation website, I have found that patients can go into acute kidney failure with rhabdomyolysis.  If they are severly dehydrated after being found on the floor after hours or days, the kidneys will be affected.  When the kidneys are affected this can cause a patient to become hyperkalemic.  (National Kidney Foundation Staff, 2023).  Also his irregular cardiac rhythms on his EKG for this as well.  When doing research on this topic, I came upon an article on WebMD.  In summary, Rhabdomyolysis can be caused by many factors.  Factors could be traumatic or non. They could be the result of a car crash for example or a fall placing a patient on their back or side for long periods of time.  Burns or snake bites can also be culprits. Finally, muscles strained at an extreme level when working out, use of alcohol or drugs, seizures or high body temperature can weight in. (Stuart, Annie. 2021).

At the hospital I currently work at we do see a fair aount of Rhabdo patients.  I have learned about their plan of care from this perspective.  Also, if I were a nurse practitioner working on this patient, I would do the following.  Some of this knowledge was also gained from a Healthline article.  I would first make sure an IV was started with fluids.  Dialysis may also be needed due to the severe kidney damage.  A complete lab panel should be run to look at other values such as creatinine.  Biocarbonate should also be introduced for the kidneys. (Case-Lo and O’Carroll, 2021).  Rest is very important in this case.  As is monitoring all heart labs such as potassium and magnesium.  Circulation should be monitored very closely on this patient due to necrotic tissue and muscle death.

This patient will need a lot of care moving forward.  If there is a substance abuse problem, this patient should also be monitored for withdrawing from drugs or alcohol.  A family member or friend should be involved to keep close watch on them upon discharge and a social worker should also be involved to share treatment options for their substance abuse.

I feel that substance abuse has a genetic factor.  From research I have done over time, and observations at the hospital, I have learned that those with mental health disorders such as depression, personality disorders and schizophrenia are more at risk to develop addictive habits. Also, reoccuring rhabdomyolysis can also have a genetic factor.  My thoughts after reading a genetics website, is that reocurring rhabdomyolysis can include genetic factors such as metabolic myopathy, disorders of intramuscular calcium release, mitochondrial disorders and muscular dystrophies.  (Blueprint Genetics Staff, 2022).
The cells involved in Rhabdomyolysis include skeletal muscle cell damage.  After reading more on the unmc website, I have learned that the cellular membrane is affected. This can lead to the release of toxic intracellular constituents.  These could be released into the blood stream. (Giannoglou, Chatzizisis and Misirli, 2006.)

If only one factor was changed in this scenario, age, my response would be different.  While in this scenario, a twenty-seven year old is involved and the prognosis to make it through is very high.  If this was an elderly patient, their change of complete recovery is low.  This may lead to many dialysis sessions for them.  This also may lead to limited mobility for them.  They may find themselves needing placement in a nursing home when they were once independent.

  • The role genetics plays in the disease.

A multitude of environmental and genetic factors may play a role in an individual’s risk of becoming dependent on substances. Family studies have shown that up to 50% of a person’s risk of becoming addicted to substances relies on their genetic makeup (NIDA, 2019).

  • Why the patient is presenting with the specific symptoms described.

He likely presents with the burning and necrotic tissue over left hip and forearm due to loss of circulation to these areas. He had an unknown down time prior to being found, and if he was laying on these areas for an extended period of time, there’s a risk of loss of circulation and perfusion to the affected areas. The elevated potassium will cause changes in EKGs including peaked T waves.

  • The physiologic response to the stimulus presented in the scenario and why you think this response occurred.

The stimulus in this scenario was the Narcan. Narcan is an opioid antagonist, it blocks the receptors that opioids bind to, creating a reversal effect (Narcan: How It’s Given, How It Works, Uses, and More, 2021). The Narcan effectively reversed the effects of the opioid medication taken by the patient, causing him to regain consciousness.

  • The cells that are involved in this process.

Neurons are involved in this process. Neural cells have receptors that bind to various hormones and chemicals, either produced by the body or introduced via medications.

  • How another characteristic (e.g., gender, genetics) would change your response.

Gender would be a topic to explore more fully in its effect on substance use disorder. According to The National Institute on Drug Abuse (NIDA) (2022), men are more likely than women to use illicit drugs. However, women are just as likely as men to develop substance abuse disorder (NIDA, 2022). I don’t think that this consideration would change my overall view and diagnosis of the patient, but it is an important factor to consider. There are also other factors to consider, such as other mental health diagnoses, socioeconomic status, and other diagnoses affecting overall health.

There are scientifically proven factors that can influence the development of substance abuse, genetic factors being one. Genetic factors and variations play a significant role in establishing individual differences in addiction risk. Genetic studies have shown an overlap in genetic variants that influence risk towards different classes of drugs. The most extensive study to date on 1.2 million individuals that assessed common genes in alcohol and nicotine use has identified genes involved with dopaminergic and glutamatergic neurotransmission, genes involved with transcription and translation, and brain development (Volkow et al., 2019). Genetic studies have also revealed an important genetic contributor that influences a vulnerability for disorders characterized by pathological tendencies to violate social norms or engage in oppositional behaviors, which substance abuse is characterized.

In this case study, the patient presented with loss of consciousness (LOC) but became responsive after receiving naloxone. He complains of a burning sensation over his left hip and forearm, and an Emergency Department (ED) exam revealed a significant amount of necrotic tissue over those areas. An EKG of the patient showed prolonged PR intervals and peaked T waves, and a lab result revealed a potassium level of 6.9 mEq/L. The patient likely has a decreased LOC due to injection or ingestion of an opioid substance. These substances decrease the central nervous system and autonomic functions necessary for living, such as blood pressure, respiration, heart rate, and body temperature (Somerville et al., 2017). This occurred due to the injection or ingestion of more substances than the body could handle, causing depression in body functions. The necrotic tissue over his left hip and forearm could be from infections at substance injection sites or from the injected substances blocking blood flow to those areas. The necrotic tissue could also result from hypoxia due to the decompensation of his central nervous system and autonomic functions when unconscious. Necrotic tissue is painful and caused by cell death. Alcohol and social drugs, especially opioids, can significantly alter cellular function and injure cellular structures resulting in cell death (McCance & Huether, 2019, p. 61). The EKG results show hyperkalemia by the peaked T waves and prolonged PR intervals. It was confirmed with the lab work that showed elevated serum potassium. A typical range for serum potassium is 3.5 – 5.0 mEq/L, so it’s clear that his levels are elevated. This could be an acute episode of hyperkalemia commonly triggered by the introduction of medications or substances affecting potassium homeostasis, and illness or dehydration also can be triggers (Hollander-Rodriguez & Calvert, 2006). The presence of typical electrocardiographic changes or a rapid rise in serum potassium indicates that this hyperkalemia is potentially life-threatening.

Due to the potential of this patient to have sustained a hypoxic injury, along with the other external stimuli such as substance use and loss of consciousness, cellular death took place. McCance & Huether (2019) state that with necrosis, there is a rapid loss of the plasma membrane structure, organelle swelling, and mitochondrial dysfunction (p. 87). Necrosis is common with ischemic and hypoxic injuries along with infections and trauma, which the patient could have sustained all three. Also, with ischemic and hypoxic injury comes a shift in extracellular potassium. This can cause the patient’s hyperkalemia. McCance & Huether (2019) also mention that as cells die, the plasma membrane’s sodium-potassium (Na+-K=) pump and sodium-calcium exchange start to fail, which increases the intracellular accumulation and sodium and calcium, leading to the cells swelling and diffusing potassium out of the cell into the extracellular space. These cellular processes are involved in the physiological response of the patient.

After reviewing the body and cellular processes involved in this case study, I don’t believe variables in characteristics of the patient would change my responses. Given the circumstances these physiological responses could have happened regardless of sex, race, or family history.

The disease for the case scenario described is a combination of disease processes, caused initially by a suspected drug overdose. The disease processes are respiratory depression secondary to drug overdose and acute kidney failure secondary to rhabdomyolysis and first-degree heart block. Opioid overdose causes respiratory depression, which decreases the amount of oxygen getting to the cells in the body and cause organs to shut down and cells to become damaged or die. The patient has a history of drug abuse and arouses after administration of Narcan, which suggests that this was the culprit. Because we do not know how long the patient was down, we only have symptoms to assume he was down for an extended period of time. The necrotic tissue over his greater trochanter and forearm, along with burning pain, indicate pressure injuries from being down for a long time. The pressure to the tissue deprives the cell of oxygen and nutrients resulting in cell tissue death of the epithelium. His elevated serum potassium levels indicate an acute kidney injury that may be due to the process of muscle cell breakdown releasing myoglobin, potassium, creatine kinase, phosphate and urate into the bloodstream, which damaged kidney cells, increasing potassium levels, which result in a peaked T wave (Cleveland Clinic, n.d.). Prolonged PR interval may be due to the excess of drug use damaging cardiac cells (McCance & Huether, 2019).

Genetics play a large part in the disease of addiction and drug abuse. It has been shown that addiction is genetic. Addiction may be worsened by environmental factors such as poverty, poor home life and environment. Another characteristic that would change my response is if the patient did not have a known history of drug abuse and did have a history of chronic kidney failure. If he did not have a history of drug addiction than I would think that this was not a genetic trait. If he had a history of chronic kidney failure, I would lean more towards the initial issue being acute kidney failure and possibly not metabolizing his medication appropriately, causing him to become unresponsive (McCance & Huether, 2019).

The role genetics plays in the disease.

                      This patient presents with Rhabdomyolysis from decreased blood supply to the area, causing autolysis. Torr & Mortimore (2022) explain that the characteristic of Rhabdomyolysis is the rapid dissolution of damaged or injured skeletal muscle that can result from many mechanisms. The authors further explain that Rhabdomyolysis causes muscular cellular breakdown, which can cause fatal electrolyte imbalances. From the explanation, one will conclude that in this case, genetics play a less important role as Rhabdomyolysis developed due to compression of muscle compartments because of prolonged immobility and substance abuse but not due to genetics. 

                                            Why is the patient presenting with the specific symptoms described?

                   The patient presents with specific symptoms because, according to (Torr & Mortimore, 2022). damage to muscles (muscle necrosis) due to Rhabdomyolysis in the hip explains the burning pain over the hip. Also, elevated potassium level is due to leakage of intracellular potassium into circulation resulting in Hyperkalemia, and ECG findings are consistent with this Hyperkalemia. McCance et al. (2019) defined Hyperkalemia as ECF greater than 5.0mEq/L and severe Hyperkalemia as serum levels greater than or equal to 6.0mEq/L. 

       Explain the physiologic response to the stimulus presented in the scenario and why you think this response occurred.

          Zimmerman (2022). emphasizes that most drugs can directly affect the skeletal muscles, resulting in Rhabdomyolysis. The writer explains further that researchers found that individuals addicted to cocaine had a reduced gray matter volume compared with individuals who did not have a cocaine dependency. Qeadan, & Madden. (2022) state that naloxone is an opioid antagonist that temporarily reverses respiratory depression and sedation and dramatically reduces opioid overdose fatalities.

       Prolonged lying down, as evident from the incident, the patient was lying down from an unknown time which could have raised the compartment pressure in vulnerable muscle compartments like the leg, hip, volar aspect of the hand, and gluteal regions (Zimmerman, 2022). McCance et al. (2019) explain that decreased blood supply to the greater trochanter and forearm caused a decrease in ATP production. The decreased ATP caused an increase in intracellular calcium. As calcium increases, there will be an exchange of potassium, and serum K+ levels will rise.

                                                        The cells that are involved in this process.

Muscle cells are mainly involved in this process. Due to damage to the muscle cells, the

myoglobin in the muscle cells leaks into the blood and causes renal toxicity (nephrons are next

involved in pathology) and metabolic acidosis. Muscle ischemia can further cause nerve damage (nerve cells). Extracellular fluid shift resulting in shock due to hypovolemia Hyperkalemia due to leaked intracellular potassium ions, which can induce dysrhythmias (myocardial cells) (McCance et al., 2019)

                                 How would another characteristic (e.g., gender, genetics) change your response?

Gender: Rhabdomyolysis occurs less in females than males. Burning pain in females could be more attributed to local tamponade due to immobility. It does not mean that females do not have the disease. On the other hand, this case presentation of Rhabdomyolysis lacks a genetic component because the illness occurred due to prolonged immobility and substance abuse.

Without more information or medical history of the patient, the underlying disease is substance use disorder. More specially, in this case, opioid use disorder. This is evidenced by the background history given by the patient’s roommate and the fact the naloxone made the patient responsive. There have been several research studies conducted on opioid addiction and genetics. In a review of opioid addiction and genetics Crist, Reiner, and Berrettini (2019) conclude that the risk for opioid abuse is increased significantly by genetics. Twin and family studies have estimated the heritability to be 23-54%. Several genes have been studied and identified as risk factors for opioid use disorder. A few of those genes include Mu-opioid Receptor, Delta-Opioid Receptor, Dopamine Receptor D2, and Brain-derived Neurotrophic Factor.

The patient presented as unresponsive, which is a side effect of opioid overdose. Opioid overdoses cause respiratory and central nervous system depression which can lead to hypoxic brain injury or death (Chimber & Moleta, 2018). The drug naloxone was given by emergency medical services (EMS), which caused them to become responsive. Naloxone is an opioid antagonist drug that reverses the effects of opioids. Upon reversal of the opioids in the patient’s system, the patient regained normal respiratory status and regained consciousness. The patient complained of pain in his left hip and forearm. Upon evaluation in the emergency department (ED), necrotic tissue was found on his forearm and greater trochanter. The pain was caused by these deep tissue injuries from both ischemic and hypoxic injuries, lack of oxygen to the body from the overdose, and decreased blood flow from laying for an unknown period. This creates local cell death and then autolysis, leading to necrosis. The changes in the EKG are a direct result of the patient’s increased potassium levels (hyperkalemia). According to Najjar (2022), “peaked T waves, usually seen when K levels are between 5.5-6.5mmol/15) Shortened QT and ST-segment elevation may follow. As K rises to 7-8mmol/L or above, the disappearance of P waves and QRS complex widening may develop”. The unknown downtime could contribute to rhabdomyolysis, which is a kidney function impairment and tissue breakdown. As a result, the patient is at high risk for tissue necrosis and an increase in potassium.

A complete medical history may change my response to this scenario. The increased potassium levels could be in part due to underlying kidney disease. The necrotic tissue could be related to IV drug use or other unknown variables. The exact drugs on board and events leading to the event could shed light on the current presentation. More testing such as a CPK level, WBC, and CT to reveal is there is gas in the wound, if an infection is present, or if in fact, the patient is in rhabdomyolysis.  Additionally, race, gender, and family history would be helpful for determining genetic predispositions.

Influence of Genetics in Necrotizing Soft Tissue Infection
Genetics is important in determining the susceptibility and severity of NSTIs. Genetic variations in the genes linked with the innate immune system can influence the risk of developing NSTI. In particular, the Toll-like receptor pathways, responsible for recognizing invading pathogens by the immune system, are associated with NSTI risk (Hua et al., 2018). In addition, polymorphisms in genes involved in the inflammatory response may also increase the susceptibility to NSTI and the severity of the infection. A study by Fernando et al. (2019) also identified genetic variations in the genes involved in coagulation and fibrinolysis that can increase the risk of developing NSTI and affect the outcome of the infection. Furthermore, other genetic factors, such as gender, age, and race, may also influence the risk and severity of NSTI and the response to treatment (Stevens et al., 2021). As such, it is crucial to consider the genetic factors when assessing the risk of NSTI in patients and tailor the treatment according to the individual’s genetic profile.

Analysis of Patient’s Symptoms
The patient is experiencing acute discomfort over their left hip and forearm, protracted PR interval, and serum potassium level of 6.9 mEq/L because of the necrotizing soft tissue infection. NSTI is a critical infection that results in tissue necrosis, or death of cells and tissues, due to bacterial toxins and enzymes (Shumba et al., 2019). These toxins and enzymes cause inflammation and tissue damage, resulting in the burning pain the patient is experiencing in the limbs. The EKG changes, such as the prolonged PR interval and peaked T waves, can be attributed to the high serum potassium level, often seen in cases of NSTI due to the systemic release of potassium from the damaged tissue (Thänert et al., 2019). The prolonged PR interval could also be attributed to the inflammation of the myocardium, which is often seen in cases of NSTI. These symptoms indicate necrotizing soft tissue infection and require prompt treatment to prevent further tissue damage.

The Physiologic Response to Necrotizing Soft Tissue Infection
The physiologic response to the NSTI in the scenario is likely an immune response. When the body is exposed to a pathogen, the innate immune system responds by producing inflammatory cytokines, such as interleukin-1, as well as chemokines, such as CXCL8, to recruit inflammatory cells to the site of infection (Hua et al., 2018). This process activates the pro-inflammatory pathways, releasing inflammatory mediators such as histamine, prostaglandins, and leukotrienes, which cause the burning pain the patient is experiencing in the limbs (Fernando et al., 2019). In addition, releasing these inflammatory mediators also activates the coagulation pathways, which can lead to prolonged PR interval and peaked T waves seen on the EKG (Thänert et al., 2019). The elevated serum potassium level is likely due to the systemic release of potassium from the damaged tissue (Thänert et al., 2019). In this light, inferring that the patient’s body is responding to the necrotizing soft tissue infection with an immune response to eliminate the pathogen and restore tissue homeostasis would be valid.

The Cells Involved
In the scenario, the cells involved in the immune response to the necrotizing soft tissue infection are neutrophils, macrophages, and lymphocytes. Neutrophils are the primary cells involved in the innate immune response to infection. They are responsible for the production of inflammatory cytokines and chemokines and for the phagocytosis of bacteria (Hua et al., 2018). Macrophages are also involved in the innate immune response. They are responsible for the production of inflammatory mediators, such as histamine, prostaglandins, and leukotrienes, which cause the burning pain the patient is experiencing in the limbs (Fernando et al., 2019). In addition, macrophages play an essential role in the clearance of dead and damaged tissue. On the other hand, lymphocytes are involved in the adaptive immune response and are responsible for producing antibodies, which help neutralize bacterial toxins and enzymes (Shumba et al., 2019). Therefore, the definite functionality of each type of cell is essential in mounting an effective immune response to the necrotizing soft tissue infection.

Impact of Patient Characteristics on Clinical Response
Characteristics such as gender and genetics can both affect the response to the NSTI in the scenario. Studies have shown that women are more likely to develop NSTI than men due to differences in the immune response and skin thickness (Hua et al., 2018). In addition, genetic variations in the genes associated with the innate immune system can influence the risk of developing NSTI and the severity of the infection (Hua et al., 2018). For example, polymorphisms in the genes associated with the Toll-like receptor pathways can increase the risk of developing NSTI and affect the outcome of the infection (Fernando et al., 2019). Furthermore, genetic variations in genes involved in the inflammatory response, coagulation, and fibrinolysis can also increase the risk of developing NSTI and the severity of the infection (Fernando et al., 2019). As such, it is important to consider the gender and genetic factors when assessing the risk of NSTI in patients and to tailor the treatment according to the individual’s gender and genetic profile.

Necrotizing soft tissue infection is a severe infection that can lead to tissue necrosis and death of cells and tissues due to bacterial toxins and enzymes. The patient in the scenario likely presents with specific symptoms due to the infection. The toxins and enzymes cause inflammation and tissue damage, resulting in a burning pain in the limbs and changes in the EKG. The cells involved in the immune response to the infection are neutrophils, macrophages, and lymphocytes, responsible for producing inflammatory cytokines, chemokines, inflammatory mediators, and antibodies. Gender and genetics can both affect the response to the infection. It is important to consider these factors when assessing the risk of NSTI in patients and tailor the treatment according to the individual’s gender and genetic profile.

In understanding the nature of opioid overdose, we must explore how opioid work in the human body. Opioids are a general class of plant-based alkaloids and synthetic drugs that, when ingested, smoked, or given IM or IV, attach to the four available opioid receptors. Most opioid drugs bind to G-protein-coupled receptors, including μ, δ, and κ opioid receptors (Volpe et al., 2011).  When opioids attach to these receptor sites, this act by i) closing voltage-sensitive calcium channels (VSCCs), (ii) stimulating potassium efflux leading to hyperpolarization, and (iii) reducing cyclic adenosine monophosphate (cAMP) production via inhibition of adenylyl cyclase. Overall, this results in reduced neuronal cell excitability, leading to reduced transmission of nerve impulses and inhibition of neurotransmitter release. This reduction in nerve impulses relaxes an individual and causes respiratory depression, for an individual to lose consciousness (Montandon, G. (2022). Naloxone is an antidote and replaces the opioids at the receptor site, thus restoring neural excitability to normal levels and restoring normal respiration and mental state.

When individuals are allowed to stay in one position, it causes pressure, especially on bony promises or any other place, by restricting blood supply to the tissue. This restriction of blood supply cuts the oxygen supply to the tissue, thus disrupting the Na/K channel that operates with ATP that requires oxygen supply. The cascade of chemical changes impairs the cell wall integrity and allows the potassium to move out to ECF (Extracellular fluid) from ICF (intracellular fluids). This movement of K (Potassium) into ECF causes hyperkalemia and hyperexcitability of nerves and thus causes cardiac tissue to cause prolonged PR interval and peaked T wave. Now we shall restore the K to a normal range of 3.5 – 5.5 mEq/L and see of there is enough pain control if the individual was using it for pain.

Explanation of Disease 

Based on the patient’s history of drug use, reaction to Narcan, and necrotic tissue, it appears that the patient could have overdosed with a drug that could be laced with a substance known as “Rizzy” powder or a synthetic opioid,  desomorphine also known “the flesh-eating zombie drug” (Houck & Ganti, 2019). It is also possible that the necrotic tissue is non-related however, due to the location of necrotic tissue and drug history this could be considered. The differential diagnosis of skin manifestations in IV drug users should include both infection and the direct caustic effects of agents. According to McCance, K. L. & Huether, S. E. (2019), it was estimated that 2.1 million people in the US suffer from substance use disorders related to prescription opioid pain relievers, and an estimated 467,000 people were addicted to heroin. Often these laced substances causing necrosis are in opioids and heroin. 

The Role Genetics Plays in Disease and Other Characteristics Effect on Response. 

An individual’s genotype is the person’s genetic makeup, and the phenotype reflects the interaction of the genotype and environment (McCance & Huether, 2019). Together, these characteristics create epigenetic marks that can affect the health and expression of the traits of that person passed to a child. If a person uses a drug such as cocaine, the DNA can be marked by increasing proteins common in addiction (NIDA, 2019). Therefore, a person’s genetics can increase their risk of addiction and drug-seeking behavior.  

Multifactorial diseases in adults include coronary heart disease, hypertension, breast cancer, colon cancer, diabetes mellitus, obesity, AD, alcoholism, schizophrenia, and bipolar affective disorder (McCance & Huether, 2019). An example according to NIDA (2019), is a community that provides healthy after-school activities has been shown to reduce vulnerability to drug addiction, and data show that access to exercise can discourage drug-seeking behavior. This effect is more pronounced in males than in females. The environment’s effect on the phenotype in that community can then take what could have been a mild genetic trait and multiply the risk for addictive behavior.   

Why the patient is presenting with the specific symptoms described

According to McCance & Huether, (2019) Hyperkalemia (potassium levels >5.0 mEq/L) may be caused by increased potassium intake, a shift from ICF to ECF potassium, or decreased renal excretion. At the cellular level, the potassium shifts from the intracellular fluid to the extracellular fluid related to decreased renal function. This also can present as a prolonged PR interval and tall, peaked T wave on an electrocardiogram. In this case, due to the likelihood of respiratory depression, hypoxia could have led to hyperkalemia by diminishing the ability to transport through the cell membrane and causing the escape of potassium to the extracellular fluid (McCance & Huether, 2019). The patient’s responsiveness was likely due to an opioid or heroin overdose laced with some substance, causing the necrotic tissue as discussed in the first paragraph under the explanation of the disease.  

The physiologic Response to the Stimulus  

Naloxone is an opioid antagonist that blocks opioid receptors from being activated. When administered in the body it travels to receptors and can even move the opioid off the receptor sites. Removing the opioid from the cell all around the body and brainstem can restore multiple organ functions including the drive to breathe (NIDA, 2022). This likely occurred in the patient scenario when the medication was administered, and he regained consciousness.  

The Cells that are Involved in this Process. 

At a cellular level, opioid receptors are found on nerve cells around the body. They carry out regulatory effects by inhibiting neuronal activity. Opioids block voltage-dependent calcium channels, activate potassium channels, and inhibit ATP, reducing neurotransmitter release. This occurs along the brainstem and throughout the body affecting all major systems (Reeves et al., 2022)When opioids are introduced into the body, the brain produces a relaxed feeling also relaxing the brainstem and therefore breathing. The spinal cord and other peripheral nerves also slow down pain signals. When someone has opioid dependence, they must increase their doses to continue to get the desired feeling. Such high doses can then create an overdose that magnifies all the actions to the point where the patient then becomes unresponsive and often stops breathing. Over time, frequent opioid use makes the body dependent on drugs. When the opioids are taken away, the body reacts with withdrawal symptoms such as headache, racing heart, sweats, vomiting, diarrhea, and tremors (Cleveland Clinic, 2022).    

In the highlighted scenario, the patient presents with an acute opioid overdose. This is highlighted by his history of substance abuse, his unresponsiveness upon his initial presentation, and his response to the naloxone. The response from the patient to the stimuli is a result of the opioid receptor antagonist, naloxone, binding to the opioid receptors and reversing or blocking the effects of the opioids (NIDA, 2017).

The patient is also presenting with hyperkalemia and a prolonged PT interval. This is because the patient’s level is greater than 6, which indicated severe hyperkalemia. With severe hyperkalemia; the ST segment becomes depressed, which leads to prolonged PT intervals. The burning and pain the patient is feeling are most likely due to necrotic tissue over the greater trochanter and forearm (McCAnce et al., 2019).

As far as genetics are concerned, there have been studies done that have reported that there are genetic factors that contribute to addictive behaviors, as well as relapse. This study also stated that there is a 31% genetic effect on drug abuse (Mistry et al., 2014). Also, men are at greater risk of overdose verses women (NIDA, 2022). therefore my response would change if the gender was different.

Upon looking at this case study, the first thing that comes to mind regarding this situation is hypoxic injury due to a lack of oxygen circulating in the bloodstream because of an overdose and respiratory depression.  Hypoxia is one of the most common causes of cellular injury.  A hypoxic state will result in a decrease in adenosine triphosphate (ATP) production (McCance, et. al., 2019).  From here, anaerobic metabolism will attempt to maintain ATP levels to avoid cellular injury and death.

ATP is generated from glycogen in the event that there is not sufficient oxygen to produce ATP.  However, after glycogen stores deplete, anaerobic metabolism stops, thus decreasing ATP again.  A lack of oxygen plays a big part in the progression of cell injury in reduced blood supply to tissues/cells.  Activated oxygen species cause the destruction of cellular membranes as well as their structure.  The reduction in ATP levels causes the sodium-potassium pump in the plasma membrane and the sodium-calcium exchange to fail.  This will result in the swelling of cells as well as the diffusion of potassium out of the cell into the extracellular fluid (ECF).  Cell membrane damage will allow a large amount of calcium to rapidly enter the cell resulting in swelling.  As a result of this swelling and damage to organelles, necrosis occurs, a common type of cell death (McCance, et. al., 2019).  This is the cellular process that appears to have happened over the patient’s greater trochanter and forearm.  Interestingly, avascular necrosis is most common around the hip joint.  As far as the patient’s forearm is concerned, if it was soft tissue, one could argue that he was experiencing skin necrosis which results in a lack of blood flow to body tissues.  Both are commonly found in substance abuse (Cleveland Clinic, n.d.).

Hyperkalemia, or a high serum potassium level, is defined as greater than 5.0mEq/L.  In this case study, the patient has a high potassium level of 6.9mEq/L.  In this case, the excess potassium could be linked to the potassium shift from the intracellular fluid (ICF) to the ECF due to decreased ATP.  The extra potassium will be excreted as long as renal function remains intact.  The prolonged PR interval found on EKG is due to cellular membranes being hypopolorized as the resting membrane potential becomes more positive.  This means that the cell is more irritable due to the cell rapidly repolarizing, and action potentials are initiated more quickly.  This is due to the resting membrane potential and the threshold potential being shortened.  If left hyperkalemia is left untreated, it can lead to arrhythmias (Viera, 2015).  To aid in helping decrease ECF potassium, calcium gluconate can be used or a calcium binder.  Another option would be a cation exchange resin such as Kayexalate (Pitt, et. al., 2015).

In my opinion, neither genetics nor gender played a role in the development of tissue necrosis or the EKG changes that were present from hyperkalemia.  The cellular response, to my understanding, would remain the same if the patient was female or of any race.

Genetics plays a role, to a greater or lesser extent, in all diseases. Variations in our DNA and differences in how that DNA functions (alone or in combinations), alongside the environment (which encompasses lifestyle), contribute to disease processes. (Jackson, Marks, May, & Wilson, 2018).  When reviewing genetics, all DNA holds the instruction guide for building a human.  While DNA is considered, mutations may occur that alter the genetic material or disease processes potentially alter the cell’s ability to build, heal or otherwise reproduce. Genetic testing and therapy as well as medical treatment can alter gene structuring, but humans have the ultimate responsibility to care for positive therapeutic results by being an advocate for a return to health and wellness.

This patient described presented with a potential opioid overdose. Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. But naloxone has no effect on someone who does not have opioids in their system, and it is not a treatment for opioid use disorder. (NIDA, 2022)

Upon regaining consciousness, the patient reported a burning sensation over the left hip and forearm.  A burning sensation is due to cellular damage at the site of injury and the nerve endings responding to painful stimuli.  Upon arrival to the emergency department, it was further noted necrotic tissue over the greater trochanter and forearm.  Cellular death leads to cellular dissolution, or necrosis (McCance and Huether, 2019). External cellular injury that causes necrosis involves damage to mitochondria with the formation of mitochondrial permeability (pg 88).

The physiologic response is gangrenous necrosis; which is not a distinctive type of cell death but refers to larger areas of tissue death.  This type of tissue death results from severe hypoxic injury, commonly occurring due to arteriosclerosis or blockage of major arteries, especially in the lower extremities (pg. 88, McCance & Huether). The outer area of the necrotic tissue should be reddened and inflamed.  Inflammation does not indicate infection, but that the tissue is damaged and the inflammation is a systemic response to limit the extent of damage.

Hypoxia results from reduced amounts of oxygen.  This occurs due to lack of air, loss of hemoglobin or hemoglobin function, (such as blood loss) or consequences of respiratory or cardiovascular disease.  Hypoxia has the potential to induce inflammation.

Ischemia is often caused by a blockage or narrowing of arteries.  If the ischemic tissue is not reperfused or opened, tissue death occurs.

The patient is hyperkalemic with a potassium of 6.9mEq/L.  This can be fatal if not reversed.  The patient is already symptomatic, presenting with a prolonged PR interval and peaked T waves.  The potassium is maintained in the intracellular fluid (ICF).  When the potassium is allowed to shift to the extracellular fluid and rises greater than 5.0 mEq/L, this can cause muscle weakness, dysrhythmias and present with changes in electrocardiograms.  In situations of hypoxia, this may lead to hyperkalemia by diminishing the efficiency of the cell membrane, resulting in the potassium escaping out to the ECF.  Burns may cause cell trauma and loss of ICF potassium to the ECF (pg 117, McCance & Huether, 2019).

Some characteristic of genetics is the patient is showing an opioid addiction.  If a genetic study were to be completed, this patient may have a genetic link toward dependency of one type or another.  Another genetic process is the patient’s age. This person is young, so hopefully will respond positively to treatment modalities and heal well with cellular mitosis and repair occurring at the site of inflammation and tissue destruction.  If the patient has a history of arteriosclerosis in the lower extremities, the patient will be predisposed to cellular destruction due to chronic hypoxia over time.  Another characteristic chronic disease process would prolong or prevent possible cellular repair.  Diabetes Mellitus would be a chronic disease example.  Diabetes would prolong the healing process as well as destroy cellular growth.

The diagnosis for this patient is Rhabdomyolysis (Myoglobinuria) it has been reported in individuals found unresponsive and immobile for long periods, such as drug overdoses. Rhabdomyolysis is the rapid breakdown of muscle and can cause hyperkalemia (because of the release of intracellular potassium into the circulation. McCance & Huether, Pg. (1430).

The role genetics plays in the disease.

Genetics did not play a role in the patient developing rhabdomyolysis. It was from the patient’s substance abuse and the unknown downtime causing muscle damage.

Why is the patient presenting with the specific symptoms described?

The patient is experiencing burning pain in the left hip and forearm due to the obstruction of blood flow to those areas that have been compressed causing ischemia and necrosis. Rhabdomyolysis is characterized by the presence of muscle pain. Because of the release of intracellular potassium into the circulation, EKG showed prolonged PR intervals and peaked T waves usually associated with Hyperkalemia.

The physiologic response to the stimulus presented in the scenario and why you think this response occurred.

The physiologic response was the patient became responsive because Naloxone is an opioid antagonist that binds to opioid receptors and can reverse and block the effects of the drug that was taken. SAMHSA.gov, (Jan 25, 2023).

The cells that are involved in this process.

Muscle cell Rhabdomyolysis is a condition characterized by time, leading to muscle hypoxia. Conditions leading to skeletal muscle ischemia. Kodadek L, et al (2022).

How another characteristic (e.g., gender, genetics) would change your response.

Genetics: People with McArdle disease (GSDV) Muscular dystrophies and Metabolic myopathies are associated with exercise intolerance and exertional rhabdomyolysis.

Gender: Woman have lower incidence of developing rhabdomyolysis


Substance abuse history and response to naloxone are the two crucial issues in the case study that is being presented. Following the administration of naloxone, it was determined that the left hip and forearm injuries were due to an opioid overdose. Respiratory depression, which results in acidemia and an electrolyte imbalance, is another side effect of opioid usage (World Health Organization, 2021). The reported EKG abnormalities are brought on by hyperkalemia. The patient experiences damage to the left hip and forearm, where necrotic tissue forms, and all of the symptoms combined lead to the diagnosis of rhabdomyolysis. Rhabdomyolysis is the rapid breakdown of muscle that causes delta lesions to force the release of intracellular chemicals into the bloodstream (McCance & Huether, 2019). Hyperkalemia can also happen when there has been significant muscle injury. Another risk factor for rhabdomyolysis is substance usage. The greater trochanter’s necrotic tissue is most likely related to heroin injection. The discussion aims to explore rhabdomyolysis, the role genetics play, why the patient is displaying the particular symptoms, the physiologic response to the stimulus, how the cells are involved in the process, and how different traits would vary my reaction.

The role genetics plays in the disease

A combination of hereditary and nongenetic variables typically influences the chance of having a common disease. In some circumstances, a genetic predisposition may work with an environmental condition to significantly raise the chance of developing a disease over time compared to either component acting alone (McCance & Huether, 2019). There may be a hereditary component to rhabdomyolysis, although typically, that is only seen in those with malignant hyperthermia, metabolic muscle abnormalities, or mitochondrial disorders (Scalco et al., 2015). I do not know enough about the circumstances of this case for me to tell if the man has these conditions. As far as I am aware, the patient has a long history of substance misuse, which is most likely what caused their rhabdomyolysis. Given that genetics affects substance abuse disorders, the two have a genetic connection. Evidence shows that genes related to the dopamine and gamma-aminobutyric acid (GABA) systems play a role (Prom-Wormley et al., 2017). Mesolimbic dopamine neurons are the critical component of the opioid function mechanism, and direct stimulation of -opioid receptors on GABA receptors lowers GABA release and causes dysregulation of these cells (Prom-Wormley et al., 2017). As a result, opioids increase dopamine levels in the brain’s frontal cortex (Prom-Wormley et al., 2017). The exact variant encoding the opioid receptors (OPRM1, rs1799971, A118G) has frequently been associated with opioid use in addition to previously characterized genes essential to dopaminergic signaling (e.g., ANKK1/DDRD2, DRD1, and DBH) (Prom-Wormley et al., 2017). 

Why the patient is presenting with the specific symptoms described

Because of the naloxone delivery, the patient is awake and speaking when arriving at the emergency room. Naloxone prevents the effects of opioid medicines, including analgesia, euphoria, sedation, respiratory depression, miosis, bradycardia, and physical dependency, by attaching to the μ-opioid receptors in the central nervous system (CNS) (National Center for Biotechnology Information, 2023). The patient is now conscious but complains of burning on the left hip and forearm, which are covered in necrotic tissue because the muscle has broken down due to intracellular contents leaking through the sarcolemma membrane (McCance & Huether, 2019). 

The physiologic response to the stimulus presented in the scenario and why you think this response occurred, and The cells that are involved in this process

The ECG data show that hyperkalemia, a longer PR interval, and peaked T waves are the physiological responses to the pain or injury to the left hip and forearm following the injection of naloxone. The sodium-potassium pump maintains low levels of potassium cells in the resting muscle, notably in the heart, for this condition, which results in this type of reaction characteristic of rhabdomyolysis (Stanley et al., 2022). When leukocytes enter a damaged muscle, they release more cytokines, prostaglandins, and free radicals that cause myolysis and necrosis of the muscle fibers as well as the release of potassium into the bloodstream, a byproduct of muscle breakdown (Stanley et al., 2022). A junctional rhythm followed by a ventricular dysrhythmia or asystole can result from a prolonged PR that hyperkalemia-related excess potassium generates (Mugmon, 2011). 

How another characteristic (e.g., genetics, gender) would change your response

Let’s say you take away the history of drug abuse and the naloxone delivery, which puts a person at risk of overdosing. The same symptoms could indicate acute or chronic kidney disease in an elderly adult, possibly linked to polypharmacy. However, I do not know the patient’s gender or genetic history in this particular instance.

Genetics plays a crucial role in identifying people susceptible to opioid addictions. The reason I believe this is possible is that from my experience working at a psych hospital, many of the patients coming in for detox and opioid use disorder have either or both parents who have a history of opioid use or substance use disorder. Research has shown that the A118G variant of the opioid receptor (MOR) gene, OPRMI, has been robustly shown to have a significant association with opioid addiction (Reed & Kreek, n.d).

In the case study, the patient was unresponsive due to opioid overdose which was evident by his response to naloxone which is an opioid receptor antagonist. Administration of this medication caused a physiologic response by binding to the opioid receptors and reversing the effects of opioids the patient had taken by restoring normal respiration (National Institute on Drug Abuse, n.d). The patient also complained of a lot of burning pain in his hip and forearm which I believe is due to the necrotic tissue on those sites. The possibility of this patient getting these symptoms can be compared to symptoms of rhabdomyolysis which can be triggered by opioid overdose. One of the categories of causes of rhabdomyolysis is non-exertional or non-traumatic causes like drugs or toxins, infection, or electrolyte disorders (Babak et al. 2017). This is the reason the patient also presented with hyperkalemia which is one of the complications of rhabdomyolysis. Hyperkalemia is responsible for the EKG demonstrating a prolonged PR interval and peaked T waves.

The cells involved in the process of this scenario are in specific tissues or brain areas. As for the possibility of other characteristics changing the response to this scenario, a person who is not susceptible through genes may have limited stimuli when taking opioid substances. The individual genetic variability in conjunction with chronic pain, both affecting stress and reward systems lead to differential responses to opioids and may determine the transition risk from therapeutic use to opioid addiction (Gerra et al. 2021).

Explanation of the disease highlighted in the scenario

The breakdown and necrosis of muscle tissue and the release of intracellular content into the bloodstream cause rhabdomyolysis. The term rhabdomyolysis refers to the disintegration of striated muscle, which releases muscular cell constituents into the extracellular fluid and circulation
(Cabral et al.,2020). Regular and illegal drugs cause rhabdomyolysis together. In this scenario, patient has a history of substance abuse. Rhabdomyolysis is a potentially lethal clinical syndrome that results from the necrosis of muscle fibers, with the passage of its components into the circulation.

The role genetics plays in the disease.

Rhabdomyolysis is the acute breakdown of myofibres resulting in systemic changes that can be life-threatening. Environmental triggers, including trauma, exercise, toxins, infections, and gene defects, can precipitate rhabdomyolysis. Defects in muscular dystrophy and myopathy genes can trigger rhabdomyolysis (Cabrera et al.,2022).

Why the patient is presenting with the specific symptoms described.

In this scenario, the roommate mentioned he didn’t know how long the patient was on the floor. The patient has a large amount of necrotic tissue over the greater trochanter as well as the forearm. Patients who remain on the floor for a long time are at risk of developing rhabdomyolysis. If a person cannot move or get off the floor, tissue necrosis can occur at the point of contact, and skeletal muscle is destroyed, releasing its contents into the bloodstream. This can eventually lead to crushing syndrome, which includes rhabdomyolysis, hyperkalemia, dysrhythmias, and acute kidney injury, and can be fatal. EKG manifestation of hyperkalemia is peaked T-waves that signal myocardial hyperexcitability(Zeng &Tomlinson,2021). Then myocardial conduction disorders appear (i.e., prolonged PR, QRS widening, loss of P-waves, and bradycardia). Substance abuse, mainly Cocaine abuse, also causes systemic adverse effects like stroke, myocardial infarction, arterial dissection, vascular thrombosis, and rhabdomyolysis.

The physiologic response to the stimulus presented in the scenario and the reason for the response occurred.

Patients who remain on the floor for a long time are at risk of developing rhabdomyolysis. Many factors can cause rhabdomyolysis. Muscle cells contain a significant amount of potassium, and when disruption of the cell’s membrane occurs, its escape into circulation results in hyperkalemiaAlso, substance abuse can result in kidney damage and also can cause the potassium level to be elevated.

The cells that are involved in this process and another characteristic( e.g., gender,genetics)would change the response

The cells that are involved in this process are muscles. Rhabdomyolysis can occur in all age groups and both sexes. The disease appears more frequent among males, African-Americans, those aged <10 and >60 years old, and in persons with a body mass index >40 kg/m2 [4]. The etiology of rhabdomyolysis may also vary depending on the age. Among adults, the most cited causes are trauma and drugs.

Question 1: The role genetics plays in the disease

Answer: Not sure what role genetic with EKG with prolong PR interval and peaked T waves

Question 2: Why the patient is presenting with:

1) burning pain over his left hip and

2) prolonged PR interval and peaked T waves,

3) elevated potassium level 6.9mEq/L

Answer:  The patient is presenting with the above symptoms due to the tissue damage that allowed the escape of potassium from the ICF into the ECF. This created abnormal high level of potassium level that caused irritation to the neuromuscular system. The imbalance of the ICF and ECF potassium create hypo polarization that led to the excited or irritable contraction of the heart muscle.  “Symptoms of hyperkalemia vary, but common characteristics are muscle weakness or paralysis and dysrhythmias with changes in the electrocardiogram”, Brashers & Rote (2019).

Question 3: Why do you think the physiologic response to the stimuli response occurred?

Answer: I think the physiologic response to the stimuli presented occurred because the tissue damage caused imbalance of ICF and ECF electrolytes imbalance which caused the increase of fluid and protein to the site of damage. The damage site was blocked from oxygen, nutrient, and movement of debris. This blockage damages the tissue over the greater trochanter and necrotic.

Question 4: What are the cells that are involved in this process?

Answer:  The Na+-K+ ATPase pump, liver and muscle cells, kidney cells

Question 5: How another characteristic, such as gender or genetics would change your response?

Answer: A person pre-genetic to cardiac, diabetic, or missing kidney problems may prove fatal or suffer      more bodily damage.

This patient is suffering from Necrosis of tissue in the greater trochanter and forearm. Necrosis is irreversible injury to cells that can eventually lead to cell death (Khalid & Azimpouran, 2022). The cause of this disease could be from chronic IV drug use. The patient is presenting with these systems because death or injury of cell or tissue causes an inflammatory reaction which results in pain. The patient was unresponsive on arrival due to drug overdose, this is apparent because naloxone was effective at reversing the unresponsiveness. Researchers used to believe that necrosis was an uncontrolled process, but recent studies show that necrosis can be controlled under genetic and chemical manipulations (McCall, 2010). Although, other genetic diseases like diabetes can put an individual at greater risk for necrosis. The form of necrosis that patient in this case study has is most likely due to infection from chronic IV drug use. The Necrotic tissue was caused by infection by a species of Clostridium which is an anaerobic bacteria (McCance & Huether, 2019). This bacterium produces enzymes and toxins that can destroy connective tissue, and death can occur from shock (McCance & Huether, 2019). Cell injury usually starts occurring before any signs or symptoms occur. This patient has an elevated potassium level of 6.9 which is likely due to necrotic tissue, when a cell is damaged, it causes the release of intracellular potassium into the blood, increasing the blood potassium levels (Simon et al., 2022). The prolonged PR interval and peaked T waves seen on the patients EKG is due to the patient hyperkalemia, as potassium is one of the essential electrolytes in cardia cells (Teymouri et al., 2022). IV drug users are at greater risks for bacteria infections that can affect that blood vessels and body tissues (Rose et al., 2022). Other characteristics that would change my response are age, medical history, and medication use.

Genetics plays a crucial role in disease processes with varying environmental factors. Our genes are distinct from who we are, which are passed on from one generation to the other. Genetics and different environmental factors decide how individuals are affected by addictions. According to (Demery-Poulos & Chambers, 2021), as illustrated by the dual use of naltrexone, alcohol- and opioid-induced rewards stem from the same neurological pathway. Accordingly, there are genes implicated in both addictions, such as the dopamine receptor D2 (DRD2) and OPRM1. A frequently studied polymorphism of DRD2 is the TaqIA SNP (rs1800497, G > A) in the ankyrin repeat and kinase domain containing one gene (ANKK1), located 10 kb downstream of DRD2. This SNP results in the loss of an N-glycosylation site that is necessary for proper membrane presentation. Carriers of TaqIA (A1+) have a 30% decreased DRD2 density in the striatum, reducing basal reward sensation This can lead to drug-seeking behavior to achieve increased stimulation; in support of the Reward Deficiency Syndrome, the A1 allele has been associated with higher heroin consumption. In a 2019 study by Li et al., heroin-addicted carriers of the A1 allele showed increased brain reactivity to heroin-related cues in the prefrontal, mesolimbic, and visuospatial attention regions. This may indicate that heroin has a greater influence on the executive function and reward system of A1 carriers. Genes are driving factors which explains why some individuals can easily get addicted to drugs. Genes determine the ability of individuals to have drug and alcohol-seeking behavior that leads to addiction. 


This patient was found unresponsive by emergency medical services; the patient was unresponsive to the use of opioids; the patient was administered naloxone. According to (Yackuboskey, Deborah 2016), deaths related to opioid overdose may be prevented if the person receives early intervention via 911 notification, basic life support, and timely administration of an opioid antagonist, such as naloxone. This medication blocks or reverses the effects of the opioid substance; it has proven effective in reversing the effects of an opioid overdose and decreasing the number of deaths attributed to it. Naloxone may be administered via intravenous, intramuscular, subcutaneous, and intranasal routes. Intranasal naloxone is the preferred route due to ease and speed of delivery, gentler awakening, safety, and cost-effectiveness. Emergency medical care is still necessary, even after the administration of naloxone.  

The patient also presented with complaints of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L. Patient presentation is the sign of rhabdomyolysis, rhabdomyolysis is the rapid breakdown of muscle that changes the release of intracellular contents, including protein pigment myoglobin, into the extracellular space and bloodstream. Myoglobinuria has been reported in individuals found unresponsive and immobile for a prolonged period after drug and alcohol overdoses (McCance & Huether, 2019). Also, according to (Cabral, et., al 2020) Medications and recreational drugs are important causes of rhabdomyolysis. Drug-induced rhabdomyolysis encompasses a large group of substances that can affect muscles either by interfering with ATP production or by increasing the permeability of the sarcolemma permitting leakage of intracellular contents.  

Furthermore, according to (Cabral, et., al 2020) under physiologic conditions, the sarcolemma membrane is lined with different pumps, channels, and exchangers. The most important of which is the Na-K-ATP-ase pump, which actively transports 3 sodium (Na+) out of the cell in exchange for every 2 potassium (K+) transported intracellularly to support a negative membrane potential. This negative potential draws Na+ inside, in exchange for calcium (Ca2+) via the Na+/Ca2+ exchanger, thus supporting low intracellular Ca2+ concentration. Tightly regulated calcium homeostasis. is essential for proper cell function – to maintain levels of calcium when the muscle is at rest and to allow the increase that is necessary for actin–myosin binding and muscle contraction 

The cells involved are intracellular fluid and extracellular fluid, according to (McCane & Huether, 2019) potassium shifts from the intracellular fluid to the extracellular fluid occur with a change in cell membrane permeability (e.g., from cell hypoxia, acidosis, or insulin deficiency). Hypoxia can lead to hyperkalemia by diminishing the efficiency of cell membrane active transport, resulting in the escape of potassium to the extracellular fluid 

Another characteristic will change my response, a different individual who lacks the D2 receptor will be less likely to be susceptible to drug addiction which can lead to a drug overdose. Genes determine our physiological characteristics, and they can influence the development and function of the brain.

The presented 27-year-old patient appears to be in opioid overdose as evidenced by the fact that she responded to Naloxone. Genetics plays a role in how fast individuals metabolize a drug (CYP2D6 and P450 enzymes). Some genes are associated with an increased likelihood of developing opioid dependency (OPRM1 gene). Knowing how genetic variations play a role in opioid metabolism, helps with identifying risk groups and with modification of prescription medications (“Update on the pharmacogenomics of pain management,” n.d.).

The physiologic response to Naloxone occurs as a result of Naloxone’s ability to block opioid receptor cells in the brain. Naloxone is also associated with the stimulation of endorphins releasing cells in the brain (“Update on the pharmacogenomics of pain management,” n.d.).

The patient is also appearing to have cardiac arrhythmia as evidenced by high T waves and increased PR intervals. If left untreated, changes in the EKG resulting from a high potassium level can cause a life-threatening V-tach and cardiac arrest. The patient also suffers from a bacterial infection as evidenced by necrotizing tissue over the forearm.