apa format and at least 2 references for each peer. there is two different attachments with two peers on each.

Respond to 
at least two of your colleagues 
on 2 different days who selected a different patient than you, using one or more of the following approaches:

· Share additional interview and communication techniques that could be effective with your colleague’s selected patient.

· Suggest additional health-related risks that might be considered.

· Validate an idea with your own experience and additional research

Peer 1


            The case study analysis assigned to me involves an 85-year-old white female living alone with no family who is in declining health. In expanding upon the case study, I utilized the SOAP note format, which is presented below:

Subjective (S): JD is an 85-year-old white woman who presents to the emergency department with concerns about declining health due to multiple falls and pain in the left hip. The falls began about a year ago and have increased in frequency and severity in the past three months. The most recent fall was today when the patient fell while getting up to use the bathroom, and she fell to the floor and landed on her left side. She immediately called 911. She states that pain in the left hip increases with weight-bearing activities, and she has been unable to put weight on the left side. She has not taken anything for the pain. She states that pain is 10/10 with any weight-bearing or ROM activities. She does not use any assistive devices for mobility. She eats one meal daily and tries to have a Boost supplemental shake daily. Patient has intermittent urine incontinence. She does not have relatives or friends available to assist her. She still drives, though she avoids driving at night.

She has a history of osteoporosis, hypertension, dyslipidemia, anxiety, and depression. Her medications include: metoprolol tartrate 50 mg twice daily, atorvastatin 20 mg daily, sertraline 50 mg daily, multivitamin daily, and vitamin D3 25 mcg daily.

Objective (O): JD is an older white woman who appears frail, malnourished, and anxious. Alert and oriented x 3. VS: 143/94, P 101, RR 20, 97% on room air at rest, and T 97.8F. Weight 91 pounds and height 5’1”. BMI is 17.2. Significant bruising was noted in the LLE from the lateral aspect of the hip that extends medially towards the groin and distally above the knee. X-rays demonstrate a left femoral neck fracture.

Assessment (A): 1.) Traumatic fracture of the left femoral neck 2.) falls 3.) malnourishment 4.) hypertension 5.) osteoporosis 6.) dyslipidemia 7.) anxiety 8.) depression.

Plan (P): Patient is being admitted to the hospital for immediate surgery for a traumatic left femoral neck fracture. Referral and transfer to orthopedics are planned. Patient was provided education on proper nutritional requirements and ho

Read a selection of your colleagues’ responses and 
respond to 
at least two of your colleagues on 
two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.

Peer 1

Pharmacokinetics is the science that analyzes how the human body interacts with a drug. It examines how drugs are absorbed, distributed, metabolized, and excreted by the body. Pharmacodynamics focuses on the biochemical and physiologic effects of drugs and their organ-specific mechanism of action, including effects on the cellular level.


As an RN, I have cared for numerous older adults suffering from chronic to acute pain associated with injuries they sustained from falls.  Recently, I had a patient suffering from severe pain due to an injury from a fall. The report from a previous nurse who helped the patient indicates that the patient at baseline was A&Ox4; however, now the patient is alert to self only with visual and auditory hallucinations.  When I reviewed the patient’s H&P, the patient has stage-3 kidney disease and is on Morphine 2mg q2hrs, oxycodone 10mg q4hrs, and Tylenol for pain control.  The patient’s MAR shows that the patient was taking both Oxycodone, Morphine, and Tylenol often together.


Age-related changes can affect the pharmacokinetics and pharmacodynamics of an opioid, thereby changing both the intensity and duration of analgesia (Rogers et al., 2013). Typically, opioids are metabolized by the liver and excreted in the urine or feces. Decreased hepatic and renal clearance often occurs with advancing age, leading to an increased half-life and decreased excretion of drugs cleared by the liver/kidney. In addition, older persons have an increase in body fat (20%–40% on average), leading to an increased volume of distribution for fat-soluble drugs (Hutchinson & O’Brien, 2007). As age-related changes in gastrointestinal absorption function to lower gastrointestinal transit times and the possibility of increased opioid-related dysmotility, in older adults, the elimination of Lipid-soluble opioids, such as fentanyl, from the body may take longer times.


Considering these factors, during morning rounds, I discussed with the provider a care plan that may help the patient with his pain besides opioids. I planned to try lidocaine patch warm packs and reduce Oxycodone from 10mg to 5mg and Morphine from 2mg to 1mg only during PT therapy, not at the same time as Oxycodone, and scheduled Tylenol. The provider agreed with the plan of care.  At the end of my shift, the