To increase awareness among nurse practitioners (NPs) regarding diagnostic and treatment guidelines for asthma for the 5-11 year age group recently updated by the National Asthma Education Prevention Program-Expert Panel 3 (NAEPP-EPR3).
NAEPP-EPR3 guidelines for the diagnosis and management of asthma released from the National Heart, Lung, and Blood Institute in August 2007, selected clinical trials, meta-analyses, and clinical reviews.
Recent research has revealed that children suffering from asthma in the United States are underdiagnosed and their asthma is poorly controlled. Compelling evidence supports that children classified as having persistent asthma following NAEPP-EPR3 guidelines benefit from daily inhaled corticosteroid therapy, yet many are misclassified and undertreated.
With application of current guidelines from NAEPP-EPR3, NPs can more effectively assess, diagnose, treat, and foster a collaborative self-management plan for children age 5-11 years. These interventions will result in an improved quality of life and decreased health risks for this young population.
To educate primary care providers on the physical effects of posttraumatic stress disorder (PTSD), explain why military veterans are at great risk, and describe how to identify PTSD in primary care clients.
Current scientific and psychiatric literature on PTSD.
PTSD is prevalent in the military community because of the frequency and type of trauma seen in the combat zone. With the ongoing military deployments, assessment for the presence of PTSD is increasingly important for comprehensive and high-quality primary care. Clients with trauma histories, such as veterans, are at increased risk for physical disorders such as heart disease and psychological disorders such as anxiety, depression, and PTSD.
Primary care clinicians, including those outside the military health system, are essential in identifying trauma histories and directing clients to appropriate care.
From July 1971, to July 1972, in a large suburban Ontario practice of two family physicians, a randomized controlled trial was conducted to assess the effects of substituting nurse practitioners for physicians in primary-care practice. Before and after the trial, the health status of patients who received conventional care from family physicians was compared with the status of those who received care mainly from nurse practitioners. Both groups of patients had a similar mortality experience, and no differences were found in in physical functional capacity, social function or emotional function. The quality of care rendered to the two groups seemed similar, as assessed by a quantitative "indicator-condition" approach. Satisfaction was high among both patients and professional personnel. Although cost effective from society's point of view, the new method of primary care was not financially profitable to doctors because of current restrictions on reimbursement for the nurse-practitioner services.
There are extensive data that describe the prescriptive behaviors of physicians (MDs) for upper respiratory tract infections; however, there is a paucity of data on the antibiotic-prescribing patterns of nurse practitioners (NPs). The purpose of this study was to describe and predict factors that are associated with antibiotic prescribing by NPs and MDs for viral upper respiratory infections in the ambulatory setting.
The study utilized a cross-sectional retrospective design of data from the National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey between 1997 and 2001. Data were collected on a national probability sample of 506 NP and 13,692 MD visits for patients with nonspecific upper respiratory tract infection, viral pharyngitis, and bronchitis.
Bivariate analysis found no significant differences in antibiotic prescribing for viral upper respiratory tract infections by NPs (50.4%) and MDs (53%). Broad-spectrum antibiotics accounted for 36.6% of the NP antibiotic prescriptions and for 33.2% of the MD antibiotic prescriptions. Multivariate analysis identified several clinical and nonclinical factors that are associated with NP antibiotic prescribing. The strongest positive predictors of NP antibiotic prescribing were black race, Medicaid insurance, Northeast region, and diagnoses of viral pharyngitis and bronchitis. The significant negative predictor was Medicaid insurance status. The strongest positive predictors of MD prescribing were viral pharyngitis, bronchitis, and non-antibiotic prescription.
The excessive use of antibiotics for upper respiratory infections of viral etiology by both NPs and MDs suggests the continuing need for educational initiatives such as "academic detailing" as well as increasing involvement by both groups of providers in the dissemination of clinical guidelines and system-based quality assurance programs. Also, the lower rate of antibiotic prescribing for viral infections by NPs for patients with Medicaid insurance suggests more appropriate cost-effective care in this population of patients. More study is needed in general on prescribing by NPs for Medicaid patients. Finally, the strong association of nonclinical factors suggests the need for awareness and improvement of prescribing decisions by both NPs and MDs.
The Provus Discrepancy Model is applied to suggest revisions to consensus curriculum and regulatory guidelines for nurse practitioners (NPs) seeking prescriptive authority.
Literature review related to prescribing policy, regulation, NP role competencies, and pharmacologic trends.
The document "Curriculum Guidelines and Regulatory Criteria for Family Nurse Practitioners Seeking Prescriptive Authority to Manage Pharmacotherapeutics in Primary Care" should be examined for relevance to current prescribing practice, scope, and influences that emerged since publication.
In order to prepare NPs of the future it is important to acknowledge the implications of increased autonomy, scope, and depth of practice that explicitly includes broad prescriptive authority.
To review the epidemiology and clinical features of migraine and to discuss the use of the 5-HT1B/1D agonists (triptans) in the treatment of moderate to severe migraine.
A Medline search was conducted for relevant recent articles on migraine and the efficacy and safety of the triptans.
With the advent of a standardized classification system for headache to simplify migraine diagnosis, new approaches to treatment, and effective new therapies, such as the triptans, many patients have obtained significant relief from the pain and disability associated with migraine.
The key to successful migraine management is to provide the most effective treatment at the earliest possible time. Under the step-care approach to migraine management, the mildest and most conservative treatment was recommended as a first step, without regard for the degree of the patient's pain or disability. This approach has been replaced by stratified care, in which migraine management is based on the severity of the patient's pain and disability. Under the stratified approach, patients with moderate or severe migraine would be prescribed effective migraine-specific drugs, such as the triptans, as first-line therapy.
Between October 2001 and February 2002, AANP implemented the National NP Practice Site Survey. The purpose of the survey was to describe the general U.S. NP workforce, including the percentage of NPs working in primary care and their settings. Data were collected from over 39,000 NPs of all specialties. Based on the survey, a description of the U.S. NP Workforce was developed. For instance, according to the survey, the average NP is female (95%) and 47 years old. She has been in practice for 8.6 years, is a family NP (35%), and is involved in direct patient practice. This report includes detail on the respondents' clinical specialization, age, years of practice, and type of practice.
Asthma is an extremely common disorder, affecting more than 17 million people in the United States. Asthma is the most frequently treated chronic disease in primary care settings and affects patients of all ages. The recently published update to the NHLBI asthma diagnosis and management guidelines, a valuable resource for NPs in all specialties, is summarized in this column.
Rheumatoid arthritis (RA) is a progressive polyarthritis that is responsible for over nine million office visits annually. It is likely that most nurse practitioners will care for one or more patients with RA because approximately 1% of the adult population is affected by this disabling disorder. The guideline reviewed in this month's column describes the recommended care of patients who have been previously diagnosed with RA.
The American Cancer Society Guidelines for Breast Cancer Screening: Update 2003 was obtained through the National Guideline Clearinghouse Web site and was critiqued for potential incorporation into practice. The updated guidelines address screening mammography, physical examination, and new technologies and describe how these may be applied to women at average risk, women at high risk, and older women. The new guidelines emphasize educating women and having them take a more active role in decision making.
The purpose of this study was to evaluate the perceived preparedness of nurse practitioners (NPs) for practice after completing their basic NP educational programs and to evaluate NPs' perceived preparedness in and their perceived importance of select clinical content areas basic to NP education.
This cross-sectional descriptive study used a written questionnaire consisting of 32 items, two of which contained 25 subitems. Subjects were asked to rate their overall level of preparedness when they completed their NP program and both their level of preparation in and the importance of 25 clinical content areas. The questionnaires were administered to attendees at two large national NP conferences in 2004; a total of 562 questionnaires were completed and used in the analysis.
Ten percent of the sample perceived that they were very well prepared for practice as an NP after completing their basic NP education. Fifty-one percent perceived that they were only somewhat or minimally prepared. Current age, years since graduation from an NP program, and age when attending the NP program did not differ significantly for those who felt prepared versus those who did not. For a number of content areas, subjects did not perceive that they were well prepared in the same areas that they perceived were very important.
Our results indicate that formal NP education is not preparing new NPs to feel ready for practice and suggests several areas where NP educational programs need to be strengthened. Practicing NPs are the basis of the NP profession, and their views need to be sought, listened to, and reflected upon as we advance toward expanded preparation at the doctoral level.
To describe practitioners' prescription of recommended initial osteoarthritis (OA) pain treatments for older adults.
A secondary data analysis was conducted with the 2008 National Ambulatory Medical Care Survey (NAMCS) that was completed by practitioners in ambulatory medical care settings. Of the 28,741 office visits, 9314 were by adult patients age 60 or older, and 871 of those visits involved a painful joint. Only 128 were also by people with practitioner-documented OA. Of those 128 visits, 21 (16.1%) were prescribed exercise and/or acetaminophen and were not prescribed non-steroidal anti-inflammatory agents (NSAIDS). No complementary alternative medical treatments were prescribed. Older adults with and without documented OA had a mean of at least four office visits with the practitioner during the past year.
OA may be under-diagnosed, under-reported, or overshadowed by co-morbid medical conditions. Older adults with persistent OA pain are at increased risk for adverse events from prescribed NSAIDs. Safe and effective multimodal pain treatments need to be prescribed for older adults with persistent OA pain.
Referral to a rheumatologist or pain management specialist should be considered when pain intensity and/or pain interference with daily activities remains moderate or greater.
The 2009-2010 AANP National Nurse Practitioner Sample Survey was designed to replicate a survey conducted previously in 1988, 1998, and 2004. The survey collected data on variables such as nurse practitioner (NP) education, specialization, practice patterns and settings, compensation, and prescribing. With responses from 13,562 practicing NPs, the survey provided a comprehensive description of the practicing NP population.
To provide nurse practitioners (NPs) with a review of the 2012 Standards of Care for the management of hospitalized patients who are hyperglycemic.
The 2012 American Diabetes Association's (ADA) Standards of Care for the treatment of inpatient hyperglycemia and selected evidence-based articles.
Because hyperglycemia occurs at alarming rates in the inpatient setting when hyperglycemia is not controlled, there is a great impact on acute and even chronic conditions. These complications will lead to increased healthcare costs.
Implications for practice:
It is essential that NPs who care for hospitalized, hyperglycemic patients are aware of the 2012 ADA Standards of Care.
To provide nurse practitioners with the information to manage patients with chronic hepatitis C (HCV) receiving a new combination drug therapy containing ribavirin and interferon alfa-2b.
Reviews of clinical trial results including large multicenter trials, Centers for Disease Control and Prevention documents, data from the drug manufacturer.
This new therapy offers the potential for HCV remission or complete cure of the HCV infection. Although virologic responses are markedly improved with combination therapy, the side effects associated with combination therapy warrant regular patient monitoring, management, and medical intervention when clinically indicated.
Combination therapy does not significantly worsen the side effects associated with mono-therapy, which are predictable, manageable, and reversible. However, proper patient education, symptom management, vigilance for serious side effects, and monitoring of hematologic parameters are critical to patient outcome.
This month's clinical practice guideline (CPG) review is on fever of uncertain source (FUS), also known as fever of unknown origin (FUO). A hospital-based committee for the Cincinnati Children's Hospital Medical Center developed this guideline to help practitioners evaluate and manage FUS in a logical manner and with a judicious use of antibiotics. This guideline should have a wide interest to practitioners due to the large number of children that annually present with fever.
The problems associated with hyperandrogenism are not uncommon in primary care settings. In fact, polycystic ovary syndrome, a common cause of androgen excess, exists in 5% to 10% of women during their reproductive years, with onset typically in adolescence. The subject of this column is the AACE's Hyperandrogenism Guidelines, which review the evaluation and treatment of the disorders causing androgenic excess.
Readers are encouraged to submit ideas and manuscripts for future CPG columns. The column editor can be contacted at: email@example.com or firstname.lastname@example.org.
The nurse practitioner needs to acknowledge that not all patients are insightful. The patient who is naive, stoical, or in denial may not return to his previous level of health. Behavioral or environmental changes may be a necessary part of recovery. The advanced practice nurse, through her research and subsequent knowledge, can identify and implement holistic changes necessary for the maintenance of health and the development of appropriate health-seeking behaviors that lower the morbidity and mortality for such conditions as abdominal aortic aneurysms. Nurse practitioners play a vital role in research, prevention and early detection of major threats to wellness (Lawler and Schmidt, 1992). Gender-sensitive research regarding factors affecting recovery are also necessary as females respond differently to such conditions as renal failure (Carlson and Eisenstat, 1995).
The overall purpose of this preliminary study to a clinical trial is to explore the feasibility of recruiting men receiving androgen ablation therapy (AAT) for locally advanced prostate cancer to a future strength training study for the prevention of osteoporosis. The threefold specific purpose of this comparative and correlational study is to (a) describe the prevalence of risk factors for osteoporosis, (b) compare functional status and symptom distress between those interested and not interested in a future strength training study, and (c) examine relationships among self-efficacy for strength training, functional status, symptom distress, years since cancer diagnosis, and cumulative dose of AAT in this at-risk population.
Data were obtained from 40 Caucasian men (mean age = 75.8 years) with locally advanced prostate cancer, capable of self-care, and receiving AAT. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires (QLQ) EORTC QLQ-C30 and EORTC QLQ-PR25 (prostate cancer specific) were used to measure functional status and symptom distress. A 6-item, investigator-developed questionnaire was used to measure self-efficacy for learning and overcoming barriers to strength training.
The majority of these men had multiple risk factors for osteoporosis, in addition to receiving AAT, and had not completed bone mineral density (BMD) testing. A high percentage (67.5%) expressed interest in a future strength training protocol for osteoporosis prevention; functional status and symptom distress did not appear to influence this interest. Several aspects of functional status and symptom distress were significantly related to self-efficacy for learning and overcoming barriers to strength training. Years since cancer diagnosis and cumulative dose of AAT were not significantly related to self-efficacy for strength training, but age was related. This study informs a planned future experimental study by establishing the recruitment potential and the decreased likelihood of symptom distress interfering with self-efficacy for participation in strength training.
Advanced practice nurses should complete assessments for osteoporosis risk factors, monitor height loss, order BMD testing and bone enhancing medications, and discuss lifestyle modifications including strength training to improve bone health in men receiving AAT for prostate cancer.
To discuss the newest 2001 changes in The Bethesda System of cervical cytology classification and management guidelines for abnormal Pap smears.
Extensive review of scientific literature and consensus guidelines.
Decision making about abnormal cervical cytology can be frustrating and controversial. It is imperative that nurse practitioners understand and practice the appropriate management protocol for cytological abnormalities.
Alarmingly, many providers are unsure of management guidelines for abnormal cervical cytology. The information in this article offers providers a clear protocol for cervical cytology classification to facilitate the confident management of abnormal Pap smears.
Teenage pregnancy is a complex issue in the current sociopolitical milieu. The enactment of abortion laws adds to the complexity of the problem, involving moral and ethical issues, as well as social, economic, and health status consequences that should be considered in the development of legislation surrounding this issue. The tree of impact diagram is a mechanism for forecasting possible consequences of abortion laws. Historical, social, developmental, economic, and legal forces are considered in creating the tree of impact in relation to the health and well-being of teenage mothers and their children.
A tree of impact diagram is a method of predicting the possible outcomes of proposed changes or innovations on current practices. Teenage pregnancy is an issue that has a great deal of personal, social and financial consequences for the teenagers, their families, and society. The consequences of repealing the laws that currently allow abortion can be discovered through a tree of impact model. Teenage pregnancy rose sharply after WWII. In 1945 the rate was 5.15/1000 women, and its peak was 1957 with 96.3/1000. During this period there were no contraceptives and abortion was illegal. By 1970 half the teenagers surveyed had engaged in sexual activity by age 17. In 1990 there were 831,000 teenage pregnancies with 382,000 ending in abortion. The WHO determined that 20-25% of maternal mortality was the result of illegal abortion. Medical abortion has a maternal death rate of .6/100,000. Teenage pregnancy cost the federal government $16.65 billion in 1985 and it is estimated that each of these families will cost an additional $13,902/year for the next 20 years. Risk of perinatal morbidity and mortality is highest among the youngest mothers, age 15 and younger. Hypertension caused by pregnancies occurs in 7-17% of the population compared to 34% when the youngest mothers are included. Adoption while an option is one that few teenagers choose. In 1971 18% of white teenage mothers and 2% of black teenage mothers chose adoption. In 1982 these figures dropped to 7.4% and 1%. Both sides of the abortion debate agree that teenage pregnancy is a problem. Both sides agree that something should be done to reduce the number of teenage pregnancies. There have be pilot projects and studies that have shown several successful methods of reducing teenage pregnancies. Some include self esteem/social skill building and others encourage educational attainment.
To examine the association between reported absences and parental smoking in school-age children, aged 6-17, and to specifically explore the impact of maternal smoking on the health and attendance of school-age children.
The sample of 7488 parent-child dyads was randomly selected from the 2002 National Health Interview Survey, a multipurpose cross-sectional household interview survey conducted by the Centers for Disease Control and Prevention. The parent sample included 2673 men and 4375 women. Children's ages ranged from 6 to 17 with a mean of 11.7 years.
Maternal, but not paternal, present and past smoking behavior significantly impacts the child's wellness and school attendance. The reasons for this disparity are unclear but may relate to synergistic effects of pre- and postnatal nicotine exposure, the traditional role of mother as caregiver, or specific smoking habits that increase environmental tobacco exposure.
Assessment and educational strategies for families regarding the hazards of childhood exposure to environmental tobacco smoke are indicated. Specific implications for the role of the nurse practitioner across diverse specialties are addressed with emphasis on the need for development of gender, age, and culturally sensitive smoking cessation programs and support networks.
To provide an overview of the role of the nurse practitioner (NP) in identifying, reporting, and managing child abuse in primary care.
Selected research, national guidelines, and the author's experience.
Child abuse is a complex phenomenon characterized by maladaptive behaviors between children and their parents.
The role of the NP includes identification of families at risk, recognition of clinical findings of abuse, diagnosis of abuse, education for families identified at risk, and management of children diagnosed with abuse. The ultimate goal is the safe return of the child to a loving family.
According to the 1988 National Household Survey conducted by the National Institute on Drug Abuse, cocaine use among the total population has decreased. This same survey also reported an increase in cocaine use among chronic abusers of the drug. As cocaine use has increased among the abuser population, so has the number of emergency room admissions for cocaine-related complaints; moreover, these patients were admitted with primarily cardiovascular complaints. It is important for the nurse practitioner to recognize the cardiotoxic effects of cocaine abuse. Cocaine abuse should be part of the differential diagnosis in patients with cardiovascular complaints.
Nurse practitioners are in a pivotal position to identify and to assist adult survivors of child sexual abuse. An awareness of the definitions, prevalence, and dynamics of sexual abuse is essential for providing holistic care. This article outlines the nurse practitioner's role in working with clients of either sex who may have been sexually abused as children. Correlates of undisclosed childhood sexual victimization are identified, as are strategies for providing a therapeutic environment for clients to disclose their abuse experience and begin the healing process.
The purpose of this study was to explore the relationships of family history of depression and alcohol abuse as a predictor of health risk behaviors among Central American teenagers.
Demographic data were collected from a convenience sample of 101 Central American mothers with a teenage daughter ages 12-17 years who were living in Northern Virginia. The research questions assessed the family history of depression, alcohol abuse, and maternal depression. Scores were calculated to predict risk of teenage health risk behaviors.
The Hispanic mothers in this study reported that their teenagers had significant health risk behaviors, including school dropout and expulsion, alcohol and substance use, pregnancy, and gang membership. Family history of depression and alcohol abuse in a first degree relative predicted teenage risk behavior 71% of the time.
There is no consensus on a standard screening approach for depression in teenagers. Developing a standardized approach to gathering information from teenagers that includes genetic family traits may have significant effects on interventions for teenage health risk behavior and ways to provide the best services for vulnerable teenagers. The results of this study have implications for nurse practitioners caring for teenagers.