Primary Care of the Adult Notes
Primary Care of the Adult
The Caring Role of the APRN
- Advanced Practice Registered Nurses (APRNs) are well-suited to provide patient-centered care.
- APRN roles require unique caring patterns that blend health knowledge and medical recommendations with general nursing care.
- The APRN has a unique opportunity to demonstrate how nursing values influence care outcomes.
Nursing vs. Medical Model
- Nursing focuses on caring at the bedside, which characterizes a nurse's knowledge and service philosophy.
- Medicine focuses on diagnosing and treating human structural and functional problems manifested physically.
Challenges for APRN Practice
- Economically driven care may conflict with the caring element of Nurse Practitioners.
Characteristics of an APRN
- Courage
- Authentic presence
- Advocacy
- Knowing
- Commitment
- Patience
Evolution of Value Based Care
- Transition from Fee for Service (volume-based care) to value-based care models.
- The introduction of Electronic Medical Records in the late 1990s/early 2000s enhanced data access.
- The arrival of the Apple iPhone in 2007 and Android in 2008.
Institute of Medicine 2001 - Crossing the Quality Chasm Report
- A systems-based approach is needed to improve US healthcare quality.
- This includes strengthening primary care, shifting to alternative payment models, and focusing on preventative and patient-centered care.
- Addressing workforce shortages, improving data analysis, promoting collaboration, and leveraging technology are crucial.
Value Based Care Aims
- Lower costs
- Care coordination
- Quality
- Data interoperability
- Patient experience
- These aims influence payment structures.
- Primary prevention focuses on preventing disease or injury by reducing risk factors, altering unhealthy behaviors, and increasing resistance.
- Preventing Exposure: Actions like controlling hazardous substances.
- Changing Unhealthy Behaviors: Education and counseling to promote healthy habits.
- Increasing Resistance: Immunization.
- Target Population: Healthy individuals.
- Examples:
- Immunization: Vaccines prevent infections.
- Health Education: Educating individuals about healthy habits.
- Promoting Safe Practices: Encouraging seatbelt use.
- Reducing Risk Factors: Addressing social determinants of health.
- Secondary prevention aims to identify and treat diseases early.
- Early detection: Identifying diseases in early stages.
- Prompt treatment: Providing timely interventions.
- Minimizing consequences: Preventing further deterioration.
- Examples:
- Screening for cancer: Mammograms, Pap tests, colonoscopies.
- Early treatment of chronic diseases: Managing high blood pressure, controlling diabetes.
- Early intervention for mental health conditions: Support groups and counseling.
- Contact tracing for infectious diseases
- Workplace modifications
- Substance abuse prevention
- Tertiary prevention focuses on managing established diseases to prevent complications and maximize quality of life.
- Managing Established Diseases: Controlling progression through medications and lifestyle modifications.
- Minimizing Negative Effects: Preventing complications through interventions.
- Rehabilitation and Support: Providing rehabilitation services and emotional support.
- Quality of Life: Helping patients maintain the highest possible quality of life.
- Examples:
- Diabetes: Blood sugar control, foot care, and exercise.
- Stroke: Rehabilitation to regain lost function.
- Heart Disease: Medications, lifestyle changes, and monitoring.
- Chronic Pain: Physical therapy and pain management strategies.
Preventative Service Task Force Recommendations
- Refer to the website for recommendations: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations#bcf
Adult Immunization Schedule
- Vaccines are needed throughout life.
- Staying up to date is essential for health protection.
- Pregnant individuals or those with medical conditions should consult their healthcare provider.
- Ages 19-26
- Ages 27-49
- Ages 50-64
- Ages 65 +
- Tdap/Td: Every pregnancy, then every 10 years for all adults.
- MMR: If aged 68 years or younger.
- Chickenpox: If U.S. born and aged 45 years or younger.
- Shingles
- HPV
- Pneumococcal
- Hepatitis A
- Hepatitis B
- Meningococcal
- Hib
- Mpox
- Consult CDC for more information: www2.cdc.gov/nip/adultimmsched/
Evidenced Based Practice
- Cumulative researched reviews are highest quality research tools such as Cochrane and UpToDate
- Focus on the best evidence
- Clinical expertise: Clinicians bring their knowledge, skills, and experience to the table to interpret and apply research findings in the context of individual patients.
- Patient values and preferences: EBM recognizes that patients' values, preferences, and circumstances play a crucial role in treatment choices
Levels of Research Quality
- Level I:
- Highest level of evidence for practice change.
- Systematic review searches all RCTs and quantitative studies on a similar clinical question.
- Cochrane Library has extensive compilation
- Meta-analyses pool results of similar RCTs in an overall effect size that estimates the average size of the relationship between intervention and desired outcome
- Level II:
- Establishes cause of a disease.
- Efficacy of a treatment or intervention.
- Maintains high degree of control with experimental conditions.
- Random assignment allows for high degree of confidence.
- Double-blinding further strengthens support for cause-and-effect relationships
- Level III:
- Evaluate effectiveness of intervention or treatment
- Subjects are not randomly assigned
- Implement many of the same methods in RCTs to ascertain internal validity of a study
- Level IV:
- Useful for answering clinical questions related to prognosis or causation
- Compare those with the disease to those without the disease-Prior exposures
- Observational studies-Course of disease is observed without interference
- Level V:
- Portray characteristics of a population or clinical situation
- Quantitative: Measurable characteristic. Can identify associations between variables but not evidence of causation
- Qualitative: Narrative for increasing understanding of the phenomena of interest
- Level VI:
- Case study
- Likelihood of decreased objectivity
- Describe history of individual or small group of patients Told in story form with descriptions of signs, symptoms, and events
- Alert to adverse event or add to knowledge
- No inferences can be made to general population
- Level VII:
- This follows the tradition approach
- May or may not be based on strong evidence
- Should not be a sole determination of changing practice
- May be the only evidence in rare situations
- Reliance on RCTs can fail to teach providers critical thinking
Challenges of Evidence Practice
- Time constraints
- Lack of resources
- Resistance to change
- Complexity of some clinical questions
- HEDIS is a tool used by most U.S. health plans to measure performance.
- It helps compare health plans.
- HEDIS measures address:
- Asthma medication use
- Beta-blocker treatment after a heart attack
- Controlling high blood pressure
- Comprehensive diabetes care
- Cancer screening
- Antidepressant medication management
- Immunization status
- Advising smokers to quit
American Association of Colleges of Nursing (AACN)
- The AACN Essentials are the core competencies, including FNPs, should possess
- Organized into 10 domains:
- Knowledge for Nursing Practice
- Person-Centered Care
- Population Health
- Scholarship for the Nursing Discipline
- Quality and Safety
- Interprofessional Partnerships
- Systems-Based Practice
- Informatics and Healthcare Technologies
- Professionalism
- Personal, Professional, and Leadership Development
The Mission of St. Vincent dePaul
- Service to the Poor: Providing practical assistance.
- Advocacy: Working for social justice.
- Evangelization: Spreading the Gospel message.
- Education and Formation: Educating individuals to become agents of change.
- Spiritual Growth: Encouraging faith and spirituality through service.