Primary Care PowerPoint Notes PDF

**PRIMARY PREVENTION**: Immunizations, health education, skin cancer prevention methods, weight control, seat belt use, education on: smoking, alcohol, drugs, protective hearing, nutrition, exercise, stress reduction **SECONDARY PREVENTION:** Screenings -- cancers, diabetes, hypertension, stds, a...

**PRIMARY PREVENTION**: Immunizations, health education, skin cancer prevention methods, weight control, seat belt use, education on: smoking, alcohol, drugs, protective hearing, nutrition, exercise, stress reduction **SECONDARY PREVENTION:** Screenings -- cancers, diabetes, hypertension, stds, anemia, height, weight, BMI screenings **TERIARY PREVENTION:** Treatment to prevent further sequelae of cardiovascular disease, respiratory disease, etc **Primary, secondary, and tertiary prevention are three levels of health promotion and disease prevention**:  - - - - - - - - - - - - - - POWERPOINT NOTES **PRIMARY CARE IN THE 21^st^ CENTURY - A CIRCLE OF CARING** Florence Nightengale -- 1861, laws of sickness and laws of health Lavinia Dock -- evolved a community health nursing model at beg of 20^th^ century Virginia Henderson -heart, head, hand of nursing -- health happens where people live, love, learn, work, play Standardized nursing protocols -- evolved from the work of early school nurses and NY public health department Martha Rogers -argued for necessity of independent basis of nursing practice where autonomous nursing practice could grow 1990 -- Benners "from novice to expert" used by NONPF to create 5 domains for framwork for primary care NP curricula **2006 -- revised NONPF** -- ***7 domains*** and 75 core competencies that NPs must demonstrate upon graduation: Management of patient health/illness status Teaching/coaching function NP patient relationship Professional role Managing and negotiating health-care delivery systems Monitoring and ensuring the quality of healthcare practice Culturally sensitive care **Swanson**: 1995 Spirit function conceptual model of nursing for the APRN The core of every person is the spirit -- the spirit is an animating or vital principle held to give live to physical organisms **Nursing** is a goal directed interpersonal relationship between the patient and nurse, based on traditional nursing process components such as assessing, planning, intervening, and evaluating Interventions are broad based and range from play, music, and stories to the utilization of counseling principles such as active listening and anticipatory guidance **Shuler's 1993 NP practice model:** Rooted in holistic patient database that includes physical, social, cultural, environmental, and spiritual dimensions The patient's physical and psychological ability to participate in wellness activities is assessed and creative, uninhibited problem-solving and identification of appropriate wellness activities are pursued **Symptom Management 1994:** Symptoms should be reviewed as subjective experiences reflecting changes in a person\'s biophysical function, sensation, or cognition. 3 dimensions The symptom experience (subjective) Symptom management strategies Symptom outcomes **Snyder and Mirr 1995:** Conceptualize advanced practice within a nursing paradigm around human responses as a focus for nursing interventions Self-care limitations Impaired functioning in areas of rest, sleep, ventilation, circulation, nutrition Pain and discomfort Emotional problems related to the illness and treatment, life-threatening events, or daily experiences like anxiety, loss, or loneliness Distortion of symbolic functions reflected in interpersonal and intellectual processes such as hallucinations Deficiencies in decision-making ability to make personal choices Self-image changes required by health status Dysfunctional perceptual orientations to health Strains related to life processes such as birth, development, and death Problematic affiliative relationships **Ryan's 2009 Integrated Theory of Health Behavior Change (ITBHC):** Health promotion activities are an integral part of the long-term health and well-being of both healthy people and those with chronic illnesses APNs are in a position to facilitate and support health behavior changes in their clients and can tailor interventions that can positively affect long-term health status **Cumbie, Conley, and Burman's 2004 model of promoting process engagement:** Client centered theory developed to help APNs managed the care of chronically ill clients Interventions of the APRN are chosen based on each client\'s needs and expectations of their care, are developed in collaboration with the client **Nurse coaching:** Promotes integrative approaches for health and wellbeing Can be used to promote behavioral change Uses motivational interviewing, nonjudgemental acceptance of the patient, the transtheoretical model of behavioral change, appreciative inquiry, cultural perspectives, and "rituals of healing" **Changing Models of Medical Practice and Research:** Contributing factors to re-examination of traditional professional roles Advances in therapeutics, progress of medicine from integrated view of illness and therapeutics to one of discrete diseases with distinct causes and specific therapeutics - Success of this led to physician specialists with narrow focus on human disease and to technologically advanced medical interventions that are removed from day to day lives of patients Some difficulties fulfilling moral and social responsibilities of medicine, realization of limits of medical progress and technological intervention Call for a better balance between cure-oriented and care-oriented medicine **The Circle of Caring:** Broadened and contextualized database, labeling of the patient's concern that incorporates the patient\'s responses to the meaning of illness in his/her day-to-day life Holistic approach to an individualized therapeutic plan that includes nursing interventions based on evidence which can include complementary therapies incorporated with surgical, pharmacologic, and non-pharmacologic interventions The outcomes are viewed based on the patient, family, group, and community perceptions of improvement, as well as the more traditional, quantified outcome measures like mortality and morbidity data This model is a synthesized view of a problem solving methodology for a variety of settings. It is a contextualized approach The phenomenon of human responses as "calls for nursing" This is the HALLMARK of broadened approach to therapeutics and interventions Caring is the CENTRAL concept in nursing and is uniquely known and expressed in nursing, nursing takes place within nursing situations, nursing is a discipline of knowledge and a professional service that's goal is nurturing persons living, caring, and growing in caring Attributes of caring: knowing, patience, authentic presence, commitment, courage, and advocacy Productive tension between healthcare professionals benefits the care of all patients **CARING AND THE ADVANCED PRACTICE NURSE:** Caring is the essence of being human, caring is the essence of nursing ALL human based services are based on caring; nursing is DIFFERENT because caring directly characterizes nursing's knowledge base and services **Medicine** -- in medicine, a fundamental commitment to caring is directing characterized in the DX and RX of human structural and functional problems, usually characterized in physical terms **Generalized patterns of caring**: ***Courage*** -- the human act, daily application of values, ethical grounding for practice, manifests itself in making one's nursing vocation on commitment to these values and beliefs that undergird caring **Authentic presence:** Intentionally being with another in the fullness of ones personhood. The caring initiated through authentic presence is the initiating and sustaining medium of nursing within the nursing situation **Advocacy:** GADOW-EXISTENTIAL ADVOCACY -- self is brought into the situation as a full partner. When the nurse offers existential advocacy, the nurse feels known, respected, and connected in a way that affirms humanity and being **Knowing:** Directly implies being deeply attuned, comes through intentional and authentic presence. There are patterns of knowing: Practitioner draws on personal knowing as essential intuitive knowing Empiric knowing -- avenue for drawing on science and skilled observation Ethical knowing -- prompts consideration of values and morals for situations Esthetic knowing -- incorporation of knowing into a situation for integrated understanding with the nursed **Commitment:** Choosing to be a member of the discipline and profession of nursing speaks to a lifelong commitment of service to humankind Directs obligation or what "ought to be" in a particular situation Conflicts to commitment -- economically driven care might conflict with calls from patients **Patience:** Trusting people to grow at their own pace, in their own way Not a passive attribute -- an active openness to "the moment alive with possibilities" Humility and courage intimately linked to patience -- the courage to let someone "be" and freedom of choice **ELEMENTS OF THE DIAGNOSTIC PROCESS:** **OLD CART** Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment **CSOC** **Chief Compliant** Specific questions -- sort out competing diagnoses Open ended questions Clarify story Address what patient thinks is wrong, establish a relationship, identify with patient what is most important to accomplish **MEDICALHISTORY** Refine hypothesis, suggest risk factors, all medications, immunizations, allergies and kind of reaction, health maintenance practices **FAMILY HISTORY** Part of risk factor assessment, genograms **SOCIAL HISTORY** Work history Functional health patterns **REVIEW OF SYSTEMS (ROS):** Questionnaire -- go from general to specific **FUNCTIONAL HEALTH PATTERNS** Marjory Gordons Nursing questions Advanced assessment **PHYSICAL EXAMINATION** Clarify and detect **DIAGNOSTIC TESTS:** Used to confirm, rule-out, or screen Vary in usefulness -- look at sensitivity -- few false negatives when high sensitivity , specificity -- few false positives when high specificity, and predictive value, look at false-positive and false-negative results, accuracy, cost and convenience **DIFFERENTIAL DIAGNOSIS** Prioritize list of possibilities One approach: "Skin In" -- think of all problems starting with the skin Present patient to preceptors Clarify problem list Decide how to best manage using clinical judgment Brief teaching, counseling **A power of attorney (POA) in healthcare**, also known as a medical power of attorney or health care proxy, is a legal document that allows someone to make medical decisions for you if you are unable to do so. The person you choose to make these decisions for you is called your healthcare agent.  Here are some things to consider about a healthcare POA:  - - - - - **A living will is** a legal document that specifies a person\'s medical treatment preferences if they are unable to make medical decisions. It\'s a type of advance directive that can help ensure a person receives the care they want if they are seriously ill or in a terminal condition.  A living will can include:  - A list of treatments to receive or avoid  - Preferences for organ and tissue donation  - Instructions for feeding tubes, breathing tubes, and dialysis machines  - Where to receive medical care, such as at home, in a nursing home, or another facility  - How nutrition should be provided  - Pain management preferences  When creating a living will, it\'s important to consider specific situations that may arise, such as when a patient is unconscious or in a vegetative state. It\'s also a good idea to discuss the living will with family members so they understand the person\'s wishes.  Living wills can vary by state, and not all states allow them. Some states offer living will registries to make them more accessible to doctors and other health care providers **A health care proxy** is a person who is authorized to make medical decisions for you if you are unable to communicate your wishes. They are also known as a representative, surrogate, or agent.  A health care proxy is a type of advance directive, and is often used in conjunction with a living will. They are important for advance care planning.  A health care proxy can: - Access your medical records - Agree to treatment decisions - Choose between different treatments - Decide whether or not to provide treatment, based on your wishes **ETHICS:** Ethics -- what one ought to do Bioethics -- when the moral choices involves healthcare Dilemma -- a situation where there are several unequally satisfying solutions OR when there is a conflict between one's values NINE provisions in ANAs code of ethics Practice with compassion and respect for the inherent worth, dignity, and personal attributes of every person, without prejudice The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population The nurse promotes, advocates for, and protects the rights, health, and safety of the patient The nurse has authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to provide optimal care The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth The nurse, through individual and collective action, establishes, maintains, and improves the moral environment of the work setting and the conditions of employment, conducive to quality health care The nurse, whether in research, practice, education, or administration, contributes to the advancement of the profession The nurse collaborates with other health professionals and the public to protect and promote human rights, health diplomacy, and health initiatives The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy **Deontology** - also known as duty-based ethics, is an ethical theory that is often used in healthcare to distinguish right from wrong by following a set of rules. Deontology is based on the idea that some actions are morally right or wrong regardless of the consequence IMMANUAL KANT **Universalizability** is an ethical principle that states that moral judgments should be equally applicable to all relevantly identical situations. It is also a principle of Immanuel Kant\'s categorical imperative, which states that one should only act in ways that they would want to become universal law **TELEOLOGY** is the idea that ethical actions are directed toward achieving a specific goal, and that the morality of an action is determined by its outcome. The term \"teleological\" comes from the Greek words telos, meaning \"end\" or \"goal\", and logos, meaning \"science\".  Teleological ethics is also known as consequentialist ethics, and it\'s often contrasted with deontological ethics, which holds that the morality of an action is independent of its outcome.  The greatest amount of happiness and the least amount of harm Some examples of teleological theories include: - A modern teleological theory that defines right conduct as that which promotes the best consequences JOHN STUART MILL **ETHICAL PRINCIPLES:** **Autonomy --** self-determination, respect for all persons, competence, informed consent **Beneficence** -- Requires positive action, balancing of harm vs benefits, principle of proportionality, example -- caring for a very contagious patient **Nonmalfeficence --** Do no harm, the foundation of healthcare, does NOT require taking positive action, **Veracity** -- Truth telling **Confidentiality** -- respect for privileged information **Fidelity** -- Keep promises, avoid false expectations **Justice** -- fairness **Established expectations for APRNS:** LACE -- licensure, accreditation, certification, education **REIMBURSMENT** -- unequal pay for APRNS - Medicare - Medicaid **MALPRACTICE -- Must have:** Duty to patient Must deviate from standard of care Harm or damages must occur as a result **Claims based policy** -- covers claims only if incident occurred when the NP paid the premium and only if still enrolled with same insurance carrier Tail coverage -- covers claims that may be filed that occurred while employed and insured even if retired **Occurrence based policy** -- if claim is filed against NP in the future, it is covered if an occurrence based policy was in effect at the time the incident occurred. \*\*\*BEST COVERAGE **SCOPE OF PRACTICE:** FULL PRACTICE -- NPs can evaluate and diagnose patients, manage treatments, prescribe including controlled substances COLLABORATIVE PRACTICE -- written statement that defines the joint practice of an MD and an APRN in a collaborative and complementary working relationship Provides mechanism for legal protection of the APRN and sets out the rights and responsibilities of each party involved RESTRICTIVE PRACTICE -- NPs ability to practice is restricted in at least one element of the NP practice, state law requires career long supervision, delegation, or team management by another health provider in order for the NP to provide patient care**\ ** The **Affordable Care Act (ACA)** has had a significant impact on Advanced Practice Registered Nurses (APRNs) and the nursing profession in several ways, including:  - 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