Primary Care Final Exam SG PDF

PRIMARY CARE OF THE FAMILY READING NOTES for units one and two: Chapters 1,2, 4, 5, 85, 86, 88 CHAPTER ONE: Scope of practice is not consistent across the states Three themes for future success: The need for nurses to play a full role in practice, education, and leadership The...

PRIMARY CARE OF THE FAMILY READING NOTES for units one and two: Chapters 1,2, 4, 5, 85, 86, 88 CHAPTER ONE: Scope of practice is not consistent across the states Three themes for future success: The need for nurses to play a full role in practice, education, and leadership The need for diversity in the nursing workforce The need for better data to evaluate progress Healthy People 2030 needs a lot of work Primary care is defined as: continuous, person centered, relationship based care that considers the needs and preferences of individuals, families, and communities Core competencies for APRNS: Domain 1: Knowledge for Nursing Practice Domain 2: Person-Centered Care Domain 3: Population Health Domain 4: Scholarship for Nursing Practice Domain 5: Quality and Safety Domain 6: Interprofessional Partnerships Domain 7: Systems-Based Practice Domain 8: Information and Healthcare Technologies Domain 9: Professionalism Domain 10: Personal, Professional, and Leadership Development CHAPTER TWO: The APRN role is grounded in the knowledge of skills and caring CARING The intentional and authentic presence of the nurse with another person who is living, caring. In nursing, caring directly characterizes a nurse’s knowledge base and service. Generalized patterns of nursing care are represented in the CIRCLE OF CARING MODEL: Courage Authentic presence Advocacy  Knowing Commitment Patience CHAPTER FIVE Elements of the diagnostic process: Onset – duration, characteristics Location – aggravating factors, relieving factors, treatment Reimbursement Payment standards in the United States are driven by insurance companies, particularly those that administer Medicare and Medicaid. APRNs have made great strides in this area and now receive third- party reimbursement in most settings. In managed care contracts, sometimes called advantage plans, providers, whether APRNs or physicians, are paid a fixed, predetermined rate. Payment by private insurance companies is contract specific and varies with each state’s insurance commission. Reimbursement has long been a controversial issue. Medicare and some other insurance companies reimburse NPs at 85% of physician rates, even though they provide the same services as physicians. This is called “incident to” billing, indicating that the care was provided incident to the supervising physician’s care. Incident to billing allows for services to be paid to the supervising physician for 100% of the charged amount rather than 85%, which an independent NP would be paid. Although incident to billing is advantageous for practices, it isn’t for NPs. This form of billing suggests that NP care is not the same quality as physician care, but many patients would disagree. Incident to billing also suggests a hierarchical approach to care rather than a team approach, suggesting that NPs need physician oversight, which is not the case. From a national standpoint, incident to billing makes NP care invisible because all services are billed under physicians’ NPI numbers rather than the NPs’ numbers who provide the services. Because NPI numbers are used to collect data regarding services provided, it is difficult for Medicare to identify and support all clinicians providing primary care services. In 2019, the Medicare Payment Advisory Commission (MedPAC) suggested doing away with incident to billing to create a more unified system (LaPointe, 2019). Other organizations, such as the AANP, support this recommendation and are working politically to remove this barrier to NP full practice authority and access to care for all persons. THIRD-PARTY PAYER RULES Whether NPs are employed by a hospital, a medical practice, a community health center (such as federally qualified health centers [FQHCs]), or are self-employed, a third-party payer most often determines reimbursement policies. Third-party payers fall into seven general categories: 1. Medicare – A, B, C (Medicare Advantage Plans), D 2. Medicaid 3. Indemnity insurance companies 4. Managed care organizations (MCOs) 5. Workers’ compensation (WC) 6. Veterans Administration 7. Auto liability In addition to these third-party payers, there are patients without health insurance, some who have strong financial assets that allow them to pay out of pocket, but most (the uninsured) do not. These patients are considered private pay. Each payer source has its own policies and fee schedules. All, however, use the Centers for Medicare and Medicaid Services (CMS) guidelines as a foundation. CMS works to make sure that the beneficiaries in its government-funded programs can obtain high-quality health care. In response to rising health-care costs, CMS enacted the Balanced Budget Act of 1997 and gave billing approval for nonphysician practitioners, including NPs. MCOs were slow to add NPs as providers. Over time, these carriers have had a growing number of NPs credentialed as providers. Payments were based on the CMS billing rules (85% of the fee schedule rate) or providers who do not credential NPs may instruct NPs to bill under the physician’s provider number. Medicare is a health insurance program for people 65 and older that has four parts: Part A, Part B, Part C, and Part D:  Part A Inpatient hospital coverage, including hospice, hospital stays, and skilled nursing  Part B  Outpatient medical coverage, including doctor visits, lab services, durable medical equipment, and other testing  Part C Medicare Advantage, which is an alternative to Parts A and B that combines several coverage types into a single plan  Part D Prescription drug coverage Medicare A—Hospital Inpatient Services Health-care providers wishing to bill Medicare can join the program by applying online at the Provider Enrollment Chain and Ownership System (PECOS) or by a using the traditional paper form (CMS-855I). Each Medicare provider is assigned a National Provider Identifier (NPI) for billing that must be used in Health Insurance Portability and Accountability Act (HIPAA) transactions. Medicare providers agree to take assignments (accept the CMS-approved amount for health services as full payment) when performing services according to current Medicare physician fee schedules and guidelines. Providers are required to submit a claim (bill) to CMS for all services (covered and uncovered) and will be paid, based on the claim for specified services. The NP’s scope of practice, prescriptive authority, and requirement of physician collaboration are designated by state legislation. Each state gives authority to the nurse licensing board to regulate APRNs. In 2021, the Medicare Part A (hospital services) deductible was $1,484, and premiums were based on the quarters of lifetime work in which Medicare taxes are paid. Medicare A out-of-pocket expense was determined by the deductible rate and limits on what is covered. In 2021, out-of-pocket hospital fees was charged as follows: Hospital stays of 1 to 60 days: no additional payment in each benefit period Days 61 to 90: $371 per day coinsurance Days 91 and beyond: $742 coinsurance per “lifetime reserved day” used. After 90 days for each benefit period, the beneficiary can use up to 60 days over their lifetime. Beyond lifetime reserve days: All costs paid by the patient (CMS, 2020e; Medicareworld, 2021) Postacute care for beneficiaries who are responsible for a $185.50 per day copayment—days 21 to 100 in a skilled nursing facility (SNF). Days 1 to 20 have no out-of-pocket post discharge for acute hospital care. Medicare B—Physician Services CMS payment policy for calendar year 2021 (CY 2021) was based on the annual physician and nonphysician provider fee schedule (Medicare Physician Fee Schedule [PFS]) (CMS, 2020e). Comments for the fee schedule were placed in the Federal Register on August 4, 2020, and took effect, as they do yearly, on or after January 1, 2021 (CMS, 2020e). The physician fee schedule reflected an administrative strategy aiming to result in “better accessibility, quality, affordability, empowerment, and innovation” (CMS, 2020e, p 1). For CMS-covered physicians, CMS identifies which services will be reimbursed (100% of the physician PFS) and then stipulates that 80% of the allowed rate will be paid by CMS and 20% is the responsibility of the patient. NPs are reimbursed by CMS at 85% of the physician’s fee, with the patient still paying a 20% share; NP fees are typically 15% lower than that of physicians (Frakes, 2006). Most patients on the traditional Medicare plan acquire a secondary insurance plan (premium costs vary by patient health status from $50 to $300 per month) to cover the 20% patient out-of-pocket expense. In addition to the 20% patient responsibility, Medicare has a yearly deductible. In 2021, the Medicare B (physician/provider and outpatient services) deductible was $203 per year. Once paid, the patient is charged 20% of the approved Medicare rate for physician office visits and some diagnostic tests. Information about Medicare beneficiary out-of-pocket expenses can be found at the official U.S. government site for Medicare (CMS, 2020e). For all CMS patients, the out-of-pocket patient responsibility payments (copays and deductibles) should be collected before rendering services. This is especially important at the beginning of the calendar year when most Medicare beneficiaries have not yet met their deductible. Patient out-of-pocket payment responsibility should be verified at each medical treatment episode. If these fees are not collected before the services are rendered, they remain the patient’s payment responsibility and will require direct patient billing. Patient billing increases the expense to the practice because of the cost and time involved in collecting funds. CMS providers are required to attempt to collect the copayments and deductible patient payments, and best practice recommends providers do so before rendering services. Medicare D—Pharmaceutical Coverage In 2003, Medicare D was added as part of the Medicare Modernization Act, and the donut hole was initially included to encourage patients to be participative consumers aware of drug costs and choices. This program offers prescription drug coverage for drugs not covered under Medicare A or B. The donut hole is a gap in coverage that begins after the person exceeds the initial coverage limit in their plan. In 2021, the initial coverage limit was $4,120, up from $4,020 in 2020. ACA legislation planned to eliminate the hole in coverage. When the out-of-pocket expenses reached $6,350 in 2021, catastrophic coverage was available. After this, the beneficiary paid only 5% of the copay for drugs for the remainder of the year (Healthline, 2019). CMS across the year pays 75% of medication costs; however, the patient must pay premiums, copayments, and deductibles. Beneficiaries can choose a plan that fits their needs and affects their premium rates. Beneficiaries must be enrolled in the Medicare A or Medicare B program, and this is an optional addition to their coverage. Plan selection affects covered medications, and there are many plan options offered to citizens across the United States. Key categories of drugs must be covered by all plan options, such as cancer treatment medications and antidepressant medication (total of six required drug categories). Pharmaceutical costs are substantial for most CMS beneficiaries, and costs have increased yearly. Premium costs per month range from approximately $12 to $195 per month. Plan coverage is seen as four parts: (1) deductible phase (pay 100% of drug discount until meet rate; range from $0 to $435/year), (2) initial coverage phase (pay copay, with plan paying $1 for generics on some plans or up to 25%), (3) coverage gap or donut hole (25% of discounted rate of brand drugs), (4) catastrophic phase (5% copay discount rate) (Eligibility Medicare, 2020). ACA plan policy included fully closing the donut hole in 2020; however, the Bipartisan Budget Act of 2018 affected this closure and delayed implementation. Medicare Advantage Plans Medicare Advantage plans offer another way for eligible citizens to obtain Medicare A (hospital) and B (physician) coverage, and these may be called Medicare C or Medicare MA plans. These plans must be approved by CMS and are offered by private insurance companies. Each Medicare MA must offer all required services. They offer all required benefits of Medicare and usually offer additional benefits, such as drug coverage, uncovered eye care, dental care, and lower copayments. Ease of using one plan for covered benefits is attractive to users. Medicare Advantage carriers are paid subsidies per member by CMS for services rendered by their plan. Beneficiaries, however, must use the health providers that participate in these plans. A limit of out-of-pocket yearly expenses for covered services is identified to beneficiaries to avoid concerns of unexpected costs. Medicare Advantage plans were designed on the premise of offering lower costs based on economic efficiencies realized by volume discounts from commercial business relationships. However, problems have been noted with these plans. Because of the high medical utilization of and greater health-care costs incurred by their beneficiaries, many Medicare MA plans have found this market to be less financially viable. In addition, beneficiaries can use noncovered services or out-of-pocket services but at a higher cost. If a plan’s payout exceeds the fixed CMS payment they receive annually, the plan incurs a loss, causing many of these carriers to leave this market. Common types of Medicare MA include the following (CMS, 2020b): Health maintenance organization (HMO) plans Preferred provider organization (PPO) plans Private fee-for-service (PFFS) plans Special needs plans (SNPs) Medicaid Medicaid offers medical assistance to individuals and families with low incomes and limited resources, as well as for those with chronic disabilities. Unlike Medicare, it was designed to be jointly funded by both federal and state governments. The federal government assists states in providing medical care to people who meet the program’s financial eligibility criteria, including children, pregnant women, parents, seniors (those with dual eligibility on Medicare with Medicaid paying copay and deductibles), and individuals with disabilities. The ACA established the income eligibility method used today, replacing the previous allocation method overseen by Aid to Families with Dependent Children. The ACA determines income eligibility for Medicaid based on the Modified Adjusted Gross Income (MAGI). Citizens who are blind, disabled, or older than 65 years are exempt from meeting the MAGI requirements. Medicaid, together with the Children’s Health Insurance Program (CHIP), provided coverage in 2020 to over 72.5 million Americans (Medicaid.gov, 2019; https://Medicaid.gov/Medicaid/eligibility/index.html). Medicaid payments are made directly to the participating providers, who in turn must accept the Medicaid (lower) payment as payment in full. Two exceptions are (1) disproportionate-share hospital payments (hospitals that care for a disproportionate share of Medicaid-eligible patients) and (2) hospice care. Although lawmakers have discussed changing the Medicaid system, with an overarching focus of putting more control in the hands of each state, currently no changes have been made. The federal government matches dollar spending for qualifying mandatory services offered by the individual state. Reimbursement rates must remain sufficient to enlist enough providers willing to perform services and ensure that medical care is available to the general population in the region. In recent years, since the MAGI, citizens have benefited from a reduced delay experienced when seeking enrollment and entering or renewing Medicaid and CHIP (Medicaid.gov, 2020). Guidelines for the Medicaid plan are available at the Medicaid Web site by state and on the Benefits for Medicaid Web site (Medicaid.gov, 2019). There are limitations and criteria for APRN reimbursable services outlined in each state’s guidelines that can be located by selecting each state on the ANA Web site (ANA, 2020). There has been an expansion of coverage services for the four APRN roles, as there is a need for practitioner services in the growing physician shortage areas. APRNs are also a cost savings as they are paid at a fraction of the Medicaid PFS. Political opposition to ACA legislation for Medicaid recipients is linked to states’ participation in the Medicaid expansion (National Academy for State Health Policy, 2020). On June 28, 2012, the U.S. Supreme Court found that the ACA Medicaid expansion was coercive to the states, ruling that the Department of Health and Human Services (HHS) had no enforcement authority over Medicaid expansion. States could opt not to accept Medicaid expansion funds, which reduced health-care services for Medicaid patient populations in those states. However, this ruling left the health-care coverage and other provisions of the ACA intact. States that did not accept the Medicaid expansion proved to have lower quality of care and reduced access for Medicaid services. Medicaid expansion had a positive financial budget and economic impact in states accepting expansion due to higher federal investment related to this program offering (RWJF, 2019) THIRD-PARTY PAYER RULES Whether NPs are employed by a hospital, a medical practice, a community health center (such as federally qualified health centers [FQHCs]), or are self-employed, a third-party payer most often determines reimbursement policies. Third-party payers fall into seven general categories: 1. Medicare – A, B, C (Medicare Advantage Plans), D 2. Medicaid 3. Indemnity insurance companies 4. Managed care organizations (MCOs) 5. Workers’ compensation (WC) 6. Veterans Administration 7. Auto liability In addition to these third-party payers, there are patients without health insurance, some who have strong financial assets that allow them to pay out of pocket, but most (the uninsured) do not. These patients are considered private pay. Each payer source has its own policies and fee schedules. All, however, use the Centers for Medicare and Medicaid Services (CMS) guidelines as a foundation. CMS works to make sure that the beneficiaries in its government-funded programs can obtain high-quality health care. In response to rising health-care costs, CMS enacted the Balanced Budget Act of 1997 and gave billing approval for nonphysician practitioners, including NPs. MCOs were slow to add NPs as providers. Over time, these carriers have had a growing number of NPs credentialed as providers. Payments were based on the CMS billing rules (85% of the fee schedule rate) or providers who do not credential NPs may instruct NPs to bill under the physician’s provider number. Medicare A—Hospital Inpatient Services Health-care providers wishing to bill Medicare can join the program by applying online at the Provider Enrollment Chain and Ownership System (PECOS) or by a using the traditional paper form (CMS-855I). Each Medicare provider is assigned a National Provider Identifier (NPI) for billing that must be used in Health Insurance Portability and Accountability Act (HIPAA) transactions. Medicare providers agree to take assignments (accept the CMS-approved amount for health services as full payment) when performing services according to current Medicare physician fee schedules and guidelines. Providers are required to submit a claim (bill) to CMS for all services (covered and uncovered) and will be paid, based on the claim for specified services. The NP’s scope of practice, prescriptive authority, and requirement of physician collaboration are designated by state legislation. Each state gives authority to the nurse licensing board to regulate APRNs. In 2021, the Medicare Part A (hospital services) deductible was $1,484, and premiums were based on the quarters of lifetime work in which Medicare taxes are paid. Medicare A out-of-pocket expense was determined by the deductible rate and limits on what is covered. In 2021, out-of-pocket hospital fees was charged as follows: Hospital stays of 1 to 60 days: no additional payment in each benefit period Days 61 to 90: $371 per day coinsurance Days 91 and beyond: $742 coinsurance per “lifetime reserved day” used. After 90 days for each benefit period, the beneficiary can use up to 60 days over their lifetime. Beyond lifetime reserve days: All costs paid by the patient (CMS, 2020e; Medicareworld, 2021) Postacute care for beneficiaries who are responsible for a $185.50 per day copayment—days 21 to 100 in a skilled nursing facility (SNF). Days 1 to 20 have no out-of-pocket post discharge for acute hospital care. Medicare B—Physician Services CMS payment policy for calendar year 2021 (CY 2021) was based on the annual physician and nonphysician provider fee schedule (Medicare Physician Fee Schedule [PFS]) (CMS, 2020e). Comments for the fee schedule were placed in the Federal Register on August 4, 2020, and took effect, as they do yearly, on or after January 1, 2021 (CMS, 2020e). The physician fee schedule reflected an administrative strategy aiming to result in “better accessibility, quality, affordability, empowerment, and innovation” (CMS, 2020e, p 1). For CMS-covered physicians, CMS identifies which services will be reimbursed (100% of the physician PFS) and then stipulates that 80% of the allowed rate will be paid by CMS and 20% is the responsibility of the patient. NPs are reimbursed by CMS at 85% of the physician’s fee, with the patient still paying a 20% share; NP fees are typically 15% lower than that of physicians (Frakes, 2006). Most patients on the traditional Medicare plan acquire a secondary insurance plan (premium costs vary by patient health status from $50 to $300 per month) to cover the 20% patient out-of-pocket expense. In addition to the 20% patient responsibility, Medicare has a yearly deductible. In 2021, the Medicare B (physician/provider and outpatient services) deductible was $203 per year. Once paid, the patient is charged 20% of the approved Medicare rate for physician office visits and some diagnostic tests. Information about Medicare beneficiary out-of-pocket expenses can be found at the official U.S. government site for Medicare (CMS, 2020e). For all CMS patients, the out-of-pocket patient responsibility payments (copays and deductibles) should be collected before rendering services. This is especially important at the beginning of the calendar year when most Medicare beneficiaries have not yet met their deductible. Patient out-of-pocket payment responsibility should be verified at each medical treatment episode. If these fees are not collected before the services are rendered, they remain the patient’s payment responsibility and will require direct patient billing. Patient billing increases the expense to the practice because of the cost and time involved in collecting funds. CMS providers are required to attempt to collect the copayments and deductible patient payments, and best practice recommends providers do so before rendering services. Medicare D—Pharmaceutical Coverage In 2003, Medicare D was added as part of the Medicare Modernization Act, and the donut hole was initially included to encourage patients to be participative consumers aware of drug costs and choices. This program offers prescription drug coverage for drugs not covered under Medicare A or B. The donut hole is a gap in coverage that begins after the person exceeds the initial coverage limit in their plan. In 2021, the initial coverage limit was $4,120, up from $4,020 in 2020. ACA legislation planned to eliminate the hole in coverage. When the out-of-pocket expenses reached $6,350 in 2021, catastrophic coverage was available. After this, the beneficiary paid only 5% of the copay for drugs for the remainder of the year (Healthline, 2019). CMS across the year pays 75% of medication costs; however, the patient must pay premiums, copayments, and deductibles. Beneficiaries can choose a plan that fits their needs and affects their premium rates. Beneficiaries must be enrolled in the Medicare A or Medicare B program, and this is an optional addition to their coverage. Plan selection affects covered medications, and there are many plan options offered to citizens across the United States. Key categories of drugs must be covered by all plan options, such as cancer treatment medications and antidepressant medication (total of six required drug categories). Pharmaceutical costs are substantial for most CMS beneficiaries, and costs have increased yearly. Premium costs per month range from approximately $12 to $195 per month. Plan coverage is seen as four parts: (1) deductible phase (pay 100% of drug discount until meet rate; range from $0 to $435/year), (2) initial coverage phase (pay copay, with plan paying $1 for generics on some plans or up to 25%), (3) coverage gap or donut hole (25% of discounted rate of brand drugs), (4) catastrophic phase (5% copay discount rate) (Eligibility Medicare, 2020). ACA plan policy included fully closing the donut hole in 2020; however, the Bipartisan Budget Act of 2018 affected this closure and delayed implementation. Medicare Advantage Plans Medicare Advantage plans offer another way for eligible citizens to obtain Medicare A (hospital) and B (physician) coverage, and these may be called Medicare C or Medicare MA plans. These plans must be approved by CMS and are offered by private insurance companies. Each Medicare MA must offer all required services. They offer all required benefits of Medicare and usually offer additional benefits, such as drug coverage, uncovered eye care, dental care, and lower copayments. Ease of using one plan for covered benefits is attractive to users. Medicare Advantage carriers are paid subsidies per member by CMS for services rendered by their plan. Beneficiaries, however, must use the health providers that participate in these plans. A limit of out-of-pocket yearly expenses for covered services is identified to beneficiaries to avoid concerns of unexpected costs. Medicare Advantage plans were designed on the premise of offering lower costs based on economic efficiencies realized by volume discounts from commercial business relationships. However, problems have been noted with these plans. Because of the high medical utilization of and greater health-care costs incurred by their beneficiaries, many Medicare MA plans have found this market to be less financially viable. In addition, beneficiaries can use noncovered services or out-of-pocket services but at a higher cost. If a plan’s payout exceeds the fixed CMS payment they receive annually, the plan incurs a loss, causing many of these carriers to leave this market. Common types of Medicare MA include the following (CMS, 2020b): Health maintenance organization (HMO) plans Preferred provider organization (PPO) plans Private fee-for-service (PFFS) plans Special needs plans (SNPs) Medicaid Medicaid offers medical assistance to individuals and families with low incomes and limited resources, as well as for those with chronic disabilities. Unlike Medicare, it was designed to be jointly funded by both federal and state governments. The federal government assists states in providing medical care to people who meet the program’s financial eligibility criteria, including children, pregnant women, parents, seniors (those with dual eligibility on Medicare with Medicaid paying copay and deductibles), and individuals with disabilities. The ACA established the income eligibility method used today, replacing the previous allocation method overseen by Aid to Families with Dependent Children. The ACA determines income eligibility for Medicaid based on the Modified Adjusted Gross Income (MAGI). Citizens who are blind, disabled, or older than 65 years are exempt from meeting the MAGI requirements. Medicaid, together with the Children’s Health Insurance Program (CHIP), provided coverage in 2020 to over 72.5 million Americans (Medicaid.gov, 2019; https://Medicaid.gov/Medicaid/eligibility/index.html). Medicaid payments are made directly to the participating providers, who in turn must accept the Medicaid (lower) payment as payment in full. Two exceptions are (1) disproportionate-share hospital payments (hospitals that care for a disproportionate share of Medicaid-eligible patients) and (2) hospice care. Although lawmakers have discussed changing the Medicaid system, with an overarching focus of putting more control in the hands of each state, currently no changes have been made. The federal government matches dollar spending for qualifying mandatory services offered by the individual state. Reimbursement rates must remain sufficient to enlist enough providers willing to perform services and ensure that medical care is available to the general population in the region. In recent years, since the MAGI, citizens have benefited from a reduced delay experienced when seeking enrollment and entering or renewing Medicaid and CHIP (Medicaid.gov, 2020). Guidelines for the Medicaid plan are available at the Medicaid Web site by state and on the Benefits for Medicaid Web site (Medicaid.gov, 2019). There are limitations and criteria for APRN reimbursable services outlined in each state’s guidelines that can be located by selecting each state on the ANA Web site (ANA, 2020). There has been an expansion of coverage services for the four APRN roles, as there is a need for practitioner services in the growing physician shortage areas. APRNs are also a cost savings as they are paid at a fraction of the Medicaid PFS. Political opposition to ACA legislation for Medicaid recipients is linked to states’ participation in the Medicaid expansion (National Academy for State Health Policy, 2020). On June 28, 2012, the U.S. Supreme Court found that the ACA Medicaid expansion was coercive to the states, ruling that the Department of Health and Human Services (HHS) had no enforcement authority over Medicaid expansion. States could opt not to accept Medicaid expansion funds, which reduced health-care services for Medicaid patient populations in those states. However, this ruling left the health-care coverage and other provisions of the ACA intact. States that did not accept the Medicaid expansion proved to have lower quality of care and reduced access for Medicaid services. Medicaid expansion had a positive financial budget and economic impact in states accepting expansion due to higher federal investment related to this program offering (RWJF, 2019) Health Insurance Portability and Accountability Act (HIPAA) HIPAA can mean different policy concerns to different people. The act is separated into two parts, Title I and Title II: Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II addresses administrative simplification and requires the U.S. Department of Health and Human Services to establish national standards for electronic health-care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. These standards were implemented to improve the efficiency and effectiveness of the nation’s health- care system by encouraging the widespread use of electronic data interchange in health care (CMS, 2005). HIPAA legislation is important to the daily management of the practitioner practice setting. This legislation focuses on password management, workstation security, e-mail and Internet use, and facility/physical security. Password protection ensures the privacy of patients’ health-care information. With increased mandatory submission of electronic billing files and EMRs, a provider must take added precautions to protect the patient’s electronic personal information 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:  Primary prevention Prevents disease, injury, or disability before it occurs. Examples include:  Immunizations  Health education  Exercise  Wearing seatbelts  Secondary prevention Detects and treats disease early to prevent it from progressing. Examples include:  Screening for breast, bowel, and cervical cancer  Blood pressure screening  Papanicolaou (Pap) smears  Mammography  Colonoscopies  Tertiary prevention Manages the consequences of disease after diagnosis. Examples include:  Rehabilitation from injuries, heart attack, or stroke  Preventing pressure sores in people confined to bed POWERPOINT NOTES PRIMARY CARE IN THE 21st 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:  Who to choose You can choose anyone who is over 18 and not your doctor or other health care provider. Your agent should be someone you trust and who understands your wishes.  Durability In most states, a POA ends if you become incapacitated. However, you can make your POA durable so that your agent's authority continues even if you are unable to communicate your wishes.  Multiple agents You can appoint more than one agent for different purposes, or write multiple agreements of the same type.  What decisions can be made Your agent can make decisions about treatment options, medication, surgery, and end-of- life care.  Benefits A healthcare POA can help ensure that your care is in line with your wishes, reduce stress for your loved ones, and improve the quality of your end-of-life care 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:  Utilitarianism 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 APRNs are reimbursed at 85% of the physician rate for medically necessary visits.  Medicaid Reimbursement for nurse practitioners (NPs) varies by state, ranging from 75% to 100% of the physician rate. Most states reimburse NPs at 100% of the rate of MDs 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:  Increased demand The ACA's focus on outcomes and preventive care has increased the demand for APRNs and nurse practitioners (NPs).  Funding for training The ACA's Graduate Nurse Education Demonstration provided federal funding to help offset the costs of training APRNs.  Increased patient outcomes NPs generally have better patient outcomes than other nurses because of their advanced education.  Increased opportunities APRNs with a Doctor of Nursing Practice (DNP) degree can lead community health centers, work on interdisciplinary teams, and advocate for policy initiatives.  Increased visibility The ACA's focus on outcomes has increased pressure on nurses to show they can provide effective care.  Increased role As a result of the ACA, APRNs are now more intimately involved in all aspects of the healthcare system. – Primary Healthcare I Pediatrics 1. Be able to provide examples of primary, secondary and tertiary prevention.  Primary care: Prevention. Immunizations, education, nutrition, exercise, weight control.   Secondary Care: Referral to specialist. Screening CA, DM2, HTN,  Tertiary Care: Treatment to prevent further sequelae of mult diseases. 2. Recognize when common pediatric immunizations are given such as hep B, Tdap -CDC schedule 3. Know the Tanner stages of development – puberty typically occurs during Tanner Stg III 4. Common pediatric milestones Bright Futures -Pocket Guide 5. Lead poisoning in children High Prevalence area or Medicaid. Women’s Health 6. Common sexually transmitted diseases and treatment do you treat the partner Disease Treatment- Do you treat the partner? Gonorrhea Chlamydia Herpes Syphilis Genital warts Trichomonas 7. Understand the menstrual cycle when -luteinizing hormone and follicle-stimulating hormone peaks, and when ovulation occurs, when would a patient experience premenstrual syndrome 8. Define primary and secondary amenorrhea Primary type begins with adolescents that attain ambulatory cycles, no pelvic pathology  Secondary type is due to pelvic pathology or a recognized medical condition such as endometriosis. 9. Be knowledgeable about iron deficiency anemia, common iron supplement doses Anemia caused by low iron intake, inefficient iron absorption in the gastrointestinal tract, or chronic blood loss. Iron deficiency anemia (IDA) is characterized by decreased or absent iron stores, low serum iron concentration, low transferrin saturation, and low hemoglobin concentration or hematocrit value. The erythrocytes are hypochromic and microcytic and the iron binding capacity is increased. This type of anemia is most commonly associated with chronic blood loss. Adults need about 180 mg of elemental iron daily during anemic states. Children need about 3 mg/kg/day during anemic states. Patient Education About Iron Replacement  For greatest absorption, take 1-2 hours before meals on empty stomach  Take with meals if GI upset occurs; this decreases iron absorption  Do not take concomitantly with antacids, tetracycline, dairy products  Bowel movements will be dark in color  Iron is highly toxic; keep out of children’s reach  Place iron drops in back of mouth to reduce staining of teeth in infants and young children  Administration of iron with vitamin C enhances absorption  Food may reduce absorption of iron by 50% 10. Contraception-what can be given during breastfeeding, during smoking and postpartum Ghk 11. What is a common side effect of progestin-based Depo-Provera injection  Irregular or no periods  Bone thinning  Weight gain  Delayed ovulation  Injection site reactions(tenderness)  Depression 12. Understand how to read a pap report-ASCUS, LSIL, etc, what are high risk strains for HPV ASCUS LSIL High-risk HPV 16, 18, 31, 33, & 42 13. Polycystic Ovarian Syndrome – what is the pathology of this? Too much androgen causing hirsutism  Hirsutism: o Excess terminal body hair.  o Male distribution: Upper lip, Chin, Periareolar Linea alba  Acne vulgaris  Male-pattern alopecia  Early adrenarche (development of pubic hair, apocrine glands, and sebaceous glands)  Menstrual cycle irregularities o Oligomenorrhea(cycle length > 35 days) o Amenorrhea(cycles absent)In addition to infrequent menses, individuals often have other types of abnormal uterine bleeding(AUB) when they do bleed, which may include:  Heavy menstrual bleeding (HMB)  Prolonged menstrual bleeding (> 8 days)  Intermenstrual bleeding o Symptoms present for 3–6 months or 3 cycle lengths due to chronic anovulation 14. How would you counsel your lactating mother with regarding nutrition Increase vegetables, fruits, whole grains, and dairy Decrease added sugars, saturated fat, and sodium Achieve adequate dietary levels of the nutrients- calcium, vitamin D, potassium, and dietary fiber. Folate, iodine, and choline: dark green vegetables and beans, peas, and lentils, dairy products, eggs, seafood, eggs, meats Supplements: Continue pre-natal vitamins 15. Osteoporosis – when to order a DEXA scan; what is recommended for calcium and vitamin D supplementation Osteopenia is precursor for osteoporosis. Women over 65 or under with one or more risk factors should be screened with DEXA scan. 16. How to diagnosis a rectocele and cystocele Rectocele: A condition where weakened tissues in the pelvis cause the rectum to sag onto the vaginal wall. Pelvic exam Cystocele: Anterior vaginal exam. Pelvic exam. May cause UTIs. Pessary if surgery is not recommended. 17. What symptoms are prevalent for primary, secondary, and tertiary syphilis? Primary Chancre* = primary lesions Painless local infection Secondary 2-12 weeks after initial infection Fever headaches swelling, rash Full body involvement = hepatitis, nephrosis, etc.. Latent Period between secondary and tertiary Can be less than or more than a year Tertiary Occurs 1-30 years after  Can lead to Neurosyphilis > meningitis Cardiosyphillis, etc... Unit 3 (Wk 3 & 4) Pediatric Developmental management and milestones of infants, children, and adolescents -Bright Futures-Pocket Guide- Bright Futures Milestones and Anticipatory Guidance.pdf (aap.org) Developmental Stages for Children Social Language Gross Motor Fine Motor Developmental Stages for Children and Adolescents Tanner staging Females: Prepubertal – Tanner 1 Pubic hair – villus hair only Breasts – Elevation of papilla only Adrenarche and ovarian growth 8-11.5 years – Tanner 2 Pubic hair – sparse along the labia Breasts – Buds are palpable – first sign of puberty in females, areole are enlarged. Clitoral enlargement, labial pigmentation, growth of uterus 11.5-13 years – Tanner 3 (Puberty) Pubic Hair – coarse and curly Breast tissue – grows with no contour or separation Axillary hair, acne 12-15 – Tanner 4 Pubic Hair – adult hair that doesn’t spread to thigh Breasts – enlargement and areole form secondary mound on breast  Menarche and development of menses Over 15 years old – Tanner 5 Pubic hair – adult hair reaching the thigh Breasts – adult breast contours present, only papilla is raised Adult genitalia Males: Prepubertal – Tanner 1 Pubic Hair – villus only Genitalia – testes Over 15 – Tanner 5 Pubic hair – adult including thigh Genitalia – testes over 4.5cm, adult sized genitals Facial hair, increase in muscle mass Screening guidelines Universal: Hearing. Newborn: Bilirubin, blood, critical congenital disease. Selective: BO, Vision Screening tools and diagnostics Hearing Blood USG Sports physical – (Dunphy, 2023. pg 1406; Hollier, pg 1045) Marfan Syndrome: genetic disorder that changes the proteins that help make healthy connective tissue. Prevention-focused healthcare encounter to screen for conditions that may predispose a person to injury risk. Components: Health history, ROS, Physical Assessment, Health Promotion Education. Z02.5 - Encounter for examination for participation in sport Autism (Hollier, 703)  Neurodevelopmental disorder characterized by persistent social communication deficits and restricted or repetitive patterns of behaviors, interest or activities. Autism Spectrum Disorder (ASD) is present is early developmental period and causes varying degrees of functional impairment. People with ASD express a broad range of intelligence, from intellectually disable to gifted. Etiology most likely multi-factorial: Neurodiversity, brain development, genetic and epigenetic. - 4x more common in boys than girls. Girls frequently underdiagnosed. Clinician must specify severity based on degree of social communication impairment/severity. Level 1- Requiring support Level 2 – Requiring substantial support Level 3 – Requiring very substantial support Screening 18-24mo; if concerns referral to pediatric neurodevelopmental specialist. The goal of ASD treatment is maximize independence, functioning and quality of life. Family Theory Definition? Mental health Depression Screening Genetic Screening in Pregnancy Trisomy 21 -Down Syndrome Autosomal trisomy of chromosome 21  Most common chromosomal abnormality in live births, cause of intellectual disability  Range of dysmorphic features, congenital anomalies (e.g. congenital heart, otolaryngeal, gastrointestinal, hematologic, endocrine, urogenital defects)  Risk factors: Advanced maternal age, previous child with trisomy 21, parental consanguinity Dysmorphic features  Microcephaly, flat occiput, flattened face; epicanthal folds; flat nasal bridge; upward- slanting palpebral fissures; small nose/mouth; protuberant tongue; low-set/small ears; short neck, excessive nuchal skin; Brushfield spots (small white/grayish spots on periphery of iris); shortened extremities; big gap between first toe (hallux)  Others ⇒ single transverse palmar crease; short 5th finger with clinodactyly Most common issues for those affected with Down's Syndrome  Septal defects between atria  Duodenal atresia  Increased risk for acute lymphoblastic leukemia  Mental retardation and an increased risk for Alzheimer disease  Sterility in males Annual childhood wellness exams Social Behavioral Developmental Milestones Newborn screenings Screening: Bilirubin, blood, critical congenital disease Newborn Assessment: Immunizations –CDC; Hollier pg 121-123 Anticipatory guidance The first priority is to attend to the concerns of the parent. Injury prevention, Violence prevention, nutritional counseling and Fostering Optimal development. Overweight & obesity With approximately 17% of children being obese, many strategies for obesity prevention have been proposed Drinking juice should be avoided before one year of age, and, if given to older children, only 100% fruit juice should be provided in limited quantities. Eating disorders Anorexia nervosa is defined by the restriction of nutrient intake relative to requirements, which leads to significantly low body weight. Patients with this eating disorder will have a fear of gaining weight along and a distorted body image with the inability to comprehend the seriousness of their condition. Bulimia nervosa is a condition that occurs most commonly in adolescent females, characterized by indulgence in binge-eating, and inappropriate compensatory behaviors(Self-induced vomiting, Extreme physical activity, Fasting, Laxatives/Diuretic abuse) to prevent weight gain. Sexuality Substance use  ability to experience pleasure.  Risk of risky sexual behavior. Addiction- Substance Use Disorder (Dunphy, 2023. pg 1209) Risk Factors: Fam Hx of SUD, Fam rejection of sexual orientation, Hx Childhood sexual abuse, low school connectedness, peers with Hx delinquent behavior. CDC. By 12th Grade 1/3 Adolescents have tried ETHO ½ Marijuana 20% Rx- opioids Infant, children, and adolescent injuries Injuries remain the leading cause of death among children,  Infants need a rear-facing car safety seat until two years of age or until they reach the height or weight limit for the specific car seat. Children should then switch to a forward-facing car seat for as long as the seat allows, usually 65 to 80 lb (30 to 36 kg).  Infants should not be left alone on any high surface, and stairs should be secured by gates. Infant walkers should be discouraged because they provide no benefit and increase falls downstairs, even if stair gates are installed.  Children should never be unsupervised around cars, driveways, and streets.  Young children should wear bicycle helmets while riding tricycles or bicycles.  Having functioning smoke detectors and an escape plan decreases the risk of fire- and smoke- related deaths.  Water heaters should be set to a maximum of 120°F (49°C) to prevent scald burns.  Infants and young children should be watched closely around any body of water, including water in bathtubs and toilets, to prevent drowning. Swimming pools and spas should be completely fenced with a self-closing, self-latching gate.  Window locks, screens, or limited-opening windows decrease injury and death from falling.  Parents or caregivers should also anchor furniture to a wall to prevent heavy pieces from toppling over.  Young children should be closely always supervised. Small objects are a choking hazard, especially for children younger than three years. Latex balloons, round objects, and food can cause life-threatening airway obstruction. Long strings and cords can strangle children.  Firearms should be kept unloaded and locked. Men’s Health 1. Prostate Screening a. Guidelines: Prostate screening generally involves the PSA test and digital rectal exam (DRE), typically recommended starting at age 50, or earlier if there are additional risk factors. Rarely indicated in young patients without any urinary complaints related to the prostate. Older patients with BPH symptoms prostate exam are indicated. b. Risk Factors: Higher risk in men over 50, African American men, and those with a family history.  c. Diagnostics: PSA levels, DRE, and if needed, biopsy. d. Referral and Follow-up: Patients with elevated PSA or abnormal DRE results should be referred to a urologist. e. Assessment Findings: Common symptoms include urinary difficulty, pain, or erectile dysfunction. 2. Testicular Cancer a. Screening: Self-exams are essential for early detection, especially for men between 15-35 years old. b. Risk Factors: Cryptorchidism, family history, and genetic predispositions. c. Assessment Findings: Presence of a painless lump, swelling, or heaviness in the scrotum. d. Treatment: Surgery, chemotherapy, and/or radiation. e. Referral and Follow-up: Early referral to oncology or urology is crucial for effective treatment. 3. Cryptorchidism a. Risk Factors: Premature birth, low birth weight, family history, hypospadias, prenatal exposure to endocrine disruptors such as pesticides. Maternal smoking or diabetes, high maternal alpha-fetoprotein levels, Kleinfelter syndrome. b. Assessment: Absence of one or both testes upon palpation of the scrotum, One or both testicles in a location other than the scrotum. Perform XM with warm hands. Infant examination: supine, frog-leg position, or sitting on parents' lap. Older child examination: supine or sitting upright cross-legged position. Most patients with cryptorchism have an inguinal hernia. c. Referral: referred for urologic evaluation, if testicle (s) not descent by the age of six months or for boys, older than six months (corrected for gestational age) with possibly possible newly diagnosed (acquire) cryptorchidism. Multiple specialist consultation for evaluation of possible disorders of sex development for all phenotypic newborn boys with bilateral nonpalpable testes. 4. Inguinal Hernia a. Risk Factors: Family history, chronic cough, obesity, and physical strain. b. Assessment: A noticeable bulge in the groin area, discomfort, especially when bending or lifting. 5. Testicular Torsion a. Subjective and Objective Findings: Acute onset of severe testicular pain, nausea, and scrotal swelling.  b. Treatment: This is a surgical emergency requiring immediate intervention to save the testicle. 6. Erectile Dysfunction a. Screening: Identifying associated risk factors, including cardiovascular disease, diabetes, and lifestyle factors. b. Risk Factors: Smoking, obesity, lack of physical activity, and psychological stressors. Sexually Transmitted and Genital Infections  Gonorrhea - Neisseria gonorrhoeae a. Testing: NAAT First urine of the day, vaginal/cervical swab b. Treatment: IM Ceftriaxone single dose c. Signs and Symptoms: Male symptoms of gonorrhea infection include: Painful urination. Pus-like discharge from the tip of the penis. Pain or swelling in one testicle  HPV a. Testing: Mostly visually found, many men are asymptomatic b. Treatment: Usually resolve in a year Patient applied Imiquimond 3.75% or 5% cream OR Podofilox 0.5% solution or gel, OR Sinecatechins 15% ointment OR Provider can perform Cryotherapy with liquid nitrogen or cyroprobe c. Signs and Symptoms: Most men asymptomatic  Yeast a. Testing: b. Treatment: c. Signs and Symptoms: itchy or burning sensation in vagina and vulva. A thick, white vaginal discharge with the consistency of cottage cheese. Redness, swelling and or white patches vagina and vulva. Small cuts or tiny cracks in the skin because of fragile skin in the area, burning in urination, pain during sex.  Chlamydia,  a. Testing: NAATS, First urine of the day, vaginal/cervical swab b. Treatment: Doxycycline 100 mg orally 2 times/day for 7 days Alternative Regimens: Azithromycin 1 g orally in a single dose OR Levofloxacin 500 mg orally once daily for 7 day c. Signs and Symptoms: Chlamydia is the most common STI, highest rates under age 25, often asymptomatic, screen under age 25 annually, new sex partner, more than 1 partner, recent partner with STI. If symptomatic: Burning upon urination, pain during sex, lower belly pain, abnormal, smelly discharge, bleeding between periods  Herpes a. Testing: PCR assays for HSV DNA or IGG testing which is often included in an STI panel b. Treatment: PRIMARY treatment: Acyclovir 400mg TID 7-10 days *dose can vary OR Famciclovir BID x 1 day 6 hours post symptoms. Recurrence: Famciclovir BID x 1 year. SUPPRESIVE – Acyclovir 400mg BID or Valacyclovir 500mg QD or 1gm c. Signs and Symptoms: Many people have no symptoms while shedding the virus  Bacterial Vaginosis - Gardnerella Vaginalis a. Testing: To be diagnosed, need at least three clinical criteria: Thin white discharge, Clue cells (seen on Wet Mount Test when Potassium hydroxide (KOH) is added), Ph>4.5, Fishy odor with the “whiff test” b. Treatment: Metronidazole 500mg orally BID for 7 days, OR metronidazole gel 0.75% one full applicator (5g) intravaginally QD 5 days OR Clindamycin cream 2% one fill applicator (5g) intravaginally at bedtime for 5 days c. Signs and Symptoms:  Trichomonas  a. Testing: Gold standard – Affirm (checks for BV, yeast, trich), wet mount - > low sensitivity, Gold standard – Affirm (checks for BV, yeast, trich) b. Treatment: Metronidazole 2g single dose OR tinidazole 2g single dose OR Metronidazole 500mg BID x 7 days c. Signs and Symptoms: Vaginal discharge that is thin, frothy, and has a foul or fishy smell , itching or burning of the genitals or inner thighs, pain or discomfort when urinating or during sex , redness or swelling of the vulva or labia , symptoms can appear within 5 to 28 days of exposure, but some people don't develop symptoms until much later. Most people with trich don't have any symptoms.  HIV HIV can cause a variety of symptoms, but some people may not have any symptoms at all in the early stages: Fever and chills Night sweats Muscle aches Rash Sore throat Fatigue Swollen lymph nodes Mouth ulcers Diarrhea that lasts for more than a week Sores of the mouth, anus, or genitals Symptoms can vary depending on the person and the stage of the disease. Some people may develop flu-like symptoms 2 to 4 weeks after getting the virus.  The only way to know for sure if you have HIV is to get tested. A lab can usually detect HIV 18 to 45 days after exposure with an antigen/antibody test on blood from a vein. A rapid antigen/antibody test can also be done with a finger stick, but it can take 18 to 90 days after exposure.  HIV can be treated with antiretroviral therapy (ART), which includes pills and shots. The goal of treatment is to have an undetectable viral load, which means the level of HIV virus in your body is low enough to not be detected by a test.  If left untreated, HIV typically turns into AIDS in about 8 to 10 years. Most people with HIV live long and healthy lives if they get ART as soon as possible and stay on PID Pelvic inflammatory disease (PID) is a bacterial infection of the reproductive organs that can be diagnosed and treated by a medical professional: Symptoms PID can cause pelvic pain, fever, chills, vaginal discharge, nausea and vomiting, and pain during urination and sex. Diagnosis A medical professional can diagnose PID with a pelvic exam and by assessing symptoms. There isn't a single test to diagnose PID, but tests can help rule out other causes. Treatment PID is usually treated with antibiotics, such as ceftriaxone, doxycycline, and metronidazole. A course of antibiotics can clear up PID within 10 to 14 days. If PID is left untreated, it can lead to chronic pelvic pain and infertility. Prevention Practicing safe sex and not having multiple sexual partners can help prevent PID. If PID is caused by a sexually transmitted infection (STI), your sexual partner should also get tested and treate  PCOS: Common feature is hypersecretion of androgens. In adult women 2 of 3 must be present for diagnosis: Hyperandrogenism Oligo – ovulation or anovulation Polycystic ovaries on ultrasound Polycystic ovary syndrome (PCOS) is a chronic condition that can be diagnosed and treated by a medical professional. Diagnosis is based on a combination of symptoms, blood tests, and an ultrasound. Treatments can include lifestyle changes, medications, or both. Irregular menstrual periods, excess hair growth, acne, obesity Lifestyle changes, medications, or both Tests Blood tests, pelvic ultrasound Treatment Hormonal birth control, metformin, or other medications Lifestyle changes Eat a high-fiber, low-sugar diet, exercise regularly, and eat four to six small meals per day Monitoring Regular monitoring of blood pressure, body mass index, and metabolic parameters Women’s Health 1. Menstrual Health a. Amenorrhea and Irregular Vaginal Bleeding: Primary or secondary amenorrhea; bleeding irregularities often point to underlying hormonal imbalances or structural issues.  Primary Amenorrhea: Complete absence of a menstrual period by the age of 16 in a person with normal sexual development.  Secondary Amenorrhea: The sudden cessation of menstrual periods for several months in a person who previously had regular cycles PCOS is most common cause of Secondary Amenorrhea b. Menstrual Cycle: Phases of the cycle—menstrual, follicular, ovulatory, and luteal phases—each with its hormonal shifts. The rise and fall of your hormones trigger the steps in your menstrual cycle. Your hormones cause the organs of your reproductive tract to respond in certain ways. The specific events that occur during your menstrual cycle are:  The menses phase: This phase begins on the first day of your period. It's when the lining of your uterus sheds through your vagina if pregnancy hasn’t occurred. Most people bleed for three to five days, but a period lasting only three days to as many as seven days is usually not a cause for worry.  The follicular phase: Less consistent phase of the cycle. This phase begins on the day you get your period and ends at ovulation (it overlaps with the menses phase and ends when you ovulate). During this time, the level of the hormone estrogen rises, which causes the lining of your uterus (the endometrium) to grow and thicken. In addition, another hormone — follicle-stimulating hormone (FSH) — causes follicles in your ovaries to grow. During days 10 to 14, one of the developing follicles will form a fully mature egg (ovum). The follicular phase of the menstrual cycle is considered less consistent compared to the luteal phase, which tends to be relatively stable in length for most women; meaning the length of the follicular phase can vary more from cycle to cycle while the luteal phase usually stays around 14 days. Ovulation: This phase occurs roughly at about day 14 in a 28-day menstrual cycle. A sudden increase in another hormone — luteinizing hormone (LH) — causes your ovary to release its egg. This event is ovulation.  The luteal (secretory) phase: This phase lasts from about day 15 to day 28. Your egg leaves your ovary and begins to travel through your fallopian tubes to your uterus. The level of the hormone progesterone rises to help prepare your uterine lining for pregnancy. If the egg becomes fertilized by sperm and attaches itself to your uterine wall (implantation), you become pregnant. If pregnancy doesn’t occur, estrogen and progesterone levels drop and the thick lining of your uterus sheds during your period. 2. PCOS a. Diagnosis: Based on symptoms like irregular periods, hyperandrogenism, and polycystic ovaries on ultrasound. Common feature is hypersecretion of androgens. In adult women 2 of 3 must be present for diagnosis: Hyperandrogenism, Oligoovulation or anovulation, Polycystic ovaries on ultrasound b. Management: Lifestyle adjustments, hormonal contraceptives, and insulin- sensitizing medications. 3. Contraception: Discussion of options from hormonal (pills, IUDs) to barrier methods, benefits, and risks. 4. Breast Cancer Screening: Mammograms and breast self-exams; follow current guidelines for age and risk factors. Manual exam in every visit. 40 and over every two years for mammograms, but also encourage self exam and perform manual exam at every wellness visit 5. Lactation and Postpartum Care a. Mastitis: Recognize symptoms like breast pain, redness, and fever; treat with antibiotics. b. Breastfeeding Support: Guidelines on feeding frequency, latch techniques, and troubleshooting. 6. Preeclampsia: Management of blood pressure, regular monitoring for proteinuria, and signs of worsening condition. 7. Labor: Stages and physiological changes; recognizing signs of labor onset. 8. RhoGAM: Administration to Rh-negative mothers to prevent alloimmunization. 9. UTI: Prevention, common symptoms like dysuria, frequency, and urgency, and appropriate antibiotic treatment. 10. Care of the Pregnant Patient a. Gestational Diabetes: Screening at 24-28 weeks, management with diet, exercise, and insulin if needed. Pregnancy Complications: 10 - 20% of pregnant patients. Early Pregnancy loss: Within the first 13 weeks of pregnancy, miscarriage spontaneous abortion (SAB). If suspected loss referral to OBGYN or midwife. After 13 weeks GYN surgeon for possible intervention. Beta HCG after SAB follow levels until 0. Advice patient not to try to conceive until results are 0. 80% loss happens in first semester 1/5 women will miscarriage at some point. Complete AB - at some point that may actually be much higher as many women may have a late period and even a positive home pregnancy test, but we'll go onto Miss Perry shortly after and assume they were just having a late period and a false positive pregnancy test completed. Ectopic pregnancies- Sever abdominal pain and bleeding between week 5- 8. Emergency referral. Gestational trophoblastic disease (GTD). Molar pregnancy, intermitting spotting, grossly enlarged uterus, extreme N/V, requires D&C referred to GYN, pt not to become pregnant withing 6 months, suspect of reoccurrence with next pregnancy. Placenta previa. provided consult is recommended. 1 in 4 women may experience bleeding during pregnancy. Common during intercourse in the first half of pregnancy. Light bleeding with no pain least risk of SAB. R/O any immediate or life- threatening concerns more than 2 pads per hour for more than 2 hours evaluate if pt is hemodynamically stable and referred as needed. Beta HCG – a test that uses a number to associate gestational age. May repeat every 2-3 days, an increase in HCG levels indicates a viable pregnancy. Helpful tool in evaluating early bleeding specially before 6 weeks. Ultrasound Gestetional sac can be seen as early as 4-5 weeks, yolk sac been seen at 5 weeks. Fetal heart beat and cardiac activity after 6-7 weeks.  Second & Third Trimester Bleeding: Emphasizes no vaginal exams and includes necessary lab tests like CBC and Type and Screen for Rh-negative cases.  Preterm Labor and Birth (Chapter 30): Identified as a leading cause of neonatal mortality with social and racial disparities impacting risk. Prevention includes nutrition, substance cessation, and adequate spacing between pregnancies.  Hypertensive Disorders (Chapter 31): Covers chronic hypertension, gestational hypertension, preeclampsia, and eclampsia, stressing accurate blood pressure measurement and early screening. Key symptoms include visual disturbances, RUQ pain, and edema.  Gestational Diabetes (Chapter 32): Discusses screening protocols at 24-28 weeks and includes a glucose tolerance test. Management in primary care highlights the adverse outcomes and weight gain recommendations for obese patients.  Hyperemesis Gravidarum (Chapter 35): Defined by symptoms like excessive nausea, likely due to high hCG, estrogen, and thyroid levels. Management strategies are outlined, including IV fluids as needed.  Hematologic & Thromboembolic Disorders (Chapter 43): Focuses on anemia, blood type issues, and specific conditions like Sickle Cell Disease and Thalassemia. Thrombocytopenia and folate deficiency are also noted.  Dermatologic Disorders (Chapter 49): Common conditions include PUPP, PG, and ICP, with reference to pre-existing conditions that may flare during pregnancy.  Group B Strep (GBS) (Chapter 50): Screening recommendations and treatment during labor to prevent neonatal mortality are discussed.  STIs in Pregnancy (Chapter 51): Regular screening and management, emphasizing treatment protocols and prevention strategies.  Medications During Pregnancy Depression: Selective serotonin reuptake inhibitors (SSRIs). These are often the first-line treatment for depression during pregnancy because they have minimal side effects and have been studied extensively. Some examples include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). However, SSRIs can cause adaptation syndrome in newborns, which is similar to withdrawal symptoms Diabetes: From the ADA: Insulin is the traditional first-choice drug for blood glucose control during pregnancy because it is the most effective for fine-tuning blood glucose and it doesn’t cross the placenta. Therefore, it is safe for the baby. Insulin can be injected with a syringe, an insulin pen, or through an insulin pump. All three methods are safe for pregnant women. High blood pressure: Studies show that three blood pressure medications are generally safe for treating high blood pressure in most pregnancies:  Methyldopa has the longest and most reassuring track record of safety in pregnancy. This medication relaxes the blood vessels, which lowers blood pressure.  Labetalol slows your heart rate, which lets your heart relax.  Nifedipine only needs to be taken once a day in the extended-release form. a. b. Pre- and Post-Pregnancy Follow-up: Importance of regular check-ups to monitor both maternal and fetal health. 11. Ectopic Pregnancy: Symptoms: Abdominal pain, vaginal bleeding, amenorrhea; may also include dizziness, fever, and syncope. 50% of patients that have an ectopic pregnancy will have: Abdominal pain, vaginal bleeding, amenorrhea. May also present with symptoms common to early pregnancy (nausea, breast fullness) Dizziness, fever, weakness, flu like symptoms, vomiting, syncope, cardiac arrest. Any of the following signs and symptoms are an EMERGENCY Abdominal rigidity, involuntary guarding, severe tenderness, evidence of hypovolemic shock (examples – orthostatic blood pressure changes, tachycardia) Diagnostics: Ultrasound imaging to visually determine location and serial quantitative beta-hCG. Treatment: Methotrexate intramuscular for non-ruptured hemodynamically stable cases. THIS IS NOT FDA APPROVED but has been endorsed by the ACOG, it avoids surgery, hcg values must be less than 1500. Surgical intervention if unstable. 12. Group B Strep Screening and Treatment: Screening at 35-37 weeks gestation; antibiotics during labor for positive cases. 13. Naegele’s Rule: Method to estimate the due date—add one year, subtract three months to the LMP and add seven days and a year. 14. Genetic Screening: Understanding indications and types, such as noninvasive prenatal testing (NIPT). 15. Family Planning: Counseling on options for future pregnancies and spacing. 16. Management of Pregnant Patients in Primary Care: Addressing primary care concerns while balancing pregnancy-related health needs. No live vaccines MMR, Varicella, Shingles, live flu.  Screening Tests: Various tests are conducted based on gestational age, including first-trimester screening, cell-free DNA testing, and Group B strep testing.  Gestational Diabetes: Diagnosed with glucose tolerance tests; managed with blood glucose monitoring and possibly insulin.  Puerperium: Postpartum period where the body adjusts and returns to its non- pregnant state, which includes uterine involution and gradual muscle tone recovery.