In the time of COVID…

ABSTRACT

JAANP Fellow Dr. Leslie-Faith Morritt Taub, NYU Adult-Gerontology Primary Care Program Director, describes the emotional, political, and social impact of COVID-19 on one graduating cohort of nurse practitioner (NP) students at New York University and one incoming cohort of students. Through the lens of a seasoned professor she describes the changes to her teaching methods because she leads these students through the course work and clinical work required to take on the role of the NP in the midst of a global pandemic in the heart of New York City.

The use of large healthcare data sets in pursuit of a clinical question

The use of large healthcare databases may be of interest to nurse practitioners who wish to answer clinical questions. This column will provide information about access to selected large healthcare databases, requirements for statistical software, and the skills required to utilize these databases.

Monitoring for and preventing the long-term sequelae of bariatric surgery

PURPOSE

To present a case study of a patient with multiple comorbid diseases who undergoes bariatric surgery.

DATA SOURCES

Recent clinical and research articles, bariatric professional society guidelines, and government sources were culled to provide recommendations for the care of the person who chooses bariatric surgery as the treatment for the comorbid conditions of obesity, type 2 diabetes, obstructive sleep apnea, hypertension, and hyperlipidemia.

CONCLUSIONS

As surgical management of obesity becomes more prevalent in an attempt to improve health-related quality of life, reduce mortality, and address the comorbidities that are prevalent in this population, nurse practitioners (NPs) need to understand what long-term management these patients will require.

IMPLICATIONS FOR PRACTICE

NPs are primary care providers for patients with chronic diseases. It is likely that they will make referrals for this surgery and follow the patient after the procedure at some point. Knowledge of what the procedures involve, what changes to expect in the comorbid conditions, and what long-term monitoring and treatment should take place in the care of these patients will provide these patients with optimal care.

If pelvic inflammatory disease is suspected empiric treatment should be initiated

PURPOSE

To assist the nurse practitioner (NP) to make a rapid diagnosis and develop a treatment plan for pelvic inflammatory disease (PID) in order to assist women to promote their health and reduce their risk of the unnecessary sequelae of infertility, tubal damage, and the possibility of a subsequent ectopic pregnancy.

DATA SOURCES

Centers for Disease Control guidelines and recent clinical practice literature were searched to provide guidance on how to diagnose, treat, and educate the patient with PID.

CONCLUSIONS

The incidence of PID is approximately 1 million women annually. PID is diagnosed in 1%-2% of sexually active women under the age of 25, with a higher incidence in African American women. Women with PID produce over 2 million emergency room and office visits and incur health care costs of over 4 billion dollars annually.

IMPLICATIONS FOR PRACTICE

PID is associated with chronic pelvic pain, infertility, and ectopic pregnancy. Symptoms can range from subtle and indolent to acute and fulminant. Having a high index of suspicion for the diagnosis will assist the NP in treating patients with this disease. Empiric antibiotic therapy should be initiated in all women at risk who have uterine, adnexal, or cervical motion tenderness on a bimanual exam with no other explanation for these symptoms. Without response to treatment, if the diagnosis is unclear, or if a surgical emergency is being considered, prompt referral to a specialist is warranted. Secondary preventive measures are discussed.

Sleep Disorders, Glucose Regulation, and Type 2 Diabetes

Recent epidemiological, biological, and behavioral evidence suggests that sleep disorders may contribute to the development of diabetes; conversely, diabetes itself may contribute to sleep disorders. Sleep appears to moderate the neurohormones that regulate blood glucose. Sleep deprivation and sleep disorders contribute to pathophysiological changes associated with the development of type 2 diabetes. In people who already have diabetes, sleep deprivation contributes to elevations of hemoglobin A1c. Symptoms that occur as a result of diabetes, such as nocturia and neuropathic pain, may in turn contribute to sleep disturbance and exacerbate sleep deprivation. The purposes of this article are to examine the scientific basis for the associations between diabetes and sleep, identify gaps in the understanding of the empirical underpinnings of these relationships, and propose directions for future research.

A case study of an older adult with severe anemia refusing blood transfusion

PURPOSE

To discuss the diagnosis and treatment of severe anemia in an older adult who presents the challenge of declining blood transfusion in a real-world scenario where critical thinking, evidence-based care, and collaboration with other providers must come together to serve this patient's unique needs.

DATA SOURCES

Extensive review of the scientific literature on anemia and the situation in which a patient refuses blood transfusion presented in a case study format.

CONCLUSIONS

A thorough physical assessment, complete health history, and appropriate diagnostic workup should be used to distinguish the normal effects of senescence from the signs and symptoms of anemia. Common conditions that cause anemia in the elderly include chronic disease, iron deficiency, and gastrointestinal bleeding. These conditions may result in profound anemia. The challenge can be compounded when, because of religious tenets, a patient does not accept a blood transfusion. This case study challenges nurse practitioners to apply knowledge, seek guidance, and make appropriate referrals to care for a patient in order to render care within the parameters of the patient's belief system.

IMPLICATIONS FOR PRACTICE

The astute primary care provider recognizes that anemia is not an expected physiological change associated with aging but a manifestation of an underlying disease process. Fatigue, weakness, and dyspnea are all symptoms of anemia that may be overlooked and attributed to the aging process. Further, in keeping with the principles of autonomy and self-determination, it is the clinician's duty to work with all patients to restore them to a state of optimal health while respecting deeply held spiritual beliefs.

Concordance of provider recommendations with American Diabetes Association's Guidelines

PURPOSE

To determine if selected client characteristics were factors influencing the provision of provider advice for diet, exercise, smoking cessation, alcohol cessation, eye and foot care, and influenza and pneumonia vaccine for those told by a provider that they had diabetes.

DATA SOURCES

Data from the 2001 National Health Interview Survey were used in a secondary analysis to answer the research question. This study used a subsample who self-reported having provider-diagnosed diabetes; the subsample comprised 2287 unweighted subjects that, when weighted, represent 6.38% of the civilian noninstitutionalized individuals with diabetes in the United States.

CONCLUSIONS

This study suggests that many patients are not receiving all the eight processes of care studied, particularly those with new onset diabetes, elders, black people, and Hispanics.

IMPLICATIONS FOR PRACTICE

This study suggests that the present paradigm is not early prevention but treatment of established disease. Changes in entrenched thinking about clinical care need to be addressed. Patients with diabetes need to have an awareness that there is a standard of optimal care, and they should be encouraged to seek those who provide this care. Further, system changes may be required to address changes that are not easily made at the provider level.