Using Diagnostics in the Clinic

Out of all the diagnostics tools used for our patients in my clinical practice setting, the following five diagnostic tools are the tools that are frequently used and observed. I will discuss the indication of each of the tools and its pros and cons. Please see table below.

  Pros Cons Indications
Electrocardiogram (ECG) It is cost effective, non-invasive, and easy to perform. (Sharma et al., 2011) Not all heart abnormalities may be detected through ECG.

Rates of false positives on screening could be as high as 40%. (Stein, 2010)

It is used to rule out myocardial infarction, arrhythmias, and many other heart problems. (Colyar, 2015)
Pregnancy test It is accurate if the test is done at the right timing (after the first day of a woman’s missed period). (Heidt, 2014) Not always accurate because early urine pregnancy tests may result in false negative result. (Heidt, 2014) It is used to confirm pregnancy. Urine is being tested to confirm a diagnosis. (Cash & Glass, 2014)
Dipstick urinalysis It is cost-effective and convenient to use that provides a rapid test result. (Nabili, 2015) It is not accurate when it comes to checking for infection if a patient does not know how to catch proper mid-stream urine. (Buttaro et al., 2013) It is a test that evaluates the urine to detect disorders such as urinary tract infection, diabetes, and kidney problems. (Buttaro et al., 2013)
Monofilament test Inexpensive, easy-to-use, and portable. (Dros et al., 2009) It can be unreliable at times especially if the patient does not know how to properly follow the instruction of when to say he/she felt the sensation of the microfilament and when he/she did not feel it. (Dros et al., 2009) It is a test to assess the loss of protective sensation and to diagnose peripheral neuropathy especially to patients diagnosed with diabetes. (Dros et al., 2009)
Rapid Fecal Occult Blood Test (FOBT) It is cost-effective and simple while it produces a rapid result. It also provides an accurate test result when the procedure is done right. (American Cancer Society, 2016) It may produce a false positive or false negative result when the procedure is not done right such as when the provider did not fully insert the finger into the anus to get enough sample or when the provider caused the anus to bleed when finger is inserted into it. (American Cancer Society, 2016) It is used to determine human hemoglobin in feces to diagnose GI bleeding, colorectal carcinoma, colon polyps, diverticulitis, and ulcerative colitis. (Teco Diagnostics, 2012)

References:

American Cancer Society. (2016). Colorectal cancer prevention and early detection. Retrieved from http://www.cancer.org/acs/groups/cid/documents/webcontent/003170-pdf.pdf

Buttaro, T.M., Trybulski, J., Bailey, P.P., Sandberg-Cook, J. (2013). Primary care: A collaborative practice. (4th ed.). St. Louis, MO: Elsevier Mosby

Cash J.C., & Glass, C.A. (2014). Family practice guidelines. (3rd ed.). New York, NY: Springer Publishing

Colyar, M. (2015). Advanced practice nursing procedures. Philadelphia, PA: F.A. Davis Company

Dros, J., Wewerinke, A., Bindels, P. J., & van Weert, H. C. (2009). Accuracy of monofilament testing to diagnose peripheral neuropathy: A systematic review. Annals of Family Medicine7(6), 555–558. http://doi.org/10.1370/afm.1016

Heidt, A. (2014). Early pregnancy tests. Retrieved from http://www.everydayfamily.com/early-pregnancy-tests/

Nabili, S. (2015). Pros and cons of dipstick. Retrieved from http://www.emedicinehealth.com/urinalysis/page4_em.htm

Sharma, S., Ghani,S., & Papadakis, M. (2011). ESC criteria for ECG interpretation in athletes: Better but not perfect. Heart, 97, 1540-1541. Doi: 10.1136/heartjnl-2011-300400

Stein, J. (2010). The pros and cons of heart abnormality screening for athletes. Los Angeles Times. Retrieved from http://articles.latimes.com/2010/oct/01/news/la-heb-ecg-screening-20101002

Teco Diagnostics. (2012). Rapid fecal occult blood test. Retrieved from http://www.tecodiagnostics.com/wp-content/uploads/2012/07/F7351.pdf

“Using the Evidence” in Practice

In my clinical setting, I have observed our medical director used the Eight Joint National Committee (JNC 8) in diagnosing and managing high blood pressure. The medical director gave me a hard copy of the JNC 8 recommendations, but at the same time, I was given a privileged to study more of the guidelines in further details by accessing it online. I accessed it at National Guideline Clearinghouse website in which it provided me detailed recommendations of when to initiate treatment to a certain population (non-black or black population), certain age group (over 18 years and over or less than 60 years old), and to patient with different kinds of comorbidities (chronic kidney disease, diabetes mellitus, congestive heart failure, coronary artery disease, or history of stroke). (National Guideline Clearinghouse, 2014). To apply it in practice, one example I can cite is a 51-year-old male black patient who has a blood pressure of 158/90. With his blood pressure, he is obviously diagnosed with hypertension and treatment should be initiated. Using the JNC 8 recommendations, the patient should be started with either a calcium channel blockers or a thiazide medication to manage his hypertension. (National Guideline Clearinghouse, 2014). I find JNC 8 recommendations very straightforward, easy to follow and understand. In my part as a clinician, the thing I am responsible for knowing is his blood pressure, age, race, and comorbidities (if any) by doing a thorough history and assessment. From the information I gathered combined with the most up to date JNC 8 recommendations, I would be able to treat my patient correctly and safely. I believe that JNC 8 recommendations’ goal is nothing but a manageable blood pressure to everybody. Its main goal is to prevent future cardiovascular, renal, pulmonary or renal complications. Overall, national guidelines like JNC 8 are being followed at my clinical setting at all times as their way of mastering their mission of health care that is safe, high quality, and effective using evidence-based practices.

Reference:

National Guideline Clearinghouse. (2014). Evidence-based guideline for the management of high blood pressure in adults. Report from the panel member appointed to the Eight Joint National Committee (JNC 8). Retrieved from https://www.guideline.gov/summaries/summary/48192/2014-evidencebased-guideline-for-the-management-of-high-blood-pressure-in-adults-Report-from-the-panel-members-appointed-to-the-Eighth-Joint-National-Committee-JNC-8

 

Getting Started

As I remain in my journey in finishing my hours for clinical practicum, I continue to do my preceptorship with my previous preceptor from last semester. I feel that I am in a fortunate position because continuing my clinical hours with the same person facilitates trust, rapport, and confidence. The clinical hour requirements for NURS 679L (240-270 hours) are more than NURS 678L (90-120 hours). NURS 678L experience was very unforgettable from day one to the last. On the first day, I felt like I am starting a new job because of new faces, new place, new processes, new workplace, and a different set of diverse patients. If I am asked to describe my experiences from last clinical practicum, I would say that is was a SUPERB one. I gain a lot of knowledge from everybody in the clinic: from doctors, physician assistants, nurse practitioners, medical assistants, and patients. I would say that NURS 678L helped me develop more of my critical thinking skills and rational about patient’s diagnosis broadmindedly and by thinking outside the box. Some of the diagnosis, procedures, and medications that I have been familiar with during NURS 678L are the treatment of sexually transmitted infections, acute pain management, anemia management, upper and lower respiratory infections management, diabetes management, and hypertension management. This semester, I am assigned to come into the clinic twice weekly to develop more of the skills and knowledge in the FNP Formulary. During the week, I have the chance to precept with a Doctor of Osteopathy and a Nurse Practitioner who focuses on primary care, women’s health, and pediatrics. My learning goals for NURS 679L are: to fully develop my critical thinking skills by using evidence-based studies for a safe clinical practice, to acquire more clinical skills performed in the primary care settings, and to be more experienced in diagnosing patient’s disease accurately. As mentioned, I have two preceptors in the clinic for this semester, some of the thoughts that came to my mind are not two preceptors are the same. Comparing them would not help, but appreciating each other’s strengths will better help me understand and learn new things. Conclusively, I know I just started a new semester but my thought about starting back to my first day of clinical practicum made me feel so excited. Excited not just because I am few more steps in finishing the program, but also I know that this is another learning experience for me that not everybody is given a chance of doing such.

Teamwork and Interprofessional Collaboration

The team at my clinical setting has a collaborative model of care. They have a combined practice among the physician, behavioral health psychologist, obstetrician, physician assistants, medical assistants, and front staffs. The power is manifested from the very top, which is the medical director. In my opinion and based on my observation, the team is working well together. One example that I can cite is that we had a patient in the clinic that verbalized in Spanish that he was depressed and has little interest or pleasure in doing things to the medical assistant. The medical assistant then reported patient’s verbalization of little interest to usual activities of life to the primary physician. Using the information given by the medical assistant, the primary physician further assessed the patient for depression. The PHQ-9 tool was used and he scored 12, which deemed to have moderate depression. In this case, the primary physician referred the patient to the behavioral health department of the clinic. The report was given to the psychologist about the assessment of the physician upon health history taking and patient’s behavior during the interview. The psychologist then addressed the depression and provided some counseling to address patient’s problem before it got worse. The given scenario is a good example of collaboration within the clinic for a more effective primary care. Regardless of wherever one role is in the team, each person in the team is important for an effective interprofessional collaboration. Collaboration in the practice setting encourages efficient health maintenance, disease prevention, and counseling in a timely manner.

Ethical Practice

Last week, I was given a chance to meet an 82-year old female patient who was accompanied by her husband, and was in the clinic for a narcotic medication refill. She said she has been suffering from moderate to severe pain on her dislocated right shoulder and needing medication refill to manage the pain. The doctor and I found out that she came back to the clinic a few weeks earlier than usual for the narcotic medication refill, which means she has finished her narcotic medications too soon. When interviewed in the clinic, the patient is calm while the husband is disheveled, aggressive and too demanding in asking the doctor for the narcotic medication refill. The policy in the clinic is that once a patient is on narcotic medication and needing regular refills of it, the patient should be referred to a pain management doctor to help in the medication dose management and especially for the pain management. All these information were explained to the patient and the husband but the husband continued to be pushy in getting more than one month of medication supply and wanting more than 30 pills per bottle refills on the narcotic medication. While on the other hand, the patient is calm about the doctor’s statement and was agreeing with the doctor’s recommendation. As a clinician, I assessed that the patient is in sound mind and body, able to comprehend and decide for her own. Though there were some contradictions on the part of the husband not wanting the referral to be done, the patient agreed to be seen by the pain specialist and understood the policy about the narcotic prescription. In this scenario, the doctor and I observed patient autonomy by going forward in sending the referral for pain management consultation to be able to further address patient’s pain issue, regardless of patient’s husband’s disagreement to it.

Theoretical Framework and EBP

I was able to meet a female, 41-year old Hispanic patient in the clinic last week who was diagnosed with hypothyroidism, borderline diabetes, obesity, and hypertriglyceridemia. In this discussion post, I want to focus on her triglycerides level. On June 24, 2015, she had a laboratory test to check her lipid panel. The result was 888 mg/dl triglycerides. This made the doctor give her all the education about having high triglycerides including its risks as well as medications to manage the triglycerides. She was asked to come back to the clinic in 3 to 4 months to re-check her lipid panel. In October of the same year, her triglycerides went down within normal level of 137 mg/dl. She did her lipid panel again in February 2016 and her triglycerides level was 149 mg/dl. I will incorporate this patient’s situation to the transtheoretical model of behavior change. This theoretical framework assesses an individual’s readiness to act on a new healthier behavior. It provides strategies or processes of change to guide the individual through the stages of change to action and maintenance. The stages include precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska & Velicer, 1997). Obviously, she is not in the precontemplation anymore. It is because precontemplation is the stage wherein a person is not aware of the problematic behavior. Before her lipid panel was checked in June, she was not aware that her lifestyle was not helping her overall healthy state. The next stage is contemplation. This stage was when she started a healthier behavior. Her doctor took the advantage of this phase of her behavior change by making the patient aware of all the pros of changing to a healthier lifestyle. The treatment plan that her doctor has made for her revolved around focusing on the positive aspect of changing the behavior while disregarding the negatives. She successfully passed this stage as evidenced by a normal level of triglyceride on October 2015 and February 2016. The next stage is the preparation phase. After all the education and information about the dangers of having a high triglycerides level, the patient is ready to start taking action. She took small steps such as doing regular exercise and eating healthy balanced diet. Her doctor’s treatment plan in this stage was based on the fact that the patient is willing to make the steps to a healthier being. The treatment plan focused on getting support from patient’s family and friends because this stage is about the more support the patient gets, the more likely she is going to keep progressing. I believe that the next stage is where Mrs. T. N. is at the moment. It is the action phase of behavior change. Action stage is where a person has changed his or her behavior and is working hard to keep moving ahead. On her last clinic visit, she verbalized that she was getting used to the routine of living a healthier lifestyle. She is working hard to reach the goal of a normal triglycerides level for the next lipid panel blood test. What is important at this phase is to consistently give the patient praises of continuing to be in the path of a healthier behavior. As the patient continues to progress in this stage, she will then go to the next phase which is maintenance in which an individual finally exhibits the new behavior consistently for over six months. And when the patient continues to adapt the healthy behavior, she will then go to the last phase and that is termination. From this phase, the patient is evidenced to be incorporating the healthy behavior for the rest of her life. If she fails to do it, she will then go back to the first stage of the theoretical framework and go over the same phases all over again. Conclusively, transtheoretical model of behavior change indeed helps assess where on the spectrum a person falls and helps guide treatment efforts accordingly.

Reference:

Prochaska, J., & Velicer, W. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38-48. doi:http://www.ncbi.nlm.nih.gov/pubmed/10170434

Safety in Practice

One of the medical errors that can be observed in the clinical setting is medication error. There are a lot of factors why medication error happened. First, it is because of the wrong documentation because of a wrong usage of abbreviations. Abbreviation indeed will help save time and effort in documenting, but the wrong usage of it may cause a mild to sometimes serious medication error. Fortunately in the clinical settings that I am working with this semester, medication error for the abbreviation reason is less likely to happen because of the use of a computer in documenting. The clinic uses a computer from the very first activity done for the patient until sending an electronic prescription to the pharmacy. Electronic documentation prevents error secondary to the usage of computer versus using a pen in documenting. For example, a number “4” might sometimes be confused with a number “9”, a “0” might be confused to letter “u” that stands for units. Medication error is likely to happen if handwriting is the source of confusion. Second, not every facility that uses electronic documentation is successful in implementing the safe practice. There will always come to a point that it is because of human error. One example I can cite is documenting the right route of an injection. Believe it or not, I see healthcare professionals who are still confused about where her or his left and right and where patient’s left and right side of the body is. With this dilemma, this will result in a confusion that will further result in an error in documentation or in a worst case, error in medication administration. In the clinical setting that I am working with right now, they handle the situation pretty decently. The medical assistant who gives the injection is always paired up with another medical assistant to help check and review each other’s work before each vaccination. I find this team up very helpful in maintaining safety in the practice setting. I believe that they do this to prevent mild consequence from happening while also preventing serious catastrophe to transpire.

Getting Started Blog

The first day of summer semester was also the first day of my clinical practicum. The feeling was unexplainable as it was the experience I have been waiting for – the start of the chapter where I get to experience the feeling of being a NP, well at least a student NP. That day, I was thinking that only a few steps to take; I will be able to reach the goal of finishing the program. On my first day of clinical, I get to meet my preceptor, Dr. Rosemary Reyes. Their clinic caters the healthcare needs of the uninsured and some who have little coverage from their insurance. They focus on primary care, women’s health, and pediatrics. During my first day, Dr. Reyes toured me around the facility and introduced me to all the staffs, including medical assistants, receptionist, phlebotomists, office staff, and two physician assistants, which were about 25-30 of them. Honestly, Dr. Reyes did not directly go over with me her expectations and concerns of working with a NP student. But she indirectly stated it to me when we were doing the rounds and while seeing patients. She expected me to do what is good, do no harm, connect with patients with respect, provide privacy at all times, and listen and address patient’s concerns appropriately. On my first day, she gave me the opportunity to start doing a physical exam to the patient. I was a tad bit nervous but her presence and support made the experience comfortable and worthwhile. When she communicates with the patients, I noticed that she raised vital questions within the patient’s problem. She formulated the questions clearly that made it easy for the patient to answer the questions. She used the same language and words that patient can understand. Additionally, she gathered and assessed the information by using all the answers of the patient to the questions to precisely interpret the situation and the problem of the patient that made her come up with well-reasoned conclusions and solutions. Though there were a lot of conclusions and solutions, she weighed them and ended up getting the best of all the best decisions out there. On my first day, I saw a majority of patients who come into the clinic to follow up with their laboratory result secondary to diabetes, hyperlipidemia, or sometimes, mixed diabetes and hyperlipidemia. Also, I often see cases of patients who seek medical help due to pain. Due to that, the drugs that I frequently saw that are listed in the FNP formulary are Meloxicam, Metformin, and Atorvastatin. Finally, my first day of clinical was an experience I would never forget. One tip that I want to share with my colleagues is to come prepared. In the clinic, you do not know who will come to seek medical help from you. But at the end of the day, I realized that as long as you know you have the knowledge that you can use to apply in the clinical setting to help treat patients, you know that you will do the right thing. Always keep your head up and don’t forget to smile.

Interprofessional Education and Collaboration

Out of all the leadership theories, I chose Transformational Leadership as a theory that can be utilized in interprofessional education and collaboration. According to Denisco and Barker (2016, p. 117), transformational leadership occurs when two or more persons engage with others in such a way that the leader and followers raise one another to higher levels of motivation and morality. In interprofessional education and collaboration, effective engagement is the key factor in patient’s safety. Each profession must raise each other, not compete or hate each other, in order to promote harmony in a collaborative environment in which the main goal is high-quality patient care.

In interprofessional collaboration, communication is very important. Communication is a complex process of transmitting a message from a sender to receiver. (Denisco & Barker, 2016, p. 136). Communication that is effective is crucial in an interprofessional education. As we know, interprofessional education is an important step in advancing health professional education in preparing health professions students to provide patient care in a collaborative team environment. (Buring et al., 2009). A good communication is important in enhancing the quality of patient care, promotes safety, lowers costs, decreases patients’ length of stay in the hospital, and reduces medical errors. One perfect example of a good and effective communication in interprofessional education is the use of SBAR (Situation, Background, Assessment, Recommendation). The technique of SBAR is to communicate to other professionals about patient’s problem by a concise statement of the problem (S for situation), while adding a pertinent and brief information related to the situation (B for background), with the professional’s analysis and considerations of options, as to what he or she found and think (A for assessment), and lastly, by recommending an action that a professional wants to do in order to address the problem or situation. (R for recommendation). Using SBAR will help solve the problem in a structured way.

Some of the potential barriers that will need to be addressed in the formation of an interprofessional team are the misunderstanding of the scope and contribution of each profession, gender, power, socialization, education, status, and cultural differences. My vision of an ideal interprofessional team includes people who do not think of the collaboration as a competition between professions. Instead, they think of it as a unified healthcare team that everybody puts all his or her effort in promoting patient safety. Each member of the team should recognize and value dissimilar professional perspectives and overlapping goals. Additionally, they should share decision-making and leadership to best meet the needs of the patient or problem. The team should interact openly. Each member must convey interest and show attentiveness in order to produce a better interaction. Furthermore, clarifying or eliciting further information is a good way to interact with each other.

Everybody can take the role of leading the team as long as that person possesses qualities that promotes engagement with his or her followers in which leader and followers find meaning and purpose in their work while growing and developing as a result of the relationship and raising one another to higher levels of motivation and morality.

 

References:

Buring, S., Bhushan, A., Broeseker, A., Conway, S., Duncan-Hewitt, W., Hanse, L., & Westberg, S. (2009). Interprofessional education: Definitions, student competencies, and guidelines for implementation. American Journal of Pharmaceutical Education, 73 (4), 59.

Denisco, S. M., & Barker, A. M. (2015). Advanced practice nursing. Burlington, MA: Jones & Bartlett Learning.

 

Equitable Distribution of Health Care

In this essay, I will be talking about a politician’s beliefs and values related to the delivery of health care. Let me start by mentioning that the system of healthcare delivery is rooted from the beliefs and values of one person. The beliefs and values govern the training and the general orientation of an individual. For politicians, their belief is about their concern for the most underprivileged classes in the society such as the poor, disabled, and children. One example is the situation of Mr. S.. Due to his chronic illnesses, he exhausted his private insurance and now, his insurance cannot pay for his healthcare cost. With the politician’s values and beliefs, they passed a law about the creation of Medicare, Medicaid, and SCHIP. Medicare, Medicaid and SCHIP are social health care program by the government to help families or individual with low income and limited resources. Through Medicaid, Mr. S. is continued to receive care from the county’s public hospital, without the worry of who is going to shoulder the cost.

The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health. Determinants of health include biological and genetic make up, individual behavior, social interactions and norms, physical environment, and access to health services (www.healthypeople.gov) For Mr. S’s case, housing, stress, insurance coverage, and unemployment are his determinants of health. I want to picture an intervention that can change Mr. S’s determinants of health. First step is a proper referral to a social worker before patient gets discharged from a county hospital. Social worker will assist Mr. S. in applying for housing program of the government. The social worker will be the middle person to help Mr. S. in finding a comfortable place to live in and to recuperate in. Once he has the place, the ordering of O2 will follow. He can’t be sent home without the O2 due to his chronic COPD. He will be helped by the same person, the social worker, in putting things into their right places. One step made by the social worker will follow the next steps. The next few steps are the plan on doing lung volume reduction surgery and the experimental lung transplant that is being considered for him.

Reference:

Determinants of Health (2015). Retrieved from http://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health