Diagnosis and Management of Common Pediatric Fingertip Trauma

Fingertip trauma commonly presents to pediatric emergency departments. Most injuries can be managed at the bedside with anesthesia, irrigation, soft tissue repair, immobilization, and follow-up. A comprehensive team approach allows for a nurse practitioner as the first point of contact with involvement of a hand surgeon and hand therapist as necessary to provide optimal care. This topical review provides an anatomical framework to assist first-line providers in the appropriate diagnosis and management of common pediatric fingertip injuries as well as identify and rule out conditions that warrant time-sensitive surgical intervention such as Seymour fracture, tendon laceration/avulsion, or dysvascular digit.     

Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training.

BACKGROUND: Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients' outcomes. OBJECTIVE: To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients' care in a step-down medical intensive care unit. METHODS: Work sampling techniques were used to collect data when the nurse practitioner had 6 months' or less experience in the role (T1), after the nurse practitioner had 12 months' experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities. RESULTS: Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001). CONCLUSION: The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients' families and collaborating with health team members.     

An evaluation of a community aged care nurse practitioner service

Evaluation aims. An evaluation is presented that aimed to augment current understandings of the nurse practitioner role by investigating potential outcomes of a community aged care nurse practitioner (ACNP) service on clients and the health care team. Background. In Australia, the nurse practitioner role is being implemented in a variety of health care settings and is characterized by extended practice: prescribing of medications, requests for diagnostic investigations, referral to medical specialists and admitting clients to inpatient facilities. Design. An exploratory qualitative evaluation method through data collection by interview and thematic analysis was undertaken. Method. All clients referred to the ACNP service between June and August 2003, and a convenience sample of health professionals, were invited to participate in individual semi‐structured interviews. Results. Findings suggested that an ACNP could provide a high quality of holistic nursing care and positively affect clients’ physical and psychological symptom management, enhance clients’ quality of life, assist with supplies, provide health education and assist with advocacy. Health professionals commented on effective collaboration with the ACNP service during their partnerships in client care provision. Conclusions. Overall, the positive effects of the ACNP service on clients and the health care team support the full implementation of the role within the community setting. Relevance to clinical practice. Funding support for the nurse practitioner role is a vital addition to consideration in the development of international policy on advanced practice nursing. Without adequate funding, the full benefits of the nurse practitioner role in clinical practice, as suggested by the findings presented in this evaluation, will be compromised.     

Obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome is estimated to affect 2 million to 3 million Americans. Obstructive sleep apnea syndrome is a breathing pattern characterized by periods of apnea alternating with periods of arousal and breathing, a pattern that recurs throughout the sleep cycle. It is important for the nurse practitioner to be able to recognize the signs and symptoms of the syndrome in order to initiate diagnostic testing. The role of the nurse practitioner also involves education of the client and family regarding the disease process and treatment modalities. The client and client's family will need help in coping with the diagnosis and possibly with the physical and psychological symptoms experienced. This article outlines the disease process, treatment modalities, possible complications and the role of the nurse practitioner in assisting the client with obstructive sleep apnea syndrome.     

Recognizing borderline personality disorder in the primary care client

The nurse practitioner is responsible for the diagnosis and treatment of a great variety of physical and psychological disorders in the ambulatory client. Frequently the diagnosis of personality disorder is missed, ignored or not even considered. This article will introduce the nurse practitioner to the various personality disorders. The main focus, borderline personality disorder, is estimated to affect 5 to 15 percent of the general population. A picture of the borderline client from etiology to treatment as well as recent research findings and suggestions for history taking and physical exam are covered. Borderline has been a difficult and confusing diagnosis to make because in the past the term has had several different meanings. This article will clarify what this diagnosis means, and will assist the nurse practitioner in the recognition, diagnosis and management of all clients with personality disorders.     

Psychotherapeutic intervention with the addict-client.

In order for the nurse therapist to be most effective with the narcotic-addicted client, she should be aware that his behavioral style many times reflects dependence, low self-esteem, and impaired reality testing. The major defense mechanisms used by the client are denial, projection, and manipulation. An attitude of hopeful expectancy on the part of the nurse is most important therapeutically in the treatment of the addict. Some therapeutic interpersonal interventions between the nurse and client are contracting, goal-setting, limit-setting, and the sharing of the responsibility for growth between the client and the nurse. The total treatment program for the client must also be scrutinized, and more than physiologic detoxification and one-to-one therapy must be provided in order for the client to have the maximum opportunity for change.     

Nursing intervention in cognitive retraining of the traumatic brain injury client

This paper deals with nursing intervention in cognitive retraining for the traumatic brain injury client in acute care rehabilitation. Clients in these settings usually receive therapeutic treatment during conventional working hours. The proposal of this article is to institute a more comprehensive approach based on nursing therapeutic intervention for cognitive remediation during evenings, weekends, and holidays. The nurse implements and maintains specific recommendations of the client's treating team, which includes the primary nurse. This results in a more intensive approach with maximum consistency of treatment, continuity of care, ongoing feedback to the therapist about the client's achievements on the nursing unit, continuous reassessment of the client's needs, and more involvement of the client's family. A case study is presented that exemplifies this concept.     

Comparing and contrasting the clinical nurse specialist and the advanced nurse practitioner roles

There is currently a great deal of ambiguity regarding the difference between the role of clinical nurse specialist and advanced nurse practitioner. In distinguishing one title from another, factors such as the educational requirements of such, what the role involves, who the client is and whether the role encroaches on a doctor's role are discussed. This paper sets out the factors that are seen by some as significant in distinguishing between a clinical nurse specialist and advanced nurse practitioner.     

An advanced nurse practitioner-led service - consequences of service redesign for managers and organizational infrastructure

barton d . & mashlan w. (2011) Journal of Nursing Management 19, 943–949 An advanced nurse practitioner-led service – consequences of service redesign for managers and organizational infrastructure Aim A service review of a secondary care advanced nurse practitioner-led service. Background An acute hospital-based elderly care rehabilitation service evolved over a 9-year period from a traditional consultant/junior doctor configuration to a consultant/advanced nurse practitioner configuration. The review evaluated the advanced nurse practitioner team’s role in the clinical setting, and the constraints experienced as a result of the traditions of the hospital organization. Evaluation The review drew its conclusions from opinion data collected from 38 professionals and non-professionals within the rehabilitation service. Key issues The organizational infrastructure and traditions that had an impact on service delivery by the advanced nurse practitioner team. There is a demand for senior management to act on developmental constraints. Conclusions The advanced nurse practitioner-led rehabilitation service was fit for purpose and an emerging model of a non-medical led care. However, important organizational constraints were identified. Implications for nursing management An advanced nurse practitioner team, working in collaboration with medical consultants, was a model for future service redesign in the acute hospital setting. Nevertheless, it presented challenges to senior health-care managers on current organizational infrastructures.     

The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study

BackgroundConsidering the high rates of pain as well as its under-management in long-term care (LTC) settings, research is needed to explore innovations in pain management that take into account limited resource realities. It has been suggested that nurse practitioners, working within an inter-professional model, could potentially address the under-management of pain in LTC.ObjectivesThis study evaluated the effectiveness of implementing a nurse practitioner-led, inter-professional pain management team in LTC in improving (a) pain-related resident outcomes; (b) clinical practice behaviours (e.g., documentation of pain assessments, use of non-pharmacological and pharmacological interventions); and, (c) quality of pain medication prescribing practices.MethodsA mixed method design was used to evaluate a nurse practitioner-led pain management team, including both a quantitative and qualitative component. Using a controlled before-after study, six LTC homes were allocated to one of three groups: 1) a nurse practitioner-led pain team (full intervention); 2) nurse practitioner but no pain management team (partial intervention); or, 3) no nurse practitioner, no pain management team (control group). In total, 345 LTC residents were recruited to participate in the study; 139 residents for the full intervention group, 108 for the partial intervention group, and 98 residents for the control group. Data was collected in Canada from 2010 to 2012.ResultsImplementing a nurse practitioner-led pain team in LTC significantly reduced residents' pain and improved functional status compared to usual care without access to a nurse practitioner. Positive changes in clinical practice behaviours (e.g., assessing pain, developing care plans related to pain management, documenting effectiveness of pain interventions) occurred over the intervention period for both the nurse practitioner-led pain team and nurse practitioner-only groups; these changes did not occur to the same extent, if at all, in the control group. Qualitative analysis highlighted the perceived benefits of LTC staff about having access to a nurse practitioner and benefits of the pain team, along with barriers to managing pain in LTC.ConclusionsThe findings from this study showed that implementing a nurse practitioner-led pain team can significantly improve resident pain and functional status as well as clinical practice behaviours of LTC staff. LTC homes should employ a nurse practitioner, ideally located onsite as opposed to an offsite consultative role, to enhance inter-professional collaboration and facilitate more consistent and timely access to pain management.     

Effects of a nurse practitioner on a multidisciplinary consultation team

Title.  Effects of a nurse practitioner on a multidisciplinary consultation team.
Aim.  This paper is a report of a study to evaluate the impact on office hours capacity, patient satisfaction, quality of life and costs of including a nurse practitioner in a multidisciplinary consultation team for patients with hand problems caused by rheumatoid arthritis.
Background.  Over 90% of patients with rheumatoid arthritis suffer symptoms in their hand joints and may be seriously disabled in performing daily, work or leisure activities. A recent promising development in the treatment of patients with a chronic disease is the co-ordinating and accompanying role of a nurse, such as a nurse practitioner, in a multidisciplinary treatment team.
Methods.  A two successive group time-series design was adopted. The intervention group ( n  = 78) visited a clinic with a nurse practitioner assigned to the team during 2003–2004. The control group ( n  = 69) was seen before inclusion of the nurse practitioner. Office hours capacity, patient satisfaction, quality of life and costs were assessed using questionnaires directly after consulting the team, and 3 and 6 months later.
Results.  Between-group comparisons of patient satisfaction and quality of life revealed no statistically significant differences. Changes within groups over time were not demonstrable. Mean office hour capacity increased by 17% ( t  = −1·906, d.f. = 32·879, P  = 0·065). The costs for professional home care or informal care were equal in the two groups.
Conclusion.  Evaluation of clinical practice using pre- and post-test design was impeded by changes in clinical practice, which made concrete conclusions difficult to draw. In future studies the satisfaction of participating clinicians should be evaluated, in addition to that of patients.     

Screening for substance abuse in a primary care setting

This article addresses the need for the nurse practitioner functioning in nearly any type of primary care setting to appreciate the potential of substance abuse in the client population. The addiction assessment tool serves as a guide for obtaining a precise health history regarding substance abuse. This information can assist the health provider in selecting the appropriate treatment strategy. A brief synopsis of substance abuse treatment modalities summarizes the vast field of research and referral sources which are available to the client. Hallmarks of recovery attempt to direct the nurse practitioner toward a realistic treatment plan.     

Challenges and leadership strategies for managers of nurse practitioners

AIM: The aim of this paper is to report on the findings from our research into the recent introduction of nurse practitioners in Alberta, Canada. Through an organizational research perspective, we identify the critical role of health care managers in developing a sustainable nurse practitioner role. BACKGROUND: Previous literature has focused on nurse practitioners themselves as the key factor in their integration into the health care system. Although they are qualified and organizationally well placed, managers of nurse practitioners have been overlooked as a critical part of implementation strategies. KEY ISSUES: We interviewed 25 nurse practitioners and seven of their managers. Through our data analysis we identified three major challenges for managers: (1) clarifying the reallocation of tasks; (2) managing altered working relationships within the team; (3) continuing to manage the team in an evolving situation. Associated with these challenges, we propose leadership strategies that managers may find useful as they work through the consequences of introducing the nurse practitioner role. These strategies are: * encourage all team members to sort out 'who does what'; * ensure that task reallocation preserves job motivating properties; * give consideration to how tasks have been allocated when issues identified as 'personal conflict' arise; * pay attention to all perspectives of the working relationships within the team; * facilitate positive relationships between team members; * lead from a 'balcony' perspective; * work with the team to develop goals that are not over focused on the nurse practitioner; * regularly share with other managers the experiences and lessons learned in introducing nurse practitioners. CONCLUSION: For managers to be most effective, they need to address three challenges that are of a managerial, not clinical, nature. By implementing specific leadership strategies, managers of nurse practitioners can facilitate the introduction of the new role and improve its sustainability in health organizations.     

Advanced nursing practice: policy, education and role development

Aims and objectives. This paper aims to explore the critical elements of advanced nursing practice in relation to policy, education and role development in order to highlight an optimal structure for clinical practice. Background. The evolution of advanced nursing practice has been influenced by changes in healthcare delivery, financial constraints and consumer demand. However, there has been wide divergence and variations in the emergence of the advanced nurse practitioner role. For the successful development and implementation of the role, policy, educational and regulatory standards are required. Conclusion. The paper highlights the value of a policy to guide the development of advanced nursing practice. Educational curricula need to be flexible and visionary to prepare the advanced nurse practitioner for practice. The core concepts for the advanced nursing practice role are: autonomy in clinical practice, pioneering professional and clinical leadership, expert practitioner and researcher. To achieve these core concepts the advanced nurse practitioner must develop advanced theoretical and clinical skills, meet the needs of the client, family and the community. Relevance to clinical practice. In a rapidly changing people‐centred healthcare environment the advanced nurse practitioner can make an important contribution to healthcare delivery. The challenges ahead are many, as the advanced nurse practitioner requires policy and appropriate educational preparation to practice at advanced level. This will enable the advanced practitioner articulate the role, to provide expert client care and to quantify their contribution to health care in outcomes research.     

Supporting Emergency Care Delivery Through Updated Emergency Nurse Practitioner Competencies

As multidisciplinary emergency care becomes increasingly complex, all team members must be aware of their respective roles and responsibilities. In the emergency department, nurse practitioners are integral members of the team. They possess a wide range of clinical and leadership competencies that allow them to perform specific and differentiated tasks within the emergency department. A well-defined competency not only contributes to the promotion of a positive work culture but also clarifies performance expectations, identifies skill gaps, and supports team development. Furthermore, it allows the nurse practitioner to adapt to changing conditions while maintaining patient safety. The competencies of emergency nurse practitioners have evolved over the past 2 decades. The authors discuss the importance of establishing clear expectations for emergency nurse practitioner practice in this article and the alignment of competencies with organizational culture and objectives.     

Education for differentiated role development for NP and CNS practice: one nursing program''s approach

Development of nurse care providers who best meet the public's health care needs is imperative. Some nurses believe the functions of nurse practitioners and clinical nurse specialists should be combined. However, the experience of the authors' nursing program argues otherwise. Two graduate nursing tracks, family nurse practitioner and rural health specialist, were developed to meet the health care needs of rural populations. Although the two tracks share expected competencies and areas of expertise to some extent, differences in practice are apparent in identified domains of practice and terminal competencies. Family nurse practitioner practice focuses on assessment, diagnosis, and management of health and illness conditions of individuals and families across the life span. Clinical nurse specialist practice incorporates traditional roles of client assessment, monitoring and coordination of care, outcome assessment, and client, family, and community education, with a new focus on case management strategies. These differences are important to care delivery in the managed care era.     

The role of the triage nurse practitioner in general medical practice: an analysis of the role

A 2-year pilot study was undertaken in a group general practice to evaluate the nurse practitioner triage role. The study was undertaken in several stages which included a patient satisfaction questionnaire survey, follow-up interviews with 30 patients from the questionnaire survey, and analysis of the nurse practitioner's work at different points over the 2-year study period. This paper describes the work of the nurse practitioner in comparison with that of seven general practitioners in a group general medical practice over a 5-day period in February 1996 and included patients' perceptions of their consultation. In this particular group medical practice, as in others throughout the country, many patients request same day appointments, often for self-limiting conditions, social advice and health education. This study demonstrates that the nurse practitioner can deal with such patients effectively and is undertaking an expanded and extended role in order to provide an holistic service to patients with which they are highly satisfied. It can be concluded that given the right kind of education and training and a supportive framework within the practice, the nurse practitioner undertaking a triage role can provide a highly effective service to patients and is a valuable member of the primary health care team.     

Defining the role of the pediatric critical care nurse practitioner in a tertiary care center

OBJECTIVE: To describe the development and implementation of a pediatric critical care nurse practitioner role in a tertiary academic pediatric intensive care unit. DATA SOURCES: Selected relevant articles from the literature. DATA EXTRACTION/SYNTHESIS: Over the past two decades, the role of critical care nurse practitioners in neonatal and adult settings has developed. More recently, the role has emerged in the setting of pediatric critical care. Literature to date focuses on implementation of the nurse practitioner role in neonatal and adult critical care units, with limited publications on the role in the pediatric critical care arena. In addition, information on the practice of critical care nurse practitioners in tertiary care centers is lacking. We therefore, sought to describe the design, implementation, scope of practice, and outcomes to date of a pediatric nurse practitioner program in our pediatric critical care unit. CONCLUSIONS: A pediatric critical care nurse practitioner role can be implemented successfully in a tertiary center's pediatric intensive care unit. However, before integration of the pediatric critical care nurse practitioner into the health care team, definition of entry level requirements and the overall role with respect to scope of practice, daily operations, and professional practice is essential. Future endeavors should include evaluation of the impact of the pediatric critical care nurse practitioner on patient outcomes in the tertiary care center.