Gastrointestinal (GI) bleeding is a commonly encountered primary care clinical challenge. The AGA Medical Position Statement: Evaluation and Management of Occult and Obscure Gastrointestinal Bleeding, reviewed in this month's clinical practice guideline column, summarizes recommendations for the initial diagnostic approach and management for occult bleeding, as well as the subsequent diagnostic and management approach for obscure bleeding. The recommendations have applicability in primary care as nurse practitioners (NPs) assess the cause of occult bleeding and consult with specialists when obscure bleeding occurs.

Gastrointestinal Hemorrhage↗

PubMed2003

National Guideline Clearinghouse guideline syntheses and comparisons.

As the number of clinical practice guidelines relevant to clinical practice continues to grow, nurse practitioners may find it confusing to choose from two or more guidelines on the same or similar topics. The National Guideline Clearinghouse provides two resources to assist clinicians in comparing multiple guidelines on similar topics: guideline syntheses and guideline comparisons. This column describes the features of these two resources, using examples from guidelines on acute pharyngitis.

Humans↗

PubMed2003

Screening, diagnosis, and monitoring of hepatic injury.

Although prophylactic vaccines and a better screened blood supply have contributed to a decreased incidence of viral hepatitis, liver injury remains a common problem. It is important that nurse practitioners know which patients are at risk for hepatic injury, when and how to screen for hepatic injury, and how to monitor patients diagnosed with hepatic damage. The National Academy of Clinical Biochemistry guidelines related to hepatic injury provide a framework for the screening, diagnosis, and monitoring of hepatic injury resulting from a variety of causes.

Acute Disease↗

PubMed2003

2001-2002 AANP national nurse practitioner practice site survey.

Between October 2001 and February 2002, AANP implemented the National NP Practice Site Survey. The purpose of the survey was to describe the general U.S. NP workforce, including the percentage of NPs working in primary care and their settings. Data were collected from over 39,000 NPs of all specialties. Based on the survey, a description of the U.S. NP Workforce was developed. For instance, according to the survey, the average NP is female (95%) and 47 years old. She has been in practice for 8.6 years, is a family NP (35%), and is involved in direct patient practice. This report includes detail on the respondents' clinical specialization, age, years of practice, and type of practice.

Employment↗

PubMed2003

Diagnosis and treatment of heel pain.

The American College of Foot and Ankle Surgeons (ACFAC) clinical practice guideline (CPG) summarizes the literature on the assessment and diagnosis of heel pain. The framework classifies heel pain depending on whether the cause is mechanical, neurological, arthritic, traumatic, or from another origin. Treatment strategies are included for the most common form of heel pain that are caused by mechanical problems.

Algorithms↗

PubMed2003

Migraine headaches.

Migraine headaches are the source of significant disability for many individuals and their management can present a considerable clinical challenge. The American Academy of Family Physicians (AAFP) and American College of Physicians--American Society of Internal Medicine (ACP-ASIM) "Pharmacologic Management of Acute Attacks of Migraine and Prevention of Migraine Headaches," provides a succinct, evidence-based resource for primary care nurse practitioners. In addition to reviewing this clinical practice guideline, this column describes related supporting documents.

Acute Disease↗

PubMed2003

Diagnosis and treatment of idiopathic thrombocytopenic purpura.

Explore the source record for details and available documents.

Humans↗

PubMed2003

Policy on acute toxic ingestion or dermal or inhalation exposure.

Many nurse practitioners (NPs) practice in emergency and urgent-care settings, and far more practice in remote settings. NPs in each of these settings should be familiar with the assessment, stabilization, and treatment of patients who seek treatment for suspected intentional or accidental poisoning. This month's clinical practice guideline (CPG) column reviews the "Clinical Policy for the Initial Approach to Patients Presenting With Acute Toxic Ingestion or Dermal or Inhalation Exposure."

Acute Disease↗

PubMed2002

Clinical practice guidelines. Managing oral anticoagulant therapy.

Clinical practice guidelines (CPG) provide recommendations based on the summary of large volumes of literature and expert opinion. They are not absolute care directives, but are intended to facilitate individualized decision making related to patient care situations. Each month this column reviews a CPG of direct relevance to clinical practice. Readers are urged to contact the author, Mary Jo Goolsby (mjgoolsby@aanp.org) with requests for reviews of specific clinical guidelines or submissions of manuscripts addressing major guidelines that readers have found helpful in their practice. The Clinical Practice Guideline column is designed to inform practitioners of the wide range of accessible and current recommendations on a myriad of clinical topics. The guideline reviewed this month is actually one part of a large report stemming from the Sixth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy. The management of oral anticoagulant therapy is but one portion of the overall report, complemented and supported by other components, including a preceding chapter that summarizes the mechanisms of action, clinical effectiveness, and therapeutic range of oral agents. This CPG focuses on following issues: (a) initiating and maintaining dosage, (b) managing non-therapeutic dosages, (c) managing the agents during invasive procedures, and (d) recognizing and responding to adverse events. Special situations are discussed, including management of patients who are elderly or pregnant, and comparisons of the management in different models of care. There is in-depth discussion of the literature, accompanied by a summary of recommendations.

Anticoagulants↗

PubMed2002

Clinical practice guidelines. USPSTF recommendations.

The set of USPSTF recommendations provides a valuable resource for clinicians in varied practice settings. Although the 2nd edition of recommendations addressed over 200 topics, only six statements have been released as part of the 3rd edition thus far. Others, not reviewed in this article include: screening for newborn hearing, screening for bacterial vaginosis during pregnancy, and screening for lipid disorders. The recommendations are conservative and, like all clinical practice guidelines, should be considered in light of one's philosophy of practice. The recommendations meet many of the criteria addressed in the initial column of this series. The factors considered by the panel members are identified, including accuracy of available screening methodologies, cost factors, and benefit/risk determinations. The evidence on which recommendations are based is rated. Exceptions to the recommendations are identified. For instance, the authors of the paper on skin cancer screenings indicate that they did not consider studies based on persons with familial skin cancers. Although no recommendation is made for or against skin cancer screenings, ways in which the skin can be assessed during physical examinations performed for other reasons are identified. The importance of individual patient preference is included. The USPSTF panel is multi-disciplinary and includes [table: see text] (http://www.guideline.gov). The statement on aspirin therapy was published in the Annals of Internal Medicine and is available, along with a second article discussing the evidence in more depth (Hayden, Pignone, Phillips, & Mulrow, 2002), at: http://www.annals.org. Print versions are available through the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse (1-800-358-9295). Readers are encouraged to obtain full copies of the recommendations that are applicable to their practice as they become available and to assess their potential application in practice.

Aspirin↗

PubMed2002

National Kidney Foundation Guidelines for chronic kidney disease: evaluation, classification, and stratification.

Chronic kidney disease is becoming more prevalent in the United States. The National Kidney Foundation has recently published a new set of guidelines to assist clinicians in providing earlier detection and treatment of kidney disease to minimize the progression to end-stage renal disease. As approximately 11% of the adult population has some degree of kidney disease, this new CPG should be applicable in many settings.

Disease Progression↗

PubMed2002

Screening, diagnosis, and clinical care for depression.

Depression is an extremely common condition, which usually responds well to prescribed treatment. Many patients have undiagnosed depression or related illnesses. There are a variety of screening tools that can be applied in practice settings. It is recommended that adult patients be screened for depression in practice sites able to coordinate the actual diagnosis and treatment of depression. This column reviews two sets of recommendations specific to the screening, diagnosis, and treatment of depression.

Adult↗

PubMedDate not supplied

The clinical nurse leader: promoting patient-centered outcomes.

In 2004, a 551-bed nonprofit hospital launched a pilot of the unit-based clinical nurse leader (CNL) role to support staff nurses and their patients. Thus far, the role has demonstrated great promise in promoting individual patient-centered outcomes, although the pilot has identified potential adaptations to enhance aggregate outcomes. These include decreasing the patient-to-CNL ratio, increasing CNL availability to 7 days a week, and reconsidering whether to fill CNL positions with nurses who were prepared as nurse practitioners.

Clinical Competence↗