This chapter describes nurses’ care of acute and critically ill patients’ families, highlighting the clinical judgment and skill required for this important relational work. A crucial aspect of family care is ensuring that a family can be with their ill loved one, as family access promotes family cohesion, connection, and closure, fosters patient well-being and provides the family with information. Commonly cited rationales to limit family access include: concerns regarding patient stability, infection, rest, privacy, the effect of visitation on the family, space limitations and healthcare providers’ performance abilities. Encouraging family involvement in care giving activities is another essential aspect of family care, and can range from minor involvement to major involvement. An excerpt highlights some of the difficulties associated with shifting care giving responsibilities from healthcare providers to family members who may be unable to see other options.
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This chapter focuses on behaviors, addiction, and eating disorders. These conditions play a major role in the recognition and treatment of obesity. The chapter identifies specific diseases in relation to the understanding of this complex issue. Behavior can be established at ages as early as toddlers or preschool age. This includes basic eating patterns. Development of good eating habits is further promoted by adult influence. The advanced practice nurse (APN) should provide education and encourage the patient and/or family to engage in the eating experience. If the APN suspects an eating disorder, proper referral to a psychiatric mental health nurse practitioner (PMHNP), psychologist and/or psychiatrist, and/or treatment center can be considered. There are five examples of an eating disorder not otherwise specified by the DSM-IV criteria: atypical anorexia nervosa, bulimia nervosa, binge-eating disorder, purging disorder, and night eating syndrome.
An initial psychological assessment should take place on the first appointment with the patient. This chapter focuses on tools that are useful for the advanced practice nurse (APN) in an outpatient clinic setting. Screening tools are one way for the APN to identify depression. Several screening tools exist for use in an outpatient setting. These include the Beck Depression Inventory, the Center for Epidemiological Studies Depression scale, the General Health Questionnaire, and the Patient Health Questionnaire. Along with depression, the APN should also screen for a possible eating disorder. Patients may be sensitive about weight, so one should approach this subject with care. Motivational interviewing can be used to address weight, weight loss, and management. Motivational interviewing is a form of counseling that uses focused conversation in collaboration with the patient in order to strengthen his or her motivation toward a goal and commitment to change.
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For graduate nurses and advanced practice nurses, the use of simulation is generally limited to acquiring various clinical skills or clinical management scenarios. Simulation is being used in the health care field to promote team training and nontechnical skills such as teamwork, communication, collaboration, and leadership. Recognizing the preference for simulation training by students and the reported increased learning and confidence in clinical skills, this chapter attempts to expand the use of simulation beyond clinical and teamwork skills into the management and administrative courses of graduate nursing education. Although incorporating simulation into the root cause analysis (RCA) process and error identification is increasing, its use in undergraduate and graduate nursing education is still limited. This chapter discusses the implementation of a hybrid simulation program for nonclinical skills, which was implemented in a graduate nursing class focused on quality, safety, and process improvement.
Critical thinking is required in performing an accurate physical assessment. Critical thinking encompasses analysis of data using the scientific knowledge base, experience, clinical competencies, attitude, and standard of care. These specific areas allow the advanced practice nurse (APN) to hone in on the health assessment and physical examination. Prior to the physical examination, a thorough health history needs to be taken. The health history or history of present illness (HPI) provides the patient’s reason for seeking out the APN and documents the chronological signs and symptoms of the problem from beginning to end. The APN should complete a head-to-toe physical assessment and review vitals and measurements. A complete physical examination for the obese patient should be similar to a normal physical examination with some slight variations. A head-to-toe physical examination includes four basic skills: inspection, palpation, percussion, and auscultation.
This chapter addresses the indications and options with regard to bariatric surgery. Referring a patient for bariatric surgery can be one of the easiest as well as one of the toughest decisions for the advanced practice nurse (APN). The chapter defines the candidates for bariatric surgery as well as addresses the different surgical procedures available. Data in more recent years have shown evidence that bariatric surgery may be safe and effective for some adolescents and patients older than age 60 under certain conditions. Candidates should also be deemed acceptable surgical patients and present optimal operative risk. The APN plays a big role in assisting the bariatric care team prior to surgery. Several surgical options exist for those requesting surgery for weight loss. Surgical options can include laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (RYGB), laparoscopic biliopancreatic diversion (BPD), and BPD/duodenal switch (BPD-DS).
Disease management focuses on the concept of reducing health care costs while improving the quality of treatment for chronic diseases. Health improvement and cost containment are the focus of disease management. With disease management, the advance practice nurse (APN) works with other providers as well as with a health care team to provide the best overall care for the treatment of the overweight and/or obese individual and his or her comorbid conditions. A proactive approach with multidisciplinary providers is developed from evidence-based practice guidelines. Chronic disease management commonly includes diseases such as diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and asthma. APNs play an integral role in management of chronic disease. Although obesity is not identified as a chronic disease, it coexists with these diseases. A team approach and routine follow-up are essential for long-term success.
Many theories exist about how to determine the proper measurement, weight, and body composition and which type of scale provides the most accurate answer. This chapter addresses different methods to weigh and measure body fat. Appropriate assessment of the patient’s weight is critical for further treatment of the overweight and/or obese patient. Body mass index (BMI), which takes into account the patient’s weight and height, has been referred to as the “fifth vital sign”. BMI gives a generalized idea of obesity; however, it is not always seen as accurate in some body types. Three terms are commonly used to identify three categories of obesity: sarcopenic obese, normal obese, and hypermuscular obese. It is important that the advanced practice nurse (APN) learns and understands the differences between scales and measurements of body composition. The APN should also be able to determine which method is appropriate for each patient.
Advanced practice registered nurses (APRNs) are nurses with a master’s, post-master’s, or doctorate level of education. Four roles encompassed under the definition of the APRN are certified nurse practitioners (CNPs), certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), and clinical nurse specialists (CNSs). Each has its own context, but all share the commonality of nursing, especially advanced practice nursing. Although education similarities as well as accreditation and certification exist, uniform state regulations for APRN practice do not. States, with their governing licensing boards and statutes, provide state practice authority. The legal scope of the APRN is individually and independently determined by each state. The educational programs that APRNs graduate from are nationally accredited; therefore, their graduates are eligible for national certification and state licensure. APRNs provide professional care across the health spectrum based on individual patient needs and educational experiences.
Pediatric obesity is a growing problem worldwide. Both the incidence and prevalence of overweight and obese children have increased. Advanced practice nurses (APNs) should realize that one must address weight at an early age. Pediatric obesity affects children and adolescents and is a serious condition that must be addressed. It is determined when the child is above his or her weight for the appropriate age and height. Risk factors that increase a child’s likelihood of becoming overweight and/or obese can include any of the following: diet, lack of exercise, psychological factors, family history or family factors, or socioeconomic factors. Children who suffer with weight gain should engage in physical activity. Parental instruction and family activity time are also helpful. With a child and family involved, family counseling may be beneficial to all. The provider must establish an early relationship with the patient and family and work to gain trust.