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Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Edited by:Third Edi Tion Clinical Guidelines for Advanced Practice nursing AN INTERPROFESSIONAL APPROACH Geraldine M. Collins-Bride, MS, rn, A n P-BC, FAA n Health Sciences Clinical Professor Adult Nurse Practitioner University of California, San Francisco Department of Community Health Systems rebek ah Kaplan, MS, C n M, rn Health Sciences Associate Clinical Professor Nurse Midwife University of California, San Francisco Department of Family Health Care Nursing and Department of Obstetrics, Gynecology, and Reproductive Sciences Jo Anne M. Saxe, dn P, MS, rn, A n P, FAA n Health Sciences Clinical Professor Adult Nurse Practitioner University of California, San Francisco Department of Community Health Systems Karen G. duderstadt, Ph d, rn, CP n P, PC n S, FAA n Health Sciences Clinical Professor Pediatric Nurse Practitioner University of California, San Francisco Department of Family Health Care Nursing Associate Editor: Lewis d. F annon, MS, rn, A n P-BC Health Sciences Assistant Clinical Professor Adult Nurse Practitioner University of California, San Francisco School of Nursing Department of Community Health Systems

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. T o contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www. jblearning. com. Copyright © 2017 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Clinical Guidelines for Advanced Practice Nursing: An Interprofessional Approach, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. T reatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindi-cations, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. World Headquarters Jones & Bartlett Learning5 Wall Street Burlington, MA 01803 978-443-5000info@jblearning. comwww. jblearning. com Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning. com. Production Credits VP, Executive Publisher: David D. Cella Executive Editor: Amanda Martin Associate Acquisitions Editor: Rebecca Myrick Editorial Assistant: Lauren Vaughn Production Manager: Carolyn Rogers Pershouse Associate Production Editor: Juna Abrams Senior Marketing Manager: Jennifer Scherzay Product Fulfillment Manager: Wendy Kilborn Composition: Cenveo Publisher Services Cover Design: Kristin E. Parker Rights & Media Specialist: Wes De Shano Media Development Editor: T roy Liston Cover Image: © Eliks/Shutterstock, © donatas1205/Shutterstock Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy Library of Congress Cataloging-in-Publication Data Collins-Bride, Geraldine M., editor. | Saxe, Jo Anne M., editor. | Duderstadt, Karen, editor. | Kaplan, Rebekah, editor. Clinical guidelines for advanced practice nursing : an interprofessional approach / [edited by] Geraldine M. Collins-Bride, Jo Anne M. Saxe, Rebekah Kaplan, and Karen G. Duderstadt. Third edition. | Burlington, MA : Jones & Bartlett Learning, [2017] | Includes bibliographical references and index. LCCN 2015048813 | ISBN 978-1-284-09313-1 (pbk. ) MESH: Advanced Practice Nursing | Nursing Care—methods | Clinical Protocols—standards | Guideline LCC RT82. 8 | NLM WY 128 | DDC 610. 73—dc23 LC record available at http://lccn. loc. gov/2015048813 6048Printed in the United States of America20 19 18 17 16 10 9 8 7 6 5 4 3 2

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

T o our patients and students, we appreciate the many lessons that we have learned from you and the trust that you have given us over the years. We are privileged to have been your healthcare provider and/or mentor. GCB, JMS, RK, KD, and LF T o my “boys” (Bob, Patrick, & Brendan) who have stopped asking when I'll be coming home! I appreciate all your support, love, and most of all, your patience and humor. GCB T o my mother, Patricia, father, John, husband, Noel, daughters (Kelly, Jocelyn, and Lydia), son-in-law, Benny, granddaughter, Mícara, and all of my wonderful brothers and sisters for your years of support, love, and laughter. Thank you for all that you are and do! JMS T o my husband, Chris, who is constantly patient and respectful of my work. Thank you for the love and support! And to the children and families I serve with humility and respect for what they have taught me over the years!     KD T o my husband, David, and sons, Ezra and Emmet. You make my world go round. Thanks for all you give me and for always making me laugh, even when faced with writing deadlines. RK T o my wonderful family and friends who have been extraordinary in their support during the production of this text. Thank you for putting up with me! Also, a huge note of gratitude to Gerri, Jo Anne, Rebekah, and Karen for allowing me to be part of something so special! LF De Dication iii

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

T o a dear friend and colleague Barbara Boland, RN, MS, ANP-BC, CDE, who was a contributing author to all three editions of this book, one of the best NPs on the planet and a wonderful friend who always made us laugh. We miss you, Barbara! a SPecia L De Dication v

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Acknowledgments xv Contributor s xvii Introduction xxvii 1 Legal Scope of Advanced Nursing Practice 1 Brian Budds and Jo Anne M. Saxe Introduction and General Background 1 Overview of Scope of Pr actice Legal Framework 1 Issues Related to Collabor ative Practice and Documentation 4 Concluding Remarks 5 Section i Pediatric Health Maintenance and Promotion 2 Fir st Well-Baby Visit 7 Annette Carley I. Introduction and gener al background 7 II. Database 8 III. Assessment 9 IV. Goals of first well-baby visit 9 V. Plan 10 VI. Resources and tools 10 3 Car e of the Postneonatal Intensive Care Unit Graduate 12 Annette Carley I. Introduction and gener al background 12 II. Database 15 III. Assessment 16 IV. Goals of clinical management 16 V. Plan 16 VI. Resources and tools 17 4 0 to 3 Years of Age Interval Visit 18 Ann Birenbaum Baker I. Introduction and gener al background 18 II. Database 18 III. Assessment 20 IV. Plan 20 5 3 to 6 Years of Age Interval Visit 23 Mary Anne M. Israel I. Introduction and gener al background 23 II. Database 23 III. Assessment 24 IV. Plan 24 6 6 to 11 Years of Age Interval Visit 27 Bridget Ward Gramkowski and Ann Birenbaum Baker I. Introduction and gener al background 27 II. Database 27 III. Assessment 29 IV. Plan 29 7 The Adolescent and Young Adult (12-21 Years of Age) Interval Visit 32 Erica Monasterio I. Introduction and gener al background 32 II. Database 33 III. Assessment 36 IV. Plan 36 V. Self-management resources 38 8 Pr eventive Immunizations for Children and Adults 40 Lucy S. Crain I. Introduction: Overview of vaccine-preventable diseases 40 Recommended U. S. Immunization Schedules and Catch- Up Schedules for Ages Birth Through 18 Years 42 I. Recommended pediatric v accine schedule 42 II. Adult immunization recommendations 44 content S vii

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

III. Database: History 81 IV. Physical examination 83 V. Assessment 84 VI. Plan 84 13 Childhood Depr ession 90 Damon Michael Williams I. Introduction 90 II. Database 92 III. Assessment 94 IV. Plan 94 V. Self-management resources 98 14 F ailure to Thrive During Infancy 99 Annette Carley I. Introduction and gener al background 99 II. Database 100 III. Assessment 101 IV. Goals of clinical management 102 V. Plan 102 VI. Resources 103 15 Child Maltr eatment 104 Naomi Schapiro I. Introduction and gener al background 104 II. Database 106 III. Assessment 110 IV. Plan 111 V. Resources 112 16 Childhood Overweight and Obesity 114 Victoria F. Keeton I. Introduction and gener al background 114 II. Database 115 III. Assessment 118 IV. Plan 118 V. Helpful online resources 121 17 Urinary Incontinence in Childr en 124 Angel K. Chen I. Introduction and gener al background 124 II. Database 126 III. Assessment 128 IV. Goals of clinical management 130 V. Plan 131 VI. Resources 134III. Immunization modalities 45 IV. Active and passive immunizations 46 V. Herd immunity 46 VI. Adverse event reporting 46 VII. Current concerns and v accination rates 47 9 Developmental Assessment: Screening for Developmental Delay and Autism 48 Abbey Alkon I. Introduction 48 II. Developmental surveillance and screening algorithm 49 III. Screening instruments 57 IV. Psychometrics 57 V. Conclusion 58 VI. Clinician resources 58 Section ii Common Complex Pediatric Presentations 10 Childhood Asthma 61 Nan Madden and Andrea Crosby Shah I. Introduction and gener al background 61 II. Database 61 III. Assessment 62 IV. Goals of clinical management 65 V. Plan 65 VI. Resources 68 11 Atopic Dermatitis in Childr en 70 Karen G. Duderstadt and Nan Madden I. Introduction and gener al background 70 II. Database 70 III. Assessment 72 IV. Goals of clinical management 72 V. Plan 73 VI. Self-management 78 VII. Psychosocial and emotional support 79 12 Attention-Deficit/Hyper activity Disorder in Children and Adolescents 80 Naomi Schapiro I. Introduction and gener al background 80 II. Overview 80viii CONTENTS

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

23 Menopause T ransition 217 Priscilla Abercrombie I. Introduction and gener al background 217 II. Database 219 III. Assessment 220 IV. Goals of clinical management 220 V. Plan 221 VI. Self-management resources and tools 226 VII. Clinical pr actice guidelines 226 24 Nonhormonal Contr aception 230 Kimberley Chastain I. Introduction and gener al background 230 II. Database 234 III. Assessment 235 IV. Goals of clinical management 235 V. Plan 235 VI. Self-management resources and tools 236 25 Urinary Incontinence in Women 237 Janis Luft I. Introduction and gener al background 237 II. Initial ev aluation 238 III. Assessment 239 IV. Goals of clinical management 240 V. Plan 240 VI. Self-management resources and tools 244 Section i V Obstetric Health Maintenance and Promotion 26 The Initial Pr enatal Visit 246 Rebekah Kaplan I. Definition and background 246 II. Database 246 III. Assessment 248 IV. Goals of clinical management 248 V. Plan 248 VI. Internet resources 252 27 Pr enatal Genetic Screening and Diagnosis 253 Deborah Anderson I. Introduction and gener al background 253 II. Database 256Section iii Common Women's Health Presentations 18 Abnormal Uterine Bleeding 140 Pilar Bernal de Pheils I. Introduction and gener al background 140 II. Database 145 19 Amenorrhea and P olycystic Ovary Syndrome 156 Pilar Bernal de Pheils I. Introduction and gener al background 156 II. Database 158 III. Assessment 161 IV. Goals of clinical management 161 V. Plan 161 VI. Self-management resources and tools 169 20 Scr eening for Intraepithelial Neoplasia and Cancer of the Lower Genital Tract 171 Mary M. Rubin and Lynn Hanson I. Introduction and gener al background 171 II. Database 176 III. Assessment 177 IV. Goals of clinical management 178 V. Plan 179 21 F emale and Male Sterilization 188 Janis Luft I. Introduction and gener al background 188 II. Database 190 III. Assessment 190 IV. Plan 190 V. Self-management resources 190 22 Hormonal Contr aception 192 Lynn Hanson I. Introduction and gener al background 192 II. Database 204 III. Assessment 205 IV. Goals of clinical management 205 V. Plan 205 Appendix 22-1: Comparison of Hormonal Contraceptive Methods 209ix Contents

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

VI. Internet resources for providers, clients, and families 288 32 Common Discomforts of Pregnancy 290 Cynthia Belew and Jamie Meyerhoff I. Introduction to common discomforts of pregnancy 290 II. P oor quality of sleep 290 III. Musculoskeletal 291 IV. Gastrointestinal tr act 294 V. Heartburn 298 33 Gestational Diabetes M ellitus: Early Detection and Management in Pregnancy 304 Maribeth Inturrisi I. Introduction and gener al background 304 II. Database 305 III. Goals of clinical management 306 IV. Plan 306 34 Hypertension in Pr egnancy: Preeclampsia-Eclampsia 313 Kim Q. Dau and Jenna Shaw-Battista I. Introduction and gener al background 313 II. Database 315 III. Assessment 316 IV. Goals of clinical management 317 V. Plan 317 35 Pr eterm Labor Management 320 Mary Barger I. Introduction and gener al background 320 II. Database 320 III. Assessment 321 IV. Goals of clinical management 321 V. Plan 321 36 Urinary Tract Infection Prevention and Management in Pregnancy 323 Mary Barger I. Introduction and gener al background 323 II. Database 323 III. Assessment 324 IV. Goals of clinical management 324 V. Plan 324III. Assessment 256 IV. Goals for clinical management 256 V. Plan 257 I. Prenatal genetic diagnosis: Introduction and general background 257 II. Database 258 III. Assessment 258 IV. Goals for clinical management 258 V. Plan 258 28 The Return Pr enatal Visit 260 Rebekah Kaplan and Margaret Hutchison I. Definition and background 260 II. Database 260 III. Assessment 262 IV. Goals of clinical management 263 V. Plan 263 29 The Postpartum Visit 268 Jenna Shaw-Battista and Holly Cost I. Introduction and gener al background 268 II. Database 269 III. Assessment 271 IV. Goals for clinical management 271 V. Plan 272 30 Guidelines for Medical Consultation, Interpro fessional Collaboration, and Transfer of Care During Pregnancy and Childbirth 277 Jenna Shaw-Battista I. Introduction and gener al background 277 Section V Common Obstetric Presentations 31 Birth Choices for Women with a Previous Cesarean Delivery 282 Rebekah Kaplan I. Introduction and gener al background 282 II. Risks and benefits of TOL versus repeat cesarean delivery 282 III. Data collection 284 IV. Goals for clinical management/assessment 284 V. Plan 284x CONTENTS

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

41 Pr eexposure Prophylaxis for HIV 385 Barbara Newlin and Brooke Finkmoore 385 I. Introduction and gener al background 385 II. Database 386 III. Assessment 388 IV. Goals of clinical management 388 V. Plan 388 VI. Resources for clinicians 389 Appendix 41-1: Behavioral Risk Assessment Questions 391 Appendix 41-2: Screening Tool for MSM 392 Appendix 41-3: Summary of Guidance for Pr EP Use 393 Appendix 41-4: Provider Checklist 394 Section V ii Common Complex Adult Gerontology Presentations 42 Abscess Management 395 Rosalie D. Bravo I. Introduction and gener al background 395 II. Database 395 III. Assessment 396 IV. Goals of clinical management 396 V. Plan 397 43 Anemia 401 Michelle M. Marin and Laurie Jurkiewicz I. Introduction and gener al background 401 II. Database 405 III. Assessment 407 IV. Goals of clinical management 410 V. Plan 410 VI. Self-management resources and tools 413 44 Anticoagulation Ther apy (Oral) 415 Fran Dreier and Linda Ray I. Introduction and gener al background 415 II. P atient education and safety 421 III. T arget-specific anticoagulants 424 45 Anxiety 428 Esker-D Ligon I. Introduction and gener al background 428 II. Database 429Section V i Adult Gerontology Health Maintenance and Promotion 37 Adult Health Maintenance and Promotion 326 Helen R. Horvath and Hattie C. Grundland I. Introduction and gener al background 326 II. Individualizing screening decisions in the geriatric population 326 III. Database 331 IV. Assessment 333 V. Goals of clinical management 333 VI. Plan 333 VII. Self-management tools and resources for health professionals 333 38 Healthcar e Maintenance for Adults with Developmental Disabilities 345 Geraldine Collins-Bride and Clarissa Kripke I. Introduction and gener al background 345 II. Database 348 III. Assessment 351 IV. Plan 352 V. Self-management resources and tools 362 39 Healthcar e Maintenance for Transgender Individuals 365 Melissa Wong and Kathryn Wyckoff I. Introduction and gener al background 365 II. Database 366 III. Assessment 367 IV. Plan 367 Appendix A: A Guide to Common Gender-Neutral Pronoun Choices Among the Trans Community 374 40 P ostexposure Prophylaxis for HIV Infection 375 Barbara Newlin and Brooke Finkmoore I. Introduction and gener al background 375 II. Database 380 III. Assessment 383 IV. Plan 383 V. Clinician and patient resources 383xi Contents

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

50 Chr onic Nonmalignant Pain Management 477 Jo Anne M. Saxe, Nicole Una, and Kellie Mc Nerney I. Introduction and gener al background 477 II. Database 478 III. Assessment 480 IV. Goals of clinical management 481 V. Plan 482 VI. P atient education 491 VII. Chronic pain support resources and tools 492 51 Chr onic Viral Hepatitis 494 Miranda Surjadi I. Introduction and gener al background 494 II. Database 495 III. Assessment 498 IV. Goals of clinical management 498 V. Plan 499 VI. Self-management resources and tools 503 52 Dementia 504 Jennifer Merrilees I. Introduction and gener al background 504 II. Database 505 III. Assessment 509 IV. Goals of clinical management 509 V. Plan 509 VI. Assessment and management of concomitant conditions 512 VII. Assessment of the status of the family caregiver 512 VIII. Resources and tools 512 53 Depr ession 514 Matt Tierney and Beth Phoenix I. Introduction and gener al background 514 II. Database 516 III. Assessment 518 IV. Goals of clinical management 519 V. Plan 521 VI. Self-management resources and tools 527 54 Diabetes Mellitus 529 Carolina Noya and Maureen Mc Grath I. Introduction and gener al background 529 II. Database 529 III. Assessment 531 IV. Goals of clinical management 532III. Assessment 431 IV. Plan 432 V. Special populations 434 VI. Self-management resources and tools 435 46 Asthma in Adolescents and Adults 436 Susan L. Janson I. Introduction and gener al background 436 II. Database 437 III. Assessment 438 IV. Goals of clinical management to control asthma 438 V. Plan 439 VI. Future update topics in asthma 446 47 Benign Pr ostatic Hyperplasia 449 Jean N. Taylor-Woodbury I. Introduction and gener al background 449 II. Database 450 III. Assessment 451 IV. Goals of clinical management 451 V. Plan 451 VI. Self-management resources and tools 454 Appendix 47-1: The American Urological Association (AUA) Symptom Index for Benign Prostatic Hyperplasia (BPH) and the Disease Specific Quality of Life Question 456 Appendix 47-2: Benign Prostatic Hyperplasia (BPH) Impact Index (“Bother” Score) 457 48 Cancer Survivor ship in Adult Primary Care 458 Tara D. Lacey and Sheila N. Lindsay I. Introduction and background 458 II. Database 459 III. Assessment 460 IV. Goals of clinical management 462 V. Plan 463 VI. Self-management resources 466 49 Chr onic Obstructive Pulmonary Disease 468 Lynda A. Mackin I. Introduction and gener al background 468 II. Database 469 III. Goals of clinical management of stable COPD 471 IV. Plan 471 V. Care from a population health perspective 475xii CONTENTS

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

V. Plan 578 VI. Self-management resources and tools 581 60 Hypertension 583 Judith Sweet and Steve Protzel I. Introduction and definition 583 II. Database 584 III. Assessment 587 IV. Goals of clinical management 587 V. Plan and management 587 61 Intimate Partner Violence (Domestic Violence) 594 Rosalind De Lisser, Deborah Johnson, Jo Anne Saxe, and Cecily Reeves I. Introduction and gener al background 594 II. T he focused IPV assessment and database 598 III. Assessment 600 IV. Goals of clinical management 601 V. Plan 601 VI. Self-management resources and tools 601 62 Irritable Bowel Syndr ome 605 Karen C. Bagatelos, Geraldine Collins-Bride, and Fran Dreier I. Introduction and gener al background 605 II. Database 606 III. Assessment 607 IV. Goals of clinical management 607 V. Plan 607 VI. Self-management e Resources 612 63 Lipid Disor ders 613 Caitlin Garvey I. Introduction and gener al background 613 II. Database 614 III. Assessment 615 IV. Goals of clinical management 615 V. Plan 615 VI. Self-management resources and tools 618 64 Low Back P ain 619 H. Kate Lawlor I. Introduction/gener al background 619 II. Database 619 III. Assessment 625 IV. Plan 626 V. Self-management resources and tools 633V. Plan 532 VI. Self-management resources and tools 537 55 Epilepsy 539 Maritza Lopez, Paul Garcia, and M. Robin Taylor I. Introduction and gener al background 539 II. Database 539 III. Assessment 540 IV. Goals of clinical management 541 V. Plan 545 VI. Self-management resources 546 56 Gastr oesophageal Reflux Disease 547 Karen C. Bagatelos, Geraldine Collins-Bride, and Fran Dreier I. Definition and overview 547 II. Database 548 III. Assessment 549 IV. Goals of clinical management 550 V. Plan 550 VI. Self-management resources 553 57 Geriatric Syndr omes 554 Courtney Gordon I. Introduction and gener al background 554 II. Database 556 III. Assessment 560 IV. Goals of clinical management 562 V. Plan 562 VI. Online resources for clinicians, patients, and caregivers 564 58 Heart F ailure 566 Lisa Guertin and Barbara Boland I. Introduction and gener al background 566 II. Database 567 III. Assessment 568 IV. Goals of clinical management 568 V. Plan 568 VI. Self-management resources and tools 574 59 Herpes Simplex Infections 575 Hattie C. Grundland and Geraldine Collins-Bride I. Introduction and gener al background 575 II. Database 577 III. Assessment 577 IV. Goals of clinical management 578xiii Contents

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

IV. Goals of clinical management 687 V. Plan 687 VI. Self-management resources and tools 690 69 Upper Back and Neck P ain Syndromes 691 Rossana Segovia I. Introduction and gener al background 691 II. Database 695 III. Assessment 699 IV. Goals of clinical management 700 V. Plan 700 VI. Self-management resources and tools 703 70 Upper Extremity Tendinopathy: Bicipital Tendinopathy, Lateral Epicondylitis, and de Quervain's Tenosynovitis 705 Barbara J. Burgel I. Introduction and gener al background 705 II. Database 706 III. Assessment 708 IV. Goals of clinical management 709 V. Plan 709 VI. Self-management resources and tools 711 71 W ound Care 713 Cynthia Johnson and Patricia Mc Carthy-Horton I. Introduction and gener al background 713 II. Database 714 III. Assessment 718 IV. Goals of clinical management 718 V. Plan 718 Index 722 65 Obesity 634 Sherri Borden, David Besio, and Geraldine Collins-Bride I. Introduction and gener al background 634 II. Database 636 III. Assessment 638 IV. Goals of clinical management 638 V. Plan 642 VI. Self-management resources 647 66 Primary Car e of HIV-Infected Adults 649 Suzan Stringari-Murray and Christopher Berryhill Fox I. Introduction and gener al background 649 II. HIV screening and testing 657 III. Database 661 IV. Assessment 663 V. Goals of clinical management 663 VI. Plan 663 VII. Resources 668 67 Smoking Cessation 672 Kellie Mc Nerney and Lewis Fannon I. Introduction and background 672 II. Database 675 III. Assessment 676 IV. Goals of clinical management 676 V. Plan 677 VI. Self-management resources 679 VII. Consultation 680 68 Thyr oid Disorders 682 Jo Anne M. Saxe I. Introduction and gener al background 682 II. Database 683 III. Assessment 687xiv CONTENTS

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

The editors would like to acknowledge the following individuals for their contributions to the publication of this book: Lou F annon, our fa bulous c olleague a nd as sociate e ditor for thi s t ext, w ho pr ovided exceptional support to authors, reviewers, and the publisher through timely and thoughtful communications, constructive editorial feedback, and meticulous attention to timelines and publishing details. It has been a pleasure and honor working with you! Our c olleagues a t UC SF in the S chools of N ursing, M edicine, P harmacy, a nd D entistry; the Department of Physical Therapy; the UCSF Medical Center; and community organizations and other universities/colleges who contributed much time and expertise as authors and reviewers of this manuscript. We are grateful for having such an esteemed team. acknow L e D gment S xv

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Priscilla Abercrombie, RN, NP, Ph D, AHN-BC Founder, Women's Health & Healing Healdsburg, CA Abbey Alkon, RN, PNP, Ph D, FAAN Professor Department of Family Health Care Nursing University of California, San Francisco, School of Nursing San Francisco, CA Deborah Anderson, MS, CNM Health Sciences Clinical Professor School of Medicine & Department of Family Health Care Nursing University of California, San Francisco Department of Obs tetrics, G ynecology & R eproductive S ciences San Francisco General Hospital San Francisco, CA Karen C. Bagatelos, RN, MSN, FNP Assistant Clinical Professor (volunteer) Department of Community Health Systems Family Nurse Practitioner Department of Medicine, Division of Gastroenterology University of California, San Francisco San Francisco, CA Ann Birenbaum Baker, RN, MS, CPNP Pediatric Nurse Practitioner Newborn Nursery, Department of Medicine, Division of Neonatology University of California San Francisco San Francisco, CA Mary K. Barger, RN, CNM, MPH, Ph D Associate Professor Hahn School of Nursing and Health Sciences and Beyster Institute for Nursing Research University of San Diego San Diego, CA Cynthia Belew, CNM, WHNP-C, MS Health Sciences Associate Clinical Professor Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CAPilar Bernal de Pheils, RN, MS, FNP-BC, FAANHealth Sciences Clinical Professor Department of Family Health Care Nursing University of California, San Francisco, School of Nursing San Francisco, CA David Besio, MS, RD Senior Clinical Dietitian UCSF Adult Weight Management Program Nutrition and Food Services University of California, San Francisco Medical Center San Francisco, CA Barbara A. Boland, RN, MS, ANP-BC, CDE Adult Nurse Practitioner Edward S. Cooper Practice University of Pennsylvania Health System Philadelphia, PA Sherri Borden, RN, MS, ANP-BC, CNS Adult Nurse Practitioner & Psychiatric Clinical Nurse Specialist & Assistant Clinical Professor (volunteer) Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Rosalie D. Bravo, RN, MS, ACNP-BC Health Sciences Associate Clinical Professor Adult/Gerontology Acute Care Nurse Practitioner Program, Department of Physiological Nursing University of California, San Francisco, School of Nursing San Francisco, CA Brian Budds, RN, MS, ANP, JD Adult Nurse Practitioner/Attorney at Law Associate Clinical Professor (volunteer)Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Adjunct Professor University of San Francisco, School of Law San Francisco, CA Assistant Professor and Vice-Chair Health Leadership and Innovation Department University of San Francisco, School of Nursing and Health Professions San Francisco, CA contributor S xvii

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Kim Q. Dau, RN, MS, CNM Health Sciences Assistant Clinical Professor Director, UCSF Nurse-Midwifery/WHNP Education Program Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Rosalind De Lisser, MS, RN, FNP-BC, PMHNP-BC Health Sciences Assistant Clinical Professor Co-Director Psychiatric Mental Health Nurse Practitioner Program Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Fran Dreier, RN, MHS, FNP Associate Clinical Professor (volunteer)Department of Community Health Systems University of California San Francisco, School of Nursing Family Nurse Practitioner, Urgent Care and Anticoagulation Clinics San Francisco, CA Karen G. Duderstadt, Ph D, RN, CPNP, PCNS, FAAN* Health Sciences Clinical Professor Director, Pediatric Nurse Practitioner Program Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Lewis D. Fannon, RN, MS, ANP-BC* Health Sciences Assistant Clinical Professor Department of Community Health Systems University of California, San Francisco School of Nursing San Francisco, CA Brooke Finkmoore, RN, MS, MPH, AGPCNP-BC Adult-Gerontology Primary Care Nurse Practitioner Mission Neighborhood Health Center San Francisco, CA Christopher Berryhill Fox, RN, MS, ANP-BC Health Sciences Assistant Clinical Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Paul A. Garcia, MD Professor of Neurology Associate Dean for Academic Affairs, School of Medicine University of California, San Francisco San Francisco, CABarbara J. Burgel, RN, ANP-BC, Ph D, FAANClinical P rofessor & C ertified O ccupational H ealth N urse S pecialist Department of Community Health Systems University of California, San Francisco, School of Nursing San Francisco, CA Annette Carley, RN, DNP, NNP-BC, PCPNP-BC Health Sciences Clinical Professor Coordinator, Advanced Practice Neonatal Nursing (APNN) Specialty Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Kimberley Chastain, MSN, ARNP-BC Clinician IIIPlanned Parenthood Seattle, WA Angel K. Chen, RN, MSN, CPNP Health Sciences Associate Clinical Professor and Vice Chair Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Geraldine M. Collins-Bride, RN, ANP-BC, MS, FAAN* Health Sciences Clinical Professor & Vice Chair of Faculty Practice Department of Community Health Systems Adult Nurse Practitioner, Division of General Internal Medicine,University of California San Francisco, Schools of Nursing and Medicine Faculty, O ffice of D evelopmental P rimary C are Department of Family and Community Medicine University of California San Francisco San Francisco, CA Holly Cost, RN, MS, CNM Associate Clinical Professor (volunteer)Department of Obs tetrics, G ynecology & R eproductive S ciences San Francisco General Hospital University of California San Francisco, School of Nursing San Francisco, CA Lucy S. Crain, MD, MPH, FAAP Clinical Professor of Pediatrics, Emerita University of California San Francisco Adjunct Professor Stanford University Palo Alto, CAxviii CONTribu TOr S

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Mary Anne M. Israel, RN, MS, PNP Health Sciences Assistant Clinical Professor Department of Family Health Care Nursing University of California, San Francisco, School of Nursing San Francisco, CA Susan L. Janson, Ph D, RN, ANP-C, CNS, FAAN Professor Emerita of Nursing and Medicine Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Cynthia Johnson, MS, GNP-BC, FGNLA Geriatric Nurse Practitioner Integrated Soft Tissue Infection Service Clinic (ISIS)San Francisco General Hospital San Francisco, CA Deborah Johnson, MSN, APRN, PMHNP-BC Health Sciences Assistant Clinical Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Laurie Jurkiewicz, RN, MS, CNM Assistant Clinical Professor (volunteer)Department of Obs tetrics, G ynecology & R eproductive S ciences San Francisco General Hospital University of California San Francisco, School of Nursing San Francisco, CA Rebekah Kaplan, RN, MS, CNM* Health Sciences Associate Clinical Professor Department of Family Health Care Nursing & School of Medicine University of California, San Francisco Department of Obs tetrics, G ynecology & R eproductive S ciences San Francisco General Hospital San Francisco, CA Victoria F. Keeton, RN, CPNP, CNS Pediatric Nurse Practitioner Children's Health Center San Francisco General Hospital San Francisco, CA Clarissa Kripke, MD, FAAFP Clinical Professor Director, O ffice of D evelopmental P rimary C are Department of Family and Community Medicine University of California San Francisco, School of Medicine San Francisco, CA T ara Lacey, RN, GNP-BC, AOCNP Geriatric Nurse Practitioner UCSF Comprehensive Cancer Center University of California San Francisco San Francisco, CACaitlin Garvey, RN, MS, AGPCNP-BCAdult-Gerontology Primary Care Nurse Practitioner U. S. Department of Veterans Affairs San Francisco VA Medical Center San Francisco, CA Courtney Gordon, DNP, GNP-BC, MSN Assistant Clinical Professor of Nursing (volunteer)Geriatric Nurse Practitioner UCSF Care at Home Division of Geriatrics University of California San Francisco San Francisco, CA Bridget Ward Gramkowski, RN, MS, CPNP Pediatric Nurse Practitioner Almaden Pediatrics San Jose, CA Hattie C. Grundland, RN, MS, ANP-BC Associate Clinical Professor (volunteer) Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Adult Nurse Practitioner Department of Public Health San Francisco, CA Lisa Guertin, RN, MS, ACNP Health Sciences Assistant Clinical Professor Department of Physiological Nursing University of California San Francisco, School of Nursing San Francisco, CA Lynn Hanson, RN, MS, WHNP Women's Health Nurse Practitioner Department of Obs tetrics, G ynecology F aculty P ractice University of California San Francisco San Francisco, CA Helen R. Horvath, RN, MS, ANP-BC, PHN Health Sciences Assistant Clinical Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Margaret Hutchison, RN, MS, CNM Leadership Council Chair, Nurse-Midwives of San Francisco General Hospital Health Sciences Clinical Professor Department of Obs tetrics, G ynecology & R eproductive S ciences University of California, San Francisco San Francisco, CA Maribeth Inturrisi, RN, MS, CNS, CDE Certified Diabetes Educator Sweet Success Program Sutter Pacific Physician Foundation San Francisco, CAxix Contributors

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Former Clinical Director, Pediatric Asthma Clinic Children's Health Center San Francisco General Hospital San Francisco, CA Michelle M. Marin, RN, MS, ANP-BC Assistant Clinical Professor (volunteer) Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Patricia Mc Carthy-Horton, MS, ANP-BC, WOCN Adult Nurse Practitioner San Francisco General Hospital San Francisco, CA Maureen Mc Grath, MS, PNP-BC, BC-ADM Health Sciences Associate Clinical Professor Coordinator, Diabetes Minor Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Kellie Mc Nerney, RN, MS, FNP-BC Family Nurse Practitioner Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Jennifer Merrilees, RN, Ph D Health Sciences Associate Clinical Professor Clinical Nurse Specialist UCSF Memory and Aging Center University of California San Francisco San Francisco, CA Jamie Meyerhoff, CNM, WHNP Women's Health Nurse Practitioner Tigerlily Women's Health & Midwifery Carmel Valley, CA Erica Monasterio, MN, FNP-BC Health Sciences Clinical Professor Director, Family Nurse Practitioner Program, Department of Family Health Care Nursing Nursing Faculty, Division of Adolescent and Y oung Adult Medicine University of California San Francisco, Schools of Nursing and Medicine San Francisco, CA Barbara Newlin, RN, MS, ANP-BC Assistant Clinical Professor (volunteer)Department of Community Health Systems University of California, San Francisco, School of Nursing San Francisco, CAH. Kate Lawlor, RN, MS, ANP-BCAssociate Clinical Professor (volunteer) Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Instructor Foundations of Patient Care University of California San Francisco, School of Medicine San Francisco, CA Esker-D Ligon, RN, MSN, ANP-BC Assistant Clinical Professor (volunteer)Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Adult Nurse Practitioner Kaiser Permanente Medical Center Vallejo, CA Sheila N. Lindsay, MS, RN, ANP-BC, OCN Adult Nurse Practitioner UCSF Helen Diller Family Comprehensive Cancer Center University of California San Francisco San Francisco, CA Maritza Lopez, RN, MS, CNS Epilepsy Clinical Nurse Specialist UCSF Epilepsy Center University of California San Francisco San Francisco, CA Janis Luft, RN, MSN, WHNP Associate Adjunct Clinical Professor (volunteer), Department of Family Health Care Nursing University of California San Francisco, School of Nursing Women's Health Nurse Practitioner UCSF Women's Health Behavioral and Non-surgical T reatment Specialist, UCSF Women's Continence Center Department of Obs tetrics, G ynecology & R eproductive S ciences San Francisco, CA Lynda A. Mackin, RN, Ph D, AGPCNP-BC, CCNS Health Sciences Clinical Professor Department of Physiological Nursing University of California San Francisco, School of Nursing San Francisco, CA Nanette Madden, RN, MS, PNP Health Sciences Associate Clinical Professor Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CAxx CONTribu TOr S

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Rossana Segovia, RN, MS, ANP-BC, COHN-S Associate Clinical Professor (volunteer)University of California San Francisco, School of Nursing San Francisco, CA Administrative Nurse Manager Primary Care Services University of California San Francisco Medical Center San Francisco, CA Andrea Crosby Shah, RN, FNP Assistant Clinical Professor (volunteer)Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Family Nurse Practitioner Children's Health Center San Francisco General Hospital San Francisco, CA Jenna Shaw-Battista, RN, Ph D, NP, CNM Health Sciences Associate Clinical Professor Department of Family Health Care Nursing University of California San Francisco School of Nursing San Francisco, CA Certified Nurse Midwife Communicare Health Services Davis, CA Suzan Stringari-Murray, RN, MS, ANP-BC Health Sciences Clinical Professor, Emerita Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Miranda Surjadi, RN, MS, ANP-BC Health Sciences Assistant Clinical Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Judith Sweet, MS, FNP-C, NC-BC Adjunct Associate Professor California Institute of Integral Studies San Francisco, CA Associate Clinical Professor (volunteer) University of California San Francisco, School of Nursing San Francisco, CA M. Robin T aylor, MSN, FNP Clinical Research Manager Department of Neurology University of California, San Francisco San Francisco, CACarolina E. Noya, FNP-BC, MSHealth Sciences Assistant Clinical Professor Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Beth Phoenix, Ph D, RN, FAAN Health Sciences Clinical Professor Co-Director, Psychiatric Mental Health Nurse Practitioner Program Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Steven Protzel, Pharm D Health Sciences Associate Clinical Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Linda Ray, RN, MSN, ANP-BC Adult Nurse Practitioner Anticoagulation Clinic, UCSF Medical Center San Francisco, CA Assistant Clinical Professor (volunteer) University of California San Francisco, School of Pharmacy San Francisco, CA Cecily Reeves, RN, MSN, Ph D, FNP-C, PA-C, DFAAPA Professor Samuel Merritt University, School of Nursing Oakland, C A Mary M. Rubin, RN-C, Ph D, CRNP, FAANPCertified Registered Nurse Practitioner Clinical Professor (retired)Women's Health Care Specialist Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco San Francisco, CA Jo Anne M. Saxe, RN, ANP-BC, MS, DNP, FAAN* Health Sciences Clinical Professor Director, Adult Gerontology Primary Care Nurse Practitioner Masters Specialty Program Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Adult Nurse Practitioner and Faculty San Francisco VA Medical Center Center of Excellence in Primary Care Education San Francisco, CA Naomi A. Schapiro, RN, Ph D, CPNP Health Sciences Clinical Professor Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CAxxi Contributors

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Jessica Axelrod, RN, MS, PNP Pediatric Nurse Practitioner Children's Health Center San Francisco General Hospital San Francisco, CA Assistant Clinical Professor (volunteer) Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Robert B. Baron, MD, MS Professor of Medicine Associate Dean for Graduate and Continuing Medical Education University of California San Francisco, School of Medicine San Francisco, CA Douglas Bauer, MD Professor University of California San Francisco, School of Medicine San Francisco, CA Lisa Benaron, MD Medical Director, Far Northern Regional Center Board Certified in Internal Medicine, Pediatrics and Neurodevelopmental Disabilities Chico, CA Peter Berman, MD, MPH Assistant Clinical Professor (volunteer)Department of Family and Community Medicine University of California San Francisco, School of Medicine San Francisco, CA Judith Bishop, CNM, MPH Clinical Professor Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco, School of Medicine San Francisco, CA Certified Nurse Midwife (volunteer) Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Aaron B. Caughey, MD, MPP, MPH, Ph D Professor and Chair Department of Obs tetrics a nd G ynecology Associate Dean for Women's Health Research & Policy Oregon H ealth & S cience U niversity Portland, OR T onya Chaffee, MD, MPH Clinical Professor Department of Pediatrics University of California San Francisco, School of Medicine Jean N. T aylor-Woodbury, RN, MS, ANP-BCAssistant Clinical Professor (volunteer)Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Adult Nurse Practitioner Department of Public Health San Francisco, CA Matthew Tierney, RN, ANP, CNS, MS Health Sciences Associate Clinical Professor Department of Community Health Systems University of California, San Francisco, School of Nursing San Francisco, CA Nicole Una, RN, ANP-BC, MS Adult Nurse Practitioner T enderloin Health Services San Francisco, CA Damon Michael Williams, RN, PMHNP-BC, MS Family Psychiatric Nurse Practitioner Portland, OR M elissa Wong, RN, MS, AGNP-BC Adult Gerontology Nurse Practitioner Petaluma Health Center Petaluma, CA Kathryn Wyckoff, RN, MS, AGNP-BC Adult Gerontology Nurse Practitioner Harborview Downtown Clinics Seattle, WA ❚reviewers Brian Alldredge, Pharm DProfessor of Clinical Pharmacy & Neurology Vice Provost, Academic Affairs University of California San Francisco, Schools of Pharmacy and Medicine San Francisco, CA Ryan Anson, RN, MS, AGPCNP Adult Gerontology Primary Care Nurse Practitioner East Bay AIDS Center Alta Bates Summit Medical Center Oakland, C A Amy (Meg) Autry, MDProfessor Director of Graduate Medical Education Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco, School of Medicine San Francisco, CAxxii CONTribu TOr S

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Roxanne Garbez, RN, Ph D, ACNP, CNS Health Sciences Clinical Professor Director, Acute Care Nurse Practitioner Program Department of Physiological Nursing University of California San Francisco, School of Nursing San Francisco, CA Courtney Giraudo, RN, MS, CNS, CPNP Pediatric Nurse Practitioner Whitney NICU Follow-Up Clinic California Pacific Medical Center San Francisco, CA Richard Goldwasser, MD Private Practice (specializing in child, adolescent, and adult psychiatry) Mill Valley, CA Psychiatrist Consultant Redwood Coast & North Bay Regional Centers Josephina T. Gomez, MSN, FNP-BC, WOCN Family Nurse Practitioner,Benign Pancreas Program Stanford Digestive Health Stanford Hospital and Clinics Stanford, CA Juan M. González, MD, Ph D, FACOG Assistant Professor Division of Maternal-Fetal Medicine Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco San Francisco, CA Caitlin Hildebrand, MSN, AGPCNP-BC, MS-HAIL Director of Patient Care Services for Home Health and Hospice American Care Quest San Francisco, CA Nurse Practitioner & Electronic Health Record Specialist On L ok S enior H ealth San Francisco, CA Gail Hornor, RNC, CPNP, DNP Pediatric Nurse Practitioner Center for Family Safety and Healing Nationwide Children's Hospital Columbus, OH K athryn Johnson, MSN, RN, PMHNP-BC Associate Clinical Professor (volunteer)Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CAMedical Director Child and Adolescent Support Advocacy and Resource Center Director T een Services, San Francisco General Hospital San Francisco, CA Angelique Champeau, RN, MN, CPNP Pediatric Nurse Practitioner University of California San Francisco Children's Hospital Division of Pediatric Urology University of California San Francisco San Francisco, CA Jyu-Lin Chen, RN, Ph D, FAAN Associate Professor Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Linda Chin, MS Consultant Harvard T. H. Chan School of Public Health Former President/Executive Director Asian T ask Force Against Domestic Violence Boston, MA Doranne Donesky, RN, Ph D, ANP Associate Adjunct Professor Department of Physiological Nursing Acute Care Nurse Practitioner Program University of California San Francisco, School of Nursing San Francisco, CA Susannah Ewing, RN, WHNP Women's Health Nurse Practitioner Department of Obs tetrics, G ynecology, a nd R eproductive S ciences University of California San Francisco San Francisco, CA Rena K. Fox, MD Professor of Clinical Medicine Division of General Internal Medicine University of California San Francisco San Francisco, CA Michelle S. Franklin, MSN, APRN, FNP-BC, PMHNP-BC Family Nurse Practitioner Life Enhancement Medical Services Principal Investigator, Nurse Practitioner Education in Developmental Disabilities Faculty, UNC-CH Carolina Institute for Developmental Disabilities Chapel Hill, NCxxiii r eviewers

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Erin Mathes, MD Assistant Professor Departments of Dermatology and Pediatrics University of California San Francisco San Francisco, CA Mary Mays, FNP, CNM, MS Health Sciences Associate Clinical Professor (volunteer)Department of Family Health Care Nursing University of California San Francisco, School of Nursing San Francisco, CA Michelle Melisko, MD Associate Clinical Professor Department of Medicine University of California San Francisco, School of Medicine San Francisco, CA Aaron Miller, RN, MS, PMHNP Health Sciences Assistant Clinical Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Carol A. Miller, MD Clinical Professor Department of Pediatrics Advisory College Mentor Miller College University of California San Francisco, School of Medicine San Francisco, CA Gina Moreno-John, MD, MPH Clinical Professor of Medicine Division of General Internal Medicine University of California San Francisco Medical Center San Francisco, CA Rebecca S. Neuwirth, RN, MSN, NP-C, WHNP-BC Adult Nurse Practitioner and Women's Health Nurse Practitioner Golden Gate Community Health San Francisco, CAKaiser Permanente Redwood City, CA Don C. Ng, MD Clinical Professor of Medicine Medical Dir ector, Ge neral M edicine C linic a t O sher Division of General Internal Medicine University of California San Francisco San Francisco, CA Lynn O'Brien, FNP-BC Associate Clinical Professor (volunteer)Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CAKatherine Julian, MDProfessor of Clinical Medicine Division of General Internal Medicine University of California San Francisco Medical Center San Francisco, CA Henry Kahn, MD Clinical Professor of Medicine Division of General Internal Medicine Health Sciences Clinical Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Steven R. Kayser, Pharm D Professor Emeritus Department of Clinical Pharmacy University of California, San Francisco, School of Pharmacy San Francisco, CA Christopher M. King, RN, MS, AGPCNP Adult Gerontology Primary Care Nurse Practitioner San Mateo Medical Center-Edison Clinic National HIV/AIDS Clinician's Consultation Center San Francisco General Hospital University of California San Francisco San Francisco, CA Sharon Knight, MD Clinical Professor Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco San Francisco, CA Abner Korn, MD Professor Director of Gynecology San Francisco General Hospital Division University of California San Francisco San Francisco, CA Charlotte Kuo, APRN-BC, ANP, CDE Adult Nurse Practitioner Diabetes Clinic San Francisco General Hospital San Francisco, CA Catherine Lyons, NP, MSN, MPH Nurse Practitioner (retired)University of California San Francisco AIDS Program San Francisco General Hospital San Francisco, CA Andrea Marmor, MD, MSEd Associate Professor Department of Pediatrics University of California San Francisco, School of Medicine San Francisco, CAxxiv CONTribu TOr S

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Suzanne Seger, CNM, MSN, MTS Health Sciences Associate Professor (volunteer)Departments of Obs tetrics & G ynecology & F amily H ealth C are N ursing University of California San Francisco San Francisco, CANurse Midwife Tiburcio Vasquez Health Center Hayward, CA Dominika Seidman, MD Associate Physician Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco, School of Medicine San Francisco, CA Carlin Senter, MD Assistant Clinical Professor Primary Care Sports Medicine Departments of M edicine a nd Or thopedics U niversity of California, San Francisco San Francisco, CA Vicki Smith, RN, MS, FNP-BC, PMHNP Assistant Clinical Professor (volunteer)Family and Psychiatric Mental Health Nurse Practitioner Department of Community Health Systems University of California, San Francisco, School of Nursing San Francisco, CA Mari-Paule Thiet, MD Professor and Vice Chair Director, Division of Maternal-Fetal Medicine Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco San Francisco, CA Stephanie T sao, MSN, ANP-BC Adult Nurse Practitioner Healthy S an F rancisco A sthma/COPD P rogram Dir ector San Francisco General Hospital San Francisco, CA Juan Vargas, MD Professor of C linical Obs tetrics, G ynecology & R eproductive S ciences Professor of Clinical Radiology University of California, San Francisco Carol S. Viele, RN, MS, OCN Associate Clinical Professor (volunteer)Department of Physiological Nursing University of California, San Francisco School of Nursing San Francisco, CAFamily Nurse Practitioner VA Medical Center San Francisco, CA Sarah B. Pawlowsky, PT, DPT, OCS Associate Clinical Professor San Francisco State University Core Faculty in the UCSF/SFSU Graduate Program in Physical Therapy San Francisco, CA Susan Penney, JD Director of Medical Risk Management University of California San Francisco Medical Center San Francisco, CA Yvonne Piper, MLIS, MS, RN, FNP-C Family Nurse Practitioner San Francisco Department of Public Health, STD Prevention and Control (City Clinic) San Francisco, CA Michael S. Policar, MD, MPH Clinical P rofessor of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco, School of Medicine San Francisco, CA Patricia Purcell, RN, MS, FNP Family Nurse Practitioner Southeast Health Center Department of Public Health San Francisco, CA Neal L. Rojas, MD, MPH Associate Clinical Professor of Pediatrics Department of Pediatrics University of California San Francisco, School of Medicine San Francisco, CA Ronald J. Ruggiero, Pharm D Pharmacist Specialist in Women's Health Clinical Professor Departments of C linical P harmacy a nd Obs tetrics, G ynecology & R eproductive Sciences University of California San Francisco San Francisco, CA George Sawaya, MD Professor Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco, School of Medicine San Francisco, CA Allyson Scott, MS, LGC Genetic Counselor Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco Medical Center San Francisco, CA xxv r eviewers

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Allen Wong, DDS, Ed D Professor and Director, AEGD Program Director, Hospital Dentistry Program University of the Pacific Dugoni School of Dentistry San Francisco, CA Mary Wong, RN, MSN, ANP-BC Adult Nurse Practitioner Division of Cardiology University of California San Francisco Medical Center San Francisco, CALaura Wagner, Ph D, RN, GNP, FAANAssistant Professor Department of Community Health Systems University of California San Francisco, School of Nursing San Francisco, CA Sharon Wiener, RN, MPH, CNM Health Sciences Clinical Professor Department of Obs tetrics, G ynecology & R eproductive S ciences University of California San Francisco San Francisco, CA Elisabeth Wilson, MD, MPH Professor Department of Family and Community Medicine University of California San Francisco, School of Medicine San Francisco, CA * Indicates they are both an author and a reviewer. xxvi CONTribu TOr S

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Our t ext s trives t o in tegrate a n in terprofessional a pproach t o clinical decision making and thus is a collaborative effort with contributions from a rich variety of disciplines: nursing, pharmacy, medicine, dentistry, nutrition, physical therapy, genetic counseling, and the legal profession. This text includes: Sections on pe diatrics, w omen's he alth, o bstetrics, a nd a dult medicine S-O-A-P ( Subjective-Objective-Assessment-Plan) for mat-ting for easy reference Client/patient e ducational r esources t o e nhance s elf-management efforts Recommendations for situa tions w hen a dvanced pr actice nurses should consider physician or specialty consultation Access t o onl ine de cision s upport a nd p atient s elf-management resources and tools via the Jones & Bartlett Learning web-based library Section on le gal s cope of pr actice for a dvanced pr actice nu rses Our hope i s th at thi s t ext w ill pr ovide a s ubstantial a nd t imely r esource for a variety of busy clinicians. We also anticipate that this text will be an important addition to decision support toolkits that clinicians rely upon for providing individualized, patient-centered, team-based care. Welcome to the third edition of our clinical guidelines text for advanced practice nurses and other clinicians in primary care. This new text, Clinical Guidelines for Advanced Practice Nursing: An Interprofessional Approach, Third Edition, builds upon the pioneering work of nurse practitioners, certified nurse-midwives, and clinical nurse specialists that began over 35 years ago in the Ambulatory Care Center at the University of California, San Francisco. The initial clinical guidelines work focused on meeting regulatory requirements for practice, targeting across the lifespan health promotion and common health problems seen in primary care settings. In the second edition, the editors and contributing authors wrote evidence-supported clinical guidelines on common, complex chronic health problems and included chapters on health promotion for select vulnerable populations (adults with developmental disabilities and transgendered individuals). In this edition, we have continued to focus on complex chronic health problems and have scrubbed and revised all the chapters with the most current evidence-supported information. Based upon feedback from a select group of readers of the second edition, we enthusiastically added several new chapters that address prevalent and often problematic chronic issues in primary care: childhood obesity, HIV Pr EP, cancer survivorship, geriatric syndromes, and lipid disorders. Many of the previous edition chapters have undergone extensive revision: abnormal uterine bleeding, hormonal contraception, prenatal genetic screening, and immunizations to name a few. intro Duction xxvii

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“Let us always be open to acknowledge, respect, and learn from great leaders in any field or discipline. Let us always be able to critique the work of any leader to move forward ideas and substantive knowledge for the betterment of humanity. For, indeed, great progress is largely contingent upon thoughtful reflections, critiques, and the creative use of worthwhile ideas. ” —Florence Nightingale Courte sy of u. S. National Library of Medicine.

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management of advanced nursing practice in the clinical setting how to approach these questions and where to begin to find the information necessary to properly understand the limits of one's scope of practice and what steps need to be taken to ensure that one's practice is consistent with the appropriate legal framework. In a number of states, it is necessary for nurses to develop writ-ten documentation to support their expanded practice. Different states use different terms to describe these documents and require different specific elements be addressed. In most cases, the specific requirements for each state can be found in statutes or regulations, as discussed later. An explanation of practice guidelines, such as Standardized Procedures that are used in California, can be viewed at http://www. rn. ca. gov/pdfs/regulations/npr-b-20. pdf. ❚Overview Of Sc Ope Of p ractice Lega L   f ramew O rk ❚State Regulation of Professional Practice Control of the scope of practice of healthcare professionals rests at the level of state government. Although there are some areas of professional practice—including those relating to the advanced practice nursing roles—for which federal regulations have an impact, the basic definitions and limits of professional practice are determined at the state level. This can sometimes lead to confusion. For example, some feder-al regulations dealing with reimbursement requirements for feder-ally funded programs, such as Medicare and Medicaid, do address what can or should be done by advanced practice nurses. One such example is found in the Medicare Conditions of Participation for Rural Health Clinics (2013). 1 The regulations require that ❚intr Oducti On and g enera L Backgr O und Nurses, like all healthcare professionals, must act within the scope of practice as outlined in statutes and regulations. Failure to com-ply with this by exceeding the permissible scope of practice could result in professional discipline or even criminal prosecution. Advanced practice nurses (e. g., clinical nurse specialists, nurse anesthetists, nurse midwives, or nurse practitioners) frequently encounter issues related to the scope of their practice. These issues may arise as part of the individual nurse's ethical and professional concern or as a result of professional “friction” between nursing and other healthcare professions. This is espe-cially so when the advanced practice nurse's scope overlaps with areas that have traditionally been viewed as the practice of medi-cine. Regardless of what may trigger such concerns, it is imperative that advanced practice nurses and practice managers know how to ascertain what is and is not part of their scope of practice and what actions they may need to take to be in compliance with the applicable law or regulation. Clear understanding of one's scope of practice, which may in some states be defined by protocols or pro-cedures, can lead to enhanced collaboration among professionals, decreased professional tension, and safer, more effective provision of health care in clinical settings. Two key questions emerge when considering the issue of advanced practice nursing and scopes of practice. The first is the extent of what one, by virtue of being an advanced practice nurse, can do. Thus, the advanced practice nurse—or perhaps the clinical manager of a set-ting in which the advanced practice nurse is working or a collaborat-ing p hysician—wants to know the duties an advanced practice nurse may legally perform. Second, one must understand what constitutes the outer boundaries of a clinician's scope of practice. For example, one must know if there needs to be a supervisory relationship and, if so, of what nature and how it should be documented. Of course, it would be wonderful if those answers were always clear, concise, and readily available. Although that may occa-sionally be the case, it is not the rule. As such, this chapter out-lines for advanced practice nurses and those responsible for the Brian Budds and Jo anne m. Saxe Lega L Sc Ope Of a dvanced n ur S ing p ractice 1 42 CFR 491 et seq. This citation is to the Code of Federal Regulations. This particular chapter of the code addresses the regulations applied to healthcare providers who participate in the Medicare Program. These regulations can be accessed at the website of the Centers for Medicare and Medicaid, https://www. cms. gov/Medicare/Provider-Enrollment-and -Certification/Certificationand Complianc/RHCs. html© Eliks/Shutterstock; © donatas1205/Shutterstock 11CHAPTER

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Although not universally the case, most of these laws—known as practice acts—are relatively easy to locate. Most states have some board or agency charged with the regulation of each of the specific healthcare professions. Using California as an example, the statutes governing the practice of nursing authorize the Board of Registered Nursing to manage the practice of nursing within California. This state agency has a website (http://www. rn. ca. gov) on which it makes available links to the specific statutes relat-ing to the practice of nursing within California (California Board of Registered Nursing, 2013). An interactive list allowing one to link to boards of registered nursing throughout the country can be found at the website of the National Council of State Boards of Nursing (2014) at https://www. ncsbn. org/115. htm. When looking at state statutes to understand issues relating to scope of practice, it should be kept in mind that statutes may be written in fairly general and expansive language rather than in point-by-point details. One can think of the statutes as setting out the broad parameters of a professional practice without spelling out each particular specific aspect of the practice. Accordingly, stat-utes may be subject to interpretation, which could lead to differing opinions as to what conduct is within or outside the scope of prac-tice. Examples of the broad language include this excerpt from the Washington State statute defining advanced practice nursing: Advanced registered nursing practice means the perfor-mance of the acts of a registered nurse and the perfor-mance of an expanded role in providing healthcare services as recognized by the medical and nursing profes-sions, the scope of which is defined by rule by the com-mission. Upon approval by the commission, an advanced registered nurse practitioner may prescribe legend drugs and controlled substances contained in Schedule V of the Uniform Controlled Substances Act, chapter 69. 50 RCW, and Schedules II through IV subject to RCW 18. 79. 240(1) (r) or (s). Nothing in this section prohibits a person from practic-ing a profession for which a license has been issued under the laws of this state or specifically authorized by any other law of the state of Washington. This section does not prohibit (1) the nursing care of the sick, without compensation, by an unlicensed per-son who does not hold himself or herself out to be an advanced registered nurse practitioner, or (2) the prac-tice of registered nursing by a licensed registered nurse or the practice of licensed practical nursing by a licensed practical nurse. (Revised Code of Washington, 2000) ❚Sources: Regulations Another authority for the control of advanced nursing practice can be found in regulations, which like statutes have the force of law. Regulations are not the result of the legislative process but rather rules or orders issued by an arm of government, such as a particu-lar agency. The process of developing regulations typically involves participating rural health clinic staff include one or more physician assistants or nurse practitioners. They further require that the phy-sician assistant or nurse practitioner work with the physician on staff to develop and review clinic policies. However, although compliance with these federal regulations is required for reimbursement for services, the individual healthcare practitioner's practice is directly regulated by the state in which she or he is licensed to practice. Thus, although the Medicare Conditions of Participation (2013) may not require that advanced practice nurses work with physicians in these settings, the rules governing who can become a nurse practitioner and what scope of practice the person has are set by the individual states and are sub-ject to significant variation from state to state. The Patient Protection and Affordable Care Act (PPACA) and its approach to accountable care organizations (ACO) demonstrate how this federal role continues to develop. The law identifies nurse practitioners among the provider types who can be considered ACO professionals, a designation that permits Medicare patients to receive care under this program and providers to share in savings. In enacting PPACA, Congress anticipated an extraordinary increase in the number of persons covered by the act and also predicted that there would be a shortage of physicians to care for these patients. Accordingly, the PPACA contemplated the expanded role of nurse practitioners. However, the initial assignment of particular Medicare beneficiaries to specific ACO entities has been limited to those ben-eficiaries who receive care from physicians. (Kendig, 2014). In response to input from many sources, the Obama Administration has proposed new federal rules to address, among other things, the assignment of beneficiaries to these ACOs even if the beneficiary receives primary care from a nonphysician provider (Medicare Program, 2014). Though not yet resolved, this issue reminds us that federal rulemaking can have an impact on our local practice. Although states clearly retain the right to define and regu-late professional scope of practice in their jurisdiction, the federal reimbursement rules can have a pragmatic, indirect role in deter-mining what each provider may do. ❚Sources: Statutes There are several sources of authority for the regulation of profes-sional practice within states (and other jurisdictions within the United States). The most basic and important of these are statutes. Statutes are laws or acts passed by the legislative body of a particu-lar jurisdiction. As such, statutes represent the voice of the people's elected representatives with regard to permissible activities. Each state enacts a professional practice act addressing the spe-cific health professions within the jurisdiction. In general, these statutes define the training requirements of healthcare profession-als and what behaviors are allowed in the practice of the profession. For example, the State of California sets the basic legal framework for the practice of nursing in its Business and Professions Code (Nursing Practice Act, 2012). Similarly, the provisions for the prac-tice of medicine, physical therapy, dentistry, and so forth are found in other sections of the Business and Professions Code. 2 CHAPTER 1 | Legal Scope of Advanced Nursing Practice

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available on its website (California Board of Registered Nursing, 2013). Among the documents listed, the board has made available a statement helping to explain the statutes and regulations in regard to the roles of nurse practitioners and certified nurse specialists working in long-term-care settings (California Board of Registered Nursing, 2011). Although this kind of statement can be extremely helpful in understanding the complexities of the statutes and regulations, it does not of itself have the force of law. Even so, should a prac-tice issue ever come to the point of being litigated, courts may be inclined to give deference to the statement of specific regulatory agencies. In professional disciplinary actions, a licensing board may attempt to use such advisory statements as a basis for establishing gross negligence and incompetence. ❚Sources: Attorney General Opinions In some circumstances, issues are very complex and even con-tentious. Sometimes these situations result in an agency or some member of government seeking an official opinion from the state's attorney general to clarify issues. This may often be the case when there has been substantial change in existing statutes and regula-tions that has led to confusion or even turf battles between orga-nized medicine and advanced practice nurses. One example of this can be found in an opinion of the State of Michigan Attorney General (1980) about the ability of physicians to grant “unlimited authority” to advanced practice nurses to pre-scribe medications. One can see in reading this opinion the evolu-tion of Michigan law that led to confusion about just how much authority may be delegated and under what circumstances. In this example, a member of the state legislature asked the attor-ney general to issue an opinion. As is often the case, the opinion carefully lays out what the issues are and what the history has been that has led to the question. Then, the attorney general issues an opinion as to how she or he understands the law. Like the statements of the regulatory agencies, an attorney gen-eral's opinion does not carry the force of law. That is to say, such an opinion does not necessarily fully resolve the issue at controversy. However, courts routinely grant “great respect” or “great weight” to the opinions of attorneys general in cases that come before them. Thus, such opinions often have the power to effectively resolve a particular issue within a jurisdiction. ❚Sources: Statements of Professional Organizations Professional organizations that represent the interest of advanced practice nurses may issue statements or information about a par-ticular topic related to scope of practice. As with the other opin-ions cited here, these opinions or statements, although often very helpful, do not carry the force of law. One thing to keep in mind is that often these statements may be issued by the organization in its role as an advocate for the particular profession or advanced practice role. These position papers may occasionally be at odds with practice guidelines issued by physician advocacy groups and those who have particular expertise in an area drawing up specific rules, making them available for public comment, and then pro-mulgating or issuing them publicly. Because regulations are often developed by the agency or arm of government closest to the actual profession, they often are more detailed and specific than statutes. Regulations often spell out the details of how to implement the vision of the legislature as stated in the statutes. State health boards often provide links to scope of practice regu-lations. However, it is easier to find these links in some states than in others. Should it be difficult to find a direct link to an individual state's law and regulations, the reader may choose to do an Internet search on such terms as “advanced practice nursing statutes” or “nurs-ing regulations” and the particular state's name. Should this not help, one could always call the particular licensing agency and ask how to access the statutes and regulations governing nursing or the specific aspect of advanced practice nursing in which one is interested. Like statutes, regulations are readily available to the public. For example, in California, regulations addressing the practice of nurs-ing are found in the California Code of Regulations (California Legislative Information, n. d. ). Regulations in Title 16 address details relating to the practice of health professions, whereas those in Title 22 regulate how health care is provided in licensed institu-tions. Both require specific language. An example is the regulation describing what must appear in a “standardized procedure” docu-ment, required to allow registered nurses to practice beyond their usual scope of practice. The website of a particular state's agency charged with the regulation of healthcare professionals often has links to the state regulations surrounding a particular profession available on that website. For example, the Commonwealth of Massachusetts Board of Registration in Nursing has its website as part of the larger Health and Human Services Agency's section of the state gov-ernment website (www. mass. gov). Selecting “Nursing” from the “ A-Z T opic Index,” one can choose the link to “Statutes, Rules and Regulations” (Commonwealth of Massachusetts, 2014). ❚Sources: Statements of Regulatory Agencies Unfortunately, even a thorough reading and analysis of all perti-nent statutes and regulations may not yield a definitive answer to all questions regarding one's scope of practice. The issue in ques-tion may be complex enough that a simple answer may not be available in the statutes and regulations. For example, it may not be precisely clear what an advanced practice nurse may do in a very specific clinical setting under specific circumstances. When this is the case, the governing body (e. g., Board of Registered Nursing) may issue an advisory statement or some sort of information addressing the specific concern. These statements can be extremely helpful in allowing clinical practices and individ-ual practitioners to understand what is permissible or required in a particular circumstance. For example, the California Board of Registered Nursing makes multiple documents and sources of information about these issues Overview of Scope of Practice Legal Framework 3

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be a source of controversy in a medical legal case. Thus, within any treatment setting, it is important to consider a wide range of sourc-es in developing standards, protocols, or policies. A particularly helpful service offered by many professional orga-nizations is a regular legislative update. These updates often review legislation that has been passed or proposed within a year and that affects the particular area of practice covered by the organization. These updates, rather than clarify specific issues, are intended to inform readers of new laws and regulations and potential trends within the states. For example, a 2014 American Association of Nurse Practitioners report provides notes on the practice environ-ment by each state (full practice, reduced practice, and restricted practice) along with legislative alerts. ❚Other Sources There are other sources available to help understand scope of prac-tice issues as they relate to advanced practice nursing. Two deserve at least a brief mention as part of this discussion. The Center for the Health Professions is part of the University of California, San Francisco. The center engages in numerous activi-ties to improve health care through research and development projects. Among their efforts has been research into scope of prac-tice of health professionals. Their publication, Overview of Nurse Practitioner Scopes of Practice in the United States—Discussion, is a very valuable tool for understanding the state of scope of practice regulation and for accessing particular information (Christian, Dower, & O'Neill, 2007). Another valuable tool is a textbook devoted to issues relating to nurse practitioner practice and legal issues. Carolyn Buppert's (2015) Nurse Practitioner's Business Practice and Legal Guide addresses, among other topics, details about state regulation of nurse practitioner practice. It is hoped that this discussion orients advanced practice nurses to the resources for determining and understanding their particular scope of practice. ❚i SSue S re L ated t O c OLL a BO rative practice and d O cumentati O n Once the advanced practice nurse has been able to identify the resources for understanding scope of practice, it is imperative to determine the level of independence with which she or he can practice and the level of collaboration that is required by her or his jurisdiction. Furthermore, if there are requirements related to col-laborative practice, one needs to be able to determine how to meet and appropriately document those requirements. It has been widely noted that there is significant disparity in the terminology used to describe advanced practice nursing. For example, statutory language describing the nature of the required relationship between advanced practice nurses and physicians can include such terms as “supervise,” “collaboration with,” “delegate,” and even “collegial working relationship” (Ritter & Hansen-Turton, 2008). Furthermore, we have already seen that the nature of this relationship can lead—as it did in Michigan—to repeated changes in legislation and regulation that, in the end, required an attorney general opinion to sort it out. Although not a comprehensive list, the following issues are offered as a guide for understanding the possible requirements and methods of documenting compliance. Practitioners should consid-er each of these areas when attempting to set up practice or under-stand the extent of their scope of practice. ❚Fully Independent Practice As of 2014, 19 states and the District of Columbia allowed nurse practitioners to practice independently of physicians (American Association of Nurse Practitioners, 2014). That is, in such states, the nurse practitioner is permitted to diagnose, treat, and prescribe medications without supervision by or collaboration with a physi-cian. Alaska, Oregon, and Washington are examples of states that have this kind of broad scope of practice. ❚Some Collaboration, Supervision, or Delegation Required Most states require documentation of some sort of relationship with physician colleagues for the advanced practice nurse to prac-tice within that scope of practice. The nature of the “collaboration,” “supervision,” or “delegation” may vary significantly from state to state. Many states with this kind of requirement also require that there be a written agreement that sets forth the terms under which this relationship is defined. California's requirement of standardized procedures is an example of this need. ❚Collaboration or Supervision or Delegation Necessary for the Advanced Practice Nurse to Prescribe Medications in Most States Apart from the other elements of advanced practice nursing, such as diagnosis, ordering of diagnostic tests, and ordering of treatments, the issue of prescribing medications can be particu-larly difficult. The history of political and legislative difficulties in approaching this issue has been well documented elsewhere. The key issue here is that the advanced practice nurse wishing to have prescribing as part of her or his practice needs to be sure that all particular scope of practice requirements are met. In some states, advanced practice nurses' prescriptive/drug authority is delegated by a physician (e. g., T exas [T exas Board of Nursing, 2013]). Other states (e. g., California) require advanced practice nurses to have signed prescriptive agreements to prescribe, order, or furnish drugs (California Board of Registered Nursing, 2013). An example of this is found in the T exas legal framework, which allows for advanced practice without a written prescriptive agreement but requires one for the advanced practice nurse to be able to prescribe (T exas Board of Nursing, 2013). 4 CHAPTER 1 | Legal Scope of Advanced Nursing Practice

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❚Precise Nature of the Supervision or Collaboration Required In situations in which a supervisory or collaborative relation-ship is required, advanced practice nurses and physicians need to understand the precise nature of what is required. Furthermore, when that relationship requires documentation, as in a collabora-tive practice agreement or a standardized procedure, the nature of the relationship should be spelled out in the agreement. It is advis-able to review the agreement on a regular basis to ensure continued understanding of the respective roles and responsibilities. State regulations may spell out what needs to be included in such an agreement and can be very helpful in drafting such an agreement. North Carolina's regulations are an example of how one can find excellent guidance in translating the statutes and the regulations into a workable document (North Carolina Board of Nursing, 2014). Issues that may arise or need to be documented properly include the following: 1. On-site supervision requirements: Only a few jurisdictions re-quire that a physician supervisor be physically present. When practicing in those states, advanced practice nurses should be aware of and document regulations relating to:  Length of time (i. e., percentage of working day) that the supervisor must be on site  What precisely constitutes “on site” within that jurisdiction  Whether there exist any exemption or modified require-ments for working in a particular area, such as remote rural setting or medically underserved setting 2. C hart review: A small number of jurisdictions require some level of advanced practice nurse chart review by collaborating physicians. In those states, attention should be paid to:  The precise number or percentage of charts required to be reviewed in a specific period of time  What constitutes a need for review and how it is to be documented  Whether there is a particular type of chart (e. g., one involving an adverse outcome) that requires review 3. L imitations on oversight for the collaborating physician:  In jurisdictions and settings that require some sort of physician oversight, the question necessarily arises as to how many practitioners may be supervised by a par-ticular physician. These issues may arise in terms of the number of nurse practitioners with whom a physician may enter into a collaborative relationship, the number of individual practitioners who may be supervised at one time in an on-site situation, and other settings. For example, the question arises in those jurisdictions that require anesthesiologist supervision of certified nurse anesthetists.  Advanced practice nurses and those physicians with whom they enter into collaborative relationships should be clear about the specific limitations and requirements of the oversight required. In those jurisdictions and situ-ations that require documentation of this relationship, it should be made clear in the practice agreement how many individuals are to be supervised and in what manner. ❚c Onc Luding remark S From this discussion, the reader should appreciate three important themes about the legal scope of advanced nursing practice and clin-ical guidelines: 1. The advanced practice nurse must have a thorough under-standing of the respective state's nurse practice act. There are several sources that provide context for one's professional scope of practice. 2. The a dvanced practice nurse must be able to clearly communi-cate with other registered nurses, physicians, healthcare adminis-trators, and healthcare consumers their scope of nursing practice. 3. The a dvanced practice nurse must communicate, often in writing, the legal scope of their practice in a clear, concise, and flexible manner that is in keeping with regulatory law and community standards. reference S American Association of Nurse Practitioners. (2014). State practice envi-ronment. Retrieved from http://www. aanp. org/legislation-regulation /state-legislation-regulation/state-practice-environment. Buppert, C. (2015). Nurse practitioner's business practice and legal guide (5th ed. ). Burlington, MA: Jones and Bartlett Learning. California Board of Registered Nursing. (2011). Nurse practitioners in long-term care settings. Retrieved from http://rn. ca. gov/pdfs/regulations /npr-b-22. pdf. California Board of Registered Nursing. (2013). Nurse practitioner practice information. Retrieved from http://rn. ca. gov/regulations/np. shtml. California Legislative Information (n. d. ). Retrieved from http://leginfo . legislature. ca. gov/faces/codes. xhtml. Christian, S., Dower, C., & O'Neill, E. (2007). Overview of nurse practi-tioner scopes of practice in the United States. Retrieved from http://futurehealth. ucsf. edu/Public/Publications-and-Resources/Content . aspx?topic=Overview_of_Nurse_Practitioner_Scopes_of _Practice_in_the_United_States. Commonwealth of Massachusetts. (2014). Nursing licensing; Statutes, rules, regulations and policies. Retrieved from http://www. mass. gov/eohhs /gov/departments/dph/programs/hcq/dhpl/nursing/nursing-regs/. Kendig, S. M. (2014). Moving toward accountable care: A policy frame-work to transform health care delivery and reimbursement. In K. A. Goudreau & M. C. Smolenski (Eds. ), Health policy and advanced prac-tice nursing: Impact and implementations (pp. 273-286). New Y ork, NY: Springer Publishing Company. References 5

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Medicare Conditions of Participation, 42 C. F. R. §§491 et seq. (2013). Retrieved from https://www. cms. gov/Medicare/Provider-Enrollment-and-Certification/Certificationand Complianc/RHCs. html. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, 79 Fed. Reg. 72760 (proposed December 8, 2014). National Council of State Boards of Nursing. (2014). Retrieved from https://www. ncsbn. org/115. htm. North Carolina Board of Nursing. (2014). Collaborative practice agreement—A guide for implementation. Retrieved from http://www. ncbon. com/dcp/i/nursing-practice-nurse-practitioner-collaborative -practice-guidelines. Nursing Practice Act, Cal. Bus. & Prof. Code §§2700 et seq. (2012). Retrieved from http://leginfo. legislature. ca. gov/faces/codes. xhtml. Revised Code of Washington §18. 79. 050. (2000). Advanced registered nursing practice defined—Exceptions. Retrieved from http://apps. leg. wa. gov/rcw/default. aspx?cite=18. 79. 050. Ritter, A., & Hansen-Turton, T. (2008). The primary care paradigm shift: An overview of the state-level legal framework governing nurse practi-tioner practice. The Health Lawyer, 20(4), 21. State of Michigan. Op. Att'y Gen. No. 5630. (1980, January 22). Retrieved from http://www. ag. state. mi. us/opinion/datafiles/1980s/op05630. htm. T exas Board of Nursing. (2013). T exas Board of Nursing Bulletin, 44(4). 6 CHAPTER 1 | Legal Scope of Advanced Nursing Practice

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SECTION I PEDIA TRIC HEALTH MAINTENANCE AND PROMOTIONwho has not voided or stooled is being considered, a documented plan for follow-up must be ensured and parents instructed about findings that warrant immediate follow-up (e. g., vomiting, inconsolability, or abdominal distention). 2. P lan for follow-up care should be confirmed and documented before discharge (Benitz et al., 2015; Hagan et al., 2008). C. Follow-up of premature and late premature infant after discharge 1. P remature infants less than 37 weeks gestational age are commonly discharged at or near their due date. At discharge, they should demonstrate cardiorespiratory, hemodynamic, and thermal stability and adequate weight gain. Exact standards for discharge are lacking but most centers consider discharge after completion of the 35th to 37th postconceptual week and stabilization of weight at 1,800-2,000 g. a. Thos e with a complicated clinical course or birth weight less than 1,500 g are typically also fol-lowed by a specialty clinic versed in premature infant care and outcome. 2. L ate preterm (i. e., 34-37 weeks gestation), also known as “near-term” infants, are frequently discharged using the same guidelines as term infants; however, this may underestimate some ongoing needs because of their immaturity or small size. Although no clear recommendations exist for timing of follow-up, the initial outpatient visit should occur no later than the first week following discharge. 3. E nhanced risks in this population that may complicate the early neonatal period or result in rehospitalization after discharge include hyperbilirubinemia, poor feeding, dehydration sepsis, and respiratory and thermal instability (National Perinatal Association, n. d. ; Whyte & Canadian Paediatric Society, Fetus & Newborn Committee, 2010). I. Intr oduction and general background The birth of a child creates new challenges for a family. The initial outpatient visit affords the provider an opportunity to establish an ongoing relationship with the infant and family, follow up on residual issues from birth, and individualize and prioritize healthcare needs. For healthy infants, the American Academy of Pediatrics recommends that this initial visit occur within the first week following discharge, dependent on the duration of the initial hospitalization (Hagan, Shaw, & Duncan, 2008). A. Follow-up of healthy infant after vaginal or cesarean delivery 1. F or vaginal delivery, discharge typically at 48 hours: follow-up should occur within 48 hours of discharge (Benitz & Committee on Fetus & Newborn, 2015). 2. F or cesarean delivery, where discharge typically occurs at 96 hours, follow-up should occur within 1 week of discharge (Hagan et al., 2008). B. Follow-up of infant after early discharge 1. Ea rly discharge (i. e., hospital discharge between 24 and 48 hours) may be offered to healthy singleton infants, born at 37-41 weeks gestation, who are appropriately grown for gestational age, have no abnormal physical findings, and who were born vaginally after an uncomplicated prenatal course. Family, environmental, and social risks should be identified and addressed. Before discharge, the infant must have completed a minimum of two successful feedings, had such issues as jaundice (if present) adequately addressed and demonstrated adequate voiding and stooling (Committee on Fetus & Newborn, 2010; Benitz et al., 2015). However, normal newborns may not void or stool within the first day of life. If discharge of the otherwise normal infant Annette Carley FIrst Well-B AB y V I s I t© Eliks/Shutterstock; © donatas1205/Shutterstock 72Chapt Er

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of breast pump; use of other devices, such as breast shields or supplemental nurs-ing systems; care of milk including label-ing, storing (refrigerator vs. freezer), and rewarming e. R eview of systems and clinical findings B. Objective 1. P hysical examination findings a. S kin: turgor, color, perfusion; note presence of rashes, birthmarks, dermal breaks, skin tags or pits, or jaundice b. H ead-eyes-ears-nose-throat-mouth i. A ssess size, shape, symmetry of head and fontanels; note presence of cephalohema-toma, caput, or cranial molding ii. A ssess red reflex, ocular mobility; note scleral color and presence of ocular opacifi-cation, drainage, and dacryostenosis iii. A ssess nares patency, drainage, and symme-try of septum iv. A ssess placement of ears, external shape/ contour, patency of canals. Note natural accumulation of vernix may obscure assess-ment of tympanic membranes in the early neonatal period. v. A ssess intactness of palate, strength of suck, presence of natal teeth, inclusion cysts c. C hest and thorax i. A ssess character of respirations; respiratory rate (normal 30-60 breaths per minute); shape and contour of thorax; breast size and shape; note presence of chest asymme-try, nipple discharge, or tenderness. Assess for increased work of breathing, including retractions and abnormal lung sounds on auscultation. d. C ardiovascular i. A ssess heart rate (normal 100-180 beats per minute), rhythm, perfusion, quality of pulses; note presence of arrhythmias or murmurs e. A bdomen and rectum i. A ssess symmetry, tone, presence of bowel sounds, anal patency, timing of first stool, stage of umbilical healing; note presence of distension and tenderness ii. A ssess liver size and note presence of hepatomegaly f. Ge nitourinary i. A ssess appearance of external genitalia, timing of first void, voiding pattern, kidney size by palpation (normally 4-5 cm in size); II. Database (may include but is not limited to) A. Subjective 1. H istory and review of systems a. P arental concerns including feelings of readiness, stress, adequacy, and support b. B irth and health history to date i. M aternal age, gravida, and parity ii. P regnancy complications, including sub-stance exposure, infections, hypertensive disorders, gestational diabetes, and poor prenatal care iii. Dur ation of labor, delivery method, compli-cations, use of anesthesia, timing of umbili-cal cord clamping iv. B irth complications, including premature rupture of membranes, meconium, need for resuscitation, and low Apgar scores at birth v. B irth date vi. Ge stational age vii. B irth weight viii. R eview of pertinent maternal and newborn lab work, including blood type and Coombs testing and bilirubin (if indicated) ix. Di scharge weight and age at discharge x. N ursery complications, including jaundice c. F amily, social, and environmental history i. M other's age, health, occupation, level of education and literacy ii. F ather's age, health, occupation, level of education and literacy iii. S iblings' age and health iv. F amily history including such conditions as asthma, allergies, atopic dermatitis, chronic lung disease, diabetes, renal dysfunction, mental health disorders, heart disease, hematologic disorders, and tuberculosis v. S ocial or environmental concerns, such as unemployment, marital problems, physical abuse, substance exposure, and adjustment to newborn in home vi. F amily source of support and religious affiliation d. N utrition history i. Bottle-feeding infants: type, frequency, and volume of feedings; proper preparation of formula; strength of suck; burping ii. B reastfeeding infants: frequency; duration; perceived satiety; strength of suck; one ver-sus two breasts used for feeding; maternal breast fullness before and after feeding; use 8 CHAPTER 2 | First Well-Baby Visit

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discharge occurs before 48 hours of age (U. S. Preventive Services T ask Force, 2008). b. H earing screen recommended, although not mandated, for all infants within the first month of age (American Academy of Pediatrics, n. d. ) and ideally before discharge (Centers for Disease Control & Prevention, 2015). c. S creening for the presence of a critical congenital heart defect (CCHD) using pulse oximetry rec-ommended, though not mandated, to improve early detection in the early newborn period (Mahle et al., 2012). d. On going monitoring for the development of jaundice. All newborns who develop jaundice within 24 hours of birth should have direct sero-logic or transcutaneous bilirubin assessment and a management plan established (Muchowski, 2014; Subcommittee on Hyperbilirubinemia, 2004). The National Perinatal Association further recommends that preterm/late pre-term infants have direct bilirubin assessment (serum or transcutaneous testing) at 24 hours of age and prior to discharge (National Perinatal Association, n. d. ; Phillips, 2013). e. I mmunizations deferred until 2 months post-natal age, except hepatitis B vaccine, which is recommended for all infants before 1 month. If immunization is received at birth, follow CDC recommendations for subsequent dosing found at: http://www. cdc. gov/vaccines/schedules/ (Centers for Disease Control & Prevention, 2015). III. Assessment A. Determine the diagnosis Determine client's current health status, and identify gen-eral health risks based on gender, age, ethnicity, or other factors. B. Motivation and ability Determine caregiver and family willingness and ability to follow through with treatment plans. IV. Goals of fir st well-baby visit A. Screening or diagnosing Choose a practical, cost-effective approach to screen-ing and diagnosis, while abiding by mandated screening protocols. note presence of ambiguous genitalia or abnormal kidney size g. M usculoskeletal i. A ssess extremities, presence of digits, intactness of spine, movement and stability of hips; note presence of deviation of gluteal cleft, hair tufts, or sacral dimple; note pres-ence of click or clunk with hip exam h. N eurobehavioral i. A ssess activity, tone, state regulation, and symmetry of movements; note presence of clonus, irritability, inconsolability, or excess sleepiness or difficulty awakening (Hagan et al., 2008; T appero & Honeyfield, 2015) 2. Es tablish a growth trend, including comparative measurements of head circumference, weight, and length from birth, and adjust for gestational age as indicated (Hagan et al., 2008). The Centers for Disease Control and Prevention (CDC) recommend World Health Organization (WHO) growth records to be used for infants up to 2 years of age (Centers for Disease Control & Prevention, 2010). 3. Obs erve parent-child interactions, including holding, comforting, responsiveness, confidence, and mutual support. Assess for evidence of parental depression including use of Edinburgh Postnatal Depression Scale (EPDS) (Earls & Committee on Psychosocial Aspects of Child & Family Health, 2010). 4. R eview supportive data from relevant diagnostic tests including: a. R esults of neonatal screening. All states require newborn blood screening and screen for at least 26 of the 31 recommended conditions including organic acid disorders, fatty acid oxidation disor-ders, amino acid metabolism disorders, hemo-globinopathies, and others, differing by state (March of Dimes, 2012). i. P henylketonuria (PKU) screening should occur after 24 hours of age, but less than the seventh postnatal day. If done before 24 hours of age, the infant must be rescreened to eliminate erroneous results (U. S. Preventive Health Services T ask Force, 2014a). ii. S ickle cell screening should occur before discharge, with confirmation of posi-tive results before 2 months of age (U. S. Preventive Health Services T ask Force, 2014b). iii. Congenital hypothyroid screening is done at the second to fourth postnatal day or immediately before discharge if Goals of first well-baby visit 9

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B. Treatment Select a treatment plan that achieves appropriate growth and development, is individualized for the caregiver and child, and maximizes caregiver compliance. V. Plan A. Screening Elicit a thorough history and perform a thorough physical examination, with growth and development assessments at the initial and all well-child visits. B. Diagnostic tests 1. N ewborn screening as required by individual state but must include assessment for congenital hypothyroidism, phenylketonuria, and sickle cell. 2. H earing screen recommended though not yet mandated (American Academy of Pediatrics, n. d. ; Centers for Disease Control & Prevention, 2015). C. Client education and anticipatory guidance (Hagan et al., 2008) 1. N utrition a. S upport the mother's nutritional needs for calo-ries, liquids, adequate rest, and emotional and social support. b. E ncourage breastfeeding or support bottle feed-ing as indicated. c. M ilk intake considered adequate if baby has five to eight wet diapers and three to four stools per day and is gaining weight appropri-ately (15 g/kg/day) (U. S. National Library of Medicine, 2013). Initial stools with breastfeed-ing may be loose and after each feeding. d. H ealthy infants should need no extra water, because both breast milk and formula provide adequate fluid for the newborn. e. E xclusive breastfeeding considered the ideal source of nutrition for the first 4-6 months; for formula feeders, always use iron-fortified formu-la, and provide 2-3 oz. every 2-3 hours; increase if infant seems hungry. f. C ounsel about safety with milk preparation and storage. 2. Gr owth and development 3. S afety, including use of car seats; exposures, such as tobacco; back-to-sleep; cardiopulmonary resuscita-t ion; when to call the provider; and illness prevention. 4. R eferrals as indicated, including encouraging mother to seek appropriate postpartum follow-up for herself. 5. W omen, Infants, & Children (WIC) referral should be initiated for eligible families. 6. F amily transition to parenthood and well-being, including obtaining adequate rest and developing routines. VI. r esources and tools A. Patient and client education 1. The American Academy of Pediatrics website contains a variety of links of interest to parents, including the Healthy Children resources. https://www . healthychildren. org/English/Pages/default. aspx. 2. The A merican Academy of Family Physicians sponsors a website called Family Doctor. org, which provides resources and links of interest to parents. www. familydoctor. org. 3. The N ational Institutes of Health sponsors a website, Medline Plus, that contains infant and newborn care resources for parents. http://www. nlm. nih. gov /medlineplus/infantandnewborncare. html. re Feren Ces American Academy of Pediatrics. (n. d. ). Early hearing detection and intervention (EHDI). Retrieved from http://www. aap. org/en-us /advocacy-and-policy/aap-health-initiatives/PEHDIC/Pages/Early -Hearing-Detection-and-Intervention. aspx. Benitz, W., & Committee on Fetus & Newborn. (2015). Hospital stay for healthy term newborn infants. Pediatrics, 135(5), 948-953. doi: 1-. 1542/peds. 2015-0699 Centers for Disease Control & Prevention. (2010). WHO growth standards are recommended for use in the U. S. for infants and children 0 to 2 years of age. Retrieved from http://www. cdc. gov/growthcharts/who_charts . htm. Centers for Disease Control & Prevention. (2014). Recommended immuni-zation schedule for children from birth through 6 years old. Retrieved from http://www. cdc. gov/vaccines/parents/downloads/parent-ver-sch -0-6yrs. pdf. Centers for Disease Control & Prevention. (2015). Hearing loss in children. Screening and diagnosis. Retrieved from www. cdc. gov/ncbddd/hearingloss /screening. html. Committee on Fetus & Newborn. (2010). Policy statement: Hospital stay for healthy term newborns. Pediatrics, 125(2), 405-409. Retrieved from http://pediatrics. aappublications. org/content/113/5/1434. full. pdf. Earls, M. F., & Committee on Psychosocial Aspects of Child & Family Health. (2010). Clinical report: Incorporating recognition and manage-ment of perinatal and postpartum depression into pediatric practice. Pediatrics, 126(5), 1032-1039. doi: 10. 1542/peds. 2010-2348 Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Supervision: First week visit. In J. F. Hagan, J. S. Shaw, & P. M. Duncan (Eds. ), Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed., pp. 289-302). Elk Grove Village, IL: American Academy of Pediatrics. 10 CHAPTER 2 | First Well-Baby Visit

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U. S. National Library of Medicine. (2013). Medline Plus. Neonatal weight gain and nutrition. Retrieved from https://www. nlm. nih. gov/medlineplus /ency/article/007302. htm. U. S. Preventive Services T ask Force. (2008). Final recommendation statement: Congenital hypothyroidism: Screening. Retrieved from http://www. uspreventiveservicestaskforce. org/Page/Document /Recommendation Statement Final/congenital-hypothyroidism-screening. U. S. Preventive Services T ask Force. (2014a). Final recommendation statement: Phenylketonuria in newborns: Screening. Retrieved from http://www. uspreventiveservicestaskforce. org/Page/Document /Recommendation Statement Final/phenylketonuria-in-newborns -screening. U. S. Preventive Services T ask Force. (2014b). Final recommendation state-ment: Sickle cell disease (hemoglobinopathies) in newborns: Screening. Retrieved from http://www. uspreventiveservicestaskforce. org/Page /Document/Recommendation Statement Final/sickle-cell-disease -hemoglobinopathies-in-newborns-screening. Whyte, R. K., & Canadian Paediatric Society, Fetus & Newborn Committee. (2010). Safe discharge of the late preterm infant. Paediatrics & Child Health, 15(10), 655-660. Mahle, W. T., Martin, G. R., Beckman, R. H., & Morrow, W. R. (2102). Section on Cardiology and Cardiac Surgery Executive Committee: Endorsement of health and human services recommendations for pulse oximetry screening for critical congenital heart disease. Pediatrics, 129(1), 190-192. doi: 10. 1542/peds. 2011-3211 March of Dimes. (2012). Newborn screening. Retrieved from http://www . marchofdimes. org/baby/newborn-screening-tests-for-your-baby. aspx. Muchowski, K. R. (2014). Evaluation and treatment of neonatal hyperbili-rubinemia. American Family Physician, 89(11), 873-878. National Perinatal Association. (n. d. ). Multidisciplinary guidelines for the care of late preterm infants. Retrieved from http://www. nationalperinatal. org/Resources/Late Preterm Guidelines NPA. pdf. Phillips, R. M. (2013). Multidisciplinary guidelines for the care of late preterm infants. Journal of Perinatology, 33(S2), S3-S4. doi: 10. 1038 /jp. 2013. 52 Subcommittee on Hyperbilirubinemia. (2004). Management of hyper-bilirubinemia in the newborn infants 35 or more weeks of gestation. Pediatrics, 114(1), 297-316. doi: 10. 1542/peds. 114. 1. 297 T appero, E. P., & Honeyfield, M. E. (Eds. ). (2015). Physical assessment of the newborn: A comprehensive approach to the art of physical examination (5th ed. ). Petaluma, CA: NICU INK Publishers. References 11

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must be physiologically stable, feeding sufficiently well to support appropriate growth, able to maintain thermal neutrality in the post-NICU environment, and capable of sustaining mature respiratory system behav-ior (Barkemeyer, 2015; Centers for Disease Control & Prevention [CDC], 2014a; AAP Committee on Fetus & Newborn, 2008; Whyte, 2012). 2. C hronic lung disease (CLD) CLD is the leading cause of pediatric lung disease occurring secondary to pulmonary system immaturity or dysfunction and the additive effects of therapies, such as oxygen or mechanical ventilation support. Also referred to as “bronchopulmonary dysplasia” (BPD), CLD commonly affects the premature infant, and despite overall improved survival and advances, such as gentler postnatal ventilation strategies and exogenous surfactant therapy, it affects more than 25% of infants born weighing less than 1,500 grams ( Jensen & Schmidt, 2014). The rate of CLD/BPD increases with decreasing gestational age at birth, and more than two-thirds of infants born ≤ 25 weeks ges-tation compared to 37% of those born between 26 and 30 weeks gestation develop this condition (Farstad, Bratlid, Medbo, Markestad, & Norwegian Extreme Prematurity Study Group, 2011). Infants with CLD/BPD are at increased risk for adverse health outcomes including chronic pulmonary morbidity, pulmonary infections, long-term growth failure, sensory defi-cits, developmental delay, and mortality ( Jensen & Schmidt, 2014). a. P ostdischarge therapies that may be used to opti-mize pulmonary function and growth include sup-plemental oxygen or ventilation, cardiorespiratory monitors, diuretics, and bronchodilators as well as enhanced nutritional strategies (Kelly, 2006b). b. S upplemental oxygen aims to optimize growth and stamina, and prevent development of cor pul-monale. For those discharged on supplemental I. Intr oduction and general background Greater numbers of recuperating infants, shorter hospital stays, and complex health demands have increased the need for com-prehensive postneonatal intensive care unit (NICU) care. Survival to discharge has improved across all gestational ages, although many survivors have residual disabilities requiring specialized care, expertise by providers versed in the needs of the fragile infant, and a provider who can intervene early (Carley, 2008; Kelly, 2006a). The American Academy of Pediatrics (AAP) has identified four categories of post-NICU infants who are considered high risk at discharge: (1) premature infants, (2) those with special health needs or who are dependent on technology, (3) those at risk because of social or family issues, and (4) those for whom early death is anticipated. Essential ele-ments at discharge include physiologic stability, active caretaker involvement and preparation to assume care, and an integrated plan for follow-up care and management (AAP Committee on Fetus & Newborn, 2008). A. Common issues for the post-NICU population include 1. The infa nt who is premature at discharge Premature infants constitute over 11% of births, and late preterm infants (of gestational age 34 0/7 to 36 6/7 weeks) comprise nearly three-quarters of preterm infants and account for most of the recent increase in numbers of preterm infants. With decreasing gesta-tional age, the incidence of neonatal complications increases; however, even late preterm infants are at risk for complications such as impaired thermoregulation, poor feeding and nutrition, gastroesophageal reflux and other gastrointestinal issues, late-onset sepsis, jaundice, or neurodevelopment impairment. These infants are also at risk for rehospitalization in the early postnatal period (Darcy, 2009; Loftin et al., 2010). For successful transition, the post-NICU premature infant Annette Carley CAre of the Postneon At A l Intens I ve C A re Un I t Gr A d UAte© Eliks/Shutterstock; © donatas1205/Shutterstock 123Chapt Er

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5. P ostnatal growth restriction Premature infants are at increased risk for poor feeding and growth failure and at discharge typically are below their healthy term counterparts in weight. Growth risks are compounded by the effects of chronic illness and genetic potential. Premature infants frequently need higher calories and nutrients than their healthy term counterparts. Diligently applied nutritional sup-port plays a key role in supporting adequate long-term growth and optimal neurologic development. a. H uman milk is the ideal food for all infants regardless of gestational age. However, an exclusive human milk diet may contribute to nutritional deficiencies in the recuperating post-NICU infant who has not attained adequate prenatal stores and has robust growth and recu-perative needs. It is often necessary to supple-ment calories, protein, sodium, and calcium in these infants (Barkemeyer, 2015). b. I f human milk is not available, premature formu-la and postdischarge formula may be indicated to optimize catch-up growth (Greer, 2007). c. P remature infants may require additional supple-mentation to support nutrient requirements for protein; calcium; phosphorus; sodium; vitamins, such as B 12, B6, D, E, and K; and trace minerals, such as zinc, copper, magnesium, selenium, and carnitine (Greer, 2007; Shah & Shah, 2009). d. R ecuperating infants, especially preterm infants need up to 130 kcal/kg/d to achieve adequate growth (Billimoria, 2014). Those born small for gestational age or those attempting to achieve adequate catch-up growth may require up to 165 kcal/kg/d. Chronic health issues creating increased nutritional demands, such as CLD or growth failure, may warrant increased caloric goals. e. S tructural or functional comorbidities, such as orofacial anomalies or altered tone, may compli-cate the nutritional plan (Kelly, 2006b). 6. N eurobehavioral and sensory deficits Infants recovering from the effects of initial illness or prematurity and the NICU environment may have residual neurobehavioral challenges. This risk increas-es with decreasing gestational age (Billimoria, 2014) and may include developmental delays, learning dis-abilities, hyperactivity, and cerebral palsy. Additionally, sensory deficits may include hearing or vision loss, auditory processing disorders, or language delay. a. H earing screening is recommended universally for all infants and indicated for the NICU infant before discharge. Hearing loss occurs in as many oxygen, adequate caretaker training and team planning for weaning should be assured (Andrews, Pellerite, Myers, & Hageman, 2014; Barkemeyer, 2015) c. H ome mechanical ventilation, although rarely needed, may be used for those infants unable to wean from mechanical ventilation before hos-pital discharge. Careful caretaker training and establishment of outpatient supports is essential (AAP Committee on Fetus & Newborn, 2008; Andrews et al., 2014). 3. A pnea Apnea is a serious condition for the neonate and may result from pulmonary disorders; infection; brain injury; or metabolic derangements, such as hypogly-cemia. Apnea is also a common complication in the preterm population, caused by immature central regu-lation of respiratory effort, and may be managed with oxygen or ventilator support, respiratory stimulants (e. g., methylxanthines), and cardiopulmonary moni-toring. Although typically resolved by 36-40 weeks postconceptual age, apnea caused by immaturity in some infants or “apnea of prematurity” may persist until the time of discharge. It is recommended that infants be free of significant apnea for 3-7 days prior to discharge (Andrews et al., 2014). 4. G astroesophageal reflux disease (GERD) Infants born prematurely, those whose early course included structural or functional disorders of the gas-trointestinal tract, those with pulmonary conditions requiring surgical intervention, and those with neuro-logic compromise are at risk for GERD. GERD may lead to erosive esophageal injury and may be associated with serious conditions, such as apnea, bronchospasm, aspiration, or long-term growth failure. a. P hysiologic reflux is common in infants; up to two-thirds of all infants less than 4 months of age exhibit regurgitation. b. P athologic reflux, also known as GERD, is associ-ated with complications including apnea, bron-chospasm, esophagitis, esophageal strictures, and failure to thrive. It may be managed conservatively with small, frequent feedings; upright position-ing; and medications to optimize gastric empty-ing; or it may necessitate surgical management for intractable cases. The use of thickened feedings has shown variable results, and this practice may carry risks for the immature gastrointestinal tract. In otherwise healthy infants beyond their due date it may be cautiously considered (Andrews et al., 2015; Horvath, Dziechciarz, & Szajewska, 2008). Introduction and general background 13

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ventilation requires dedicated personnel and ongoing caregiver support including respite care. d. N utritional support may be achieved with com-plementary enteral feedings or parenteral nutri-tion. In-home use of intermittent orogastric gavage or gastrostomy feedings requires vigilant attention to safety, hygiene, and education and support of caregivers. Efforts should concentrate on encouraging oral feeding skills. e. W eaning from supplemental nutritional support can be considered when the infant demonstrates consistent appropriate growth, under the super-vision of a nutrition specialist (Barkemeyer, 2015; Kelly, 2006b). f. A p lan for emergency management in the case of equipment malfunction must be in place (AAP Committee on Fetus & Newborn, 2008). 8. P ostnatal infection Convalescing post-NICU patients, especially pre-term infants, are at risk for complications related to infections, including respiratory syncytial virus (RSV) and influenza virus. Their increased vulner-ability to infections may result in acute decompen-sation and the need for rehospitalization. At-risk infants discharged during peak RSV transmission seasons (i. e., October through March in the United States) should receive RSV prophylaxis in addition to routine immunizations given at recommended intervals (AAP Committee on Infectious Diseases & Bronchiolitis Guidelines Committee, 2014; CDC, 2014b; Kelly, 2006b). B. Additional issues for the post-NICU population may include 1. S ocial and environmental risks The AAP identifies premature birth, need for hospi-talization, presence of birth defects, and infant dis-ability as risks for family dysfunction and child abuse. These risks are compounded by family and environ-mental risks, such as low socioeconomic status, lack of social supports, substance exposure, and lack of family involvement during the infant's hospitalization. Identifying strategies to enhance infant safety and family functioning before discharge is encouraged (AAP Committee on Fetus & Newborn, 2008). a. V ulnerable child syndrome is recognized as a potential outcome caused by the effects of pro-tracted neonatal hospitalization, parental anxi-ety or depression, impact of the illness on the family, or lack of social supports. This has been associated with excessive healthcare use and risk of impaired infant developmental outcome (Kokotos, 2009). as 1. 5% of all post-NICU infants (Andrews et al., 2014) and up to 50% of abnormal infant hear-ing screening occurs in NICU graduates (Kelly, 2006b). Special risks for the NICU population include a history of assisted ventilation, use of ototoxic pharmaceuticals, hyperbilirubinemia, infection, and craniofacial disorders (Andrews et al., 2014; Billimoria, 2014). Early interven-tion (i. e., at age < 6 months) enhances language development (Kelly, 2006b). Those with risks should have ongoing assessment including for-mal audiology evaluation by 30 months of age, even in cases with a normal initial hearing screen (Billimoria, 2014). b. V ision screening is recommended for preterm infants less than 1,500-g birth weight (or < 30 weeks gestation), those with a complicated medical course, and those exposed to supple-mental oxygen. Severe retinopathy occurs in approximately 7% of infants born between 24-28 weeks gestation. Even without established reti-nopathy of prematurity. NICU infants are at risk for impaired visual acuity, refractive errors, and strabismus (Andrews et al., 2014). The first examination typically occurs at 31-34 weeks postconceptual age, with regular follow-up until vascular maturity is ensured at 3-6 months (Billimoria, 2014; Kelly, 2006b). c. F ormal developmental assessment is indicated for all at-risk infants including those born pre-term or with a complicated clinical course. d. Go als of developmental follow-up include opti-mizing growth and development to maximize long-term potential, integrating the infant into family and community, and providing early intervention to reduce medical, social, and emo-tional burden (Kuppala, T abangin, Haberman, Steichen & Y olton, 2012). 7. D ependence on technology Infants with unresolved cardiopulmonary issues, such as apnea, chronic hypoxia, or growth failure, may require technologic support in the home after discharge. a. P ulmonary support may be achieved with sup-plemental oxygen, cardiopulmonary monitor-ing, or the use of mechanical ventilation. b. W eaning from ventilatory support is dictated by the infant demonstrating normal oxygen satu-ration, resolution of apnea or bradycardia, and showing appropriate growth. c. U se of in-home technology requires vigilant attention to safety and hygiene, consistent edu-cation, and support of caretakers. Mechanical 14 CHAPTER 3 | Care of the Postneonatal Intensive Care Unit Graduate

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b. A posttraumatic stress disorder has been report-ed in parents of infants in the NICU, caused by ongoing stress of the hospitalization and uncertainty of neonatal outcome that may have a negative impact on the quality of interactions with the infant as well as between the parents (Hynan, Mounts, & Vanderbilt, 2013; Shaw et al., 2009). It is especially important to identify stress and depression in fathers whose degree of dysfunction may be overlooked because of a pri-mary focus on the mother. 2. I nfant with anticipated early death T o enhance the quality of remaining life, infants with terminal disorders may be discharged to the home for hospice care. Discharge planning and follow-up care attend to family needs and concerns and occur with the involvement of home nursing. Necessary elements include creating a plan for management of infant pain and discomfort, securing arrangements for equipment or supplies, and providing ongoing sup-port to parents, siblings, or extended family members (AAP Committee on Fetus & Newborn, 2008). II. d atabase (may include but is not limited to) A. Subjective database 1. H istory and review of systems a. P arental concerns including feelings of readiness, stress, adequacy, and support. b. B irth and health history to date. i. B irth history, including gravida and parity, pregnancy complications, delivery method and birth complications, Apgar scores ii. I nfant birth date, weight, and gestational age (AGA, LGA, or SGA/IUGR status) iii. N eonatal course including complications c. F amily, social, and environmental history. i. M aternal age, health, occupation, and level of education ii. P aternal age, health, occupation, and level of education iii. S ibling ages, health, and history of prematurity iv. F amily history including chronic conditions v. P arental head circumference and stature to compare with infant measurements vi. S ocial or environmental concerns, such as unemployment, abuse, marital problems, and lack of supportd. N utrition history. i. D ate feedings initiated, formula versus breast milk, nipple versus gavage, feeding tolerance, complications ii. P arenteral nutrition support, use of hyper-alimentation, peripheral versus central vas-cular access e. R eview of systems and clinical findings. i. D ysmorphic features, which may suggest a genetic syndrome ii. S kin, including rashes, birthmarks, scars, or jaundice iii. H ead, ears, eyes, nose, and throat including a. H igh arched palate caused by oral intubation b. N ostril distortion caused by feeding tube c. H ead circumference: poor head growth in the premature infant strongly predic-tive of impaired cognitive function, academic performance, and behavioral issues d. H ead shape may be transiently dis-torted as a consequence of NICU care practices that create positional deformities such as dolichocephaly (Billimoria, 2014). iv. C hest and thorax, including character of respirations, respiratory rate, and shape and contour of the thorax; findings may includea. H yperexpansion caused by air trapping b. T achypnea caused by chronic hypoxia c. H ypercarbia v. C ardiovascular, including presence of mur-murs, perfusion, and quality of pulses vi. A bdomen and rectum, including stool pat-tern, distention, and inguinal or umbilical hernias vii. Ge nitourinary, including voiding pattern viii. M usculoskeletal, including symmetry of movements, strength, and tone ix. N eurobehavioral, including activity, tone, state regulation, and tremulousness x. I mmune, including immunizations received before dischargea. F ollow Centers for Disease Control and Prevention recommendations for dos-ing by chronologic age (CDC, 2014b). xi. S upportive data from relevant diagnostic tests includinga. R esults of neonatal screen (phenyl-ketonuria, sickle cell, and congenital hypothyroidism screening mandated in all states)Database 15

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b. H earing screening c. V ision screening d. D evelopmental screening e. L aboratory studies including base-line blood gas, oxygen saturation, electrolytes f. I maging studies including most recent chest radiograph, cranial ultrasound, or other cranial imaging study B. Objective 1. P hysical examination findings a. Es tablish a growth trend including comparative measurements of head circumference, weight, and length from birth. Plot and adjust for gesta-tional age until 2 years of age. b. Thor ough physical examination including vital signs and blood pressure. c. Es sential to take into account size at birth (T able 3-1 ) and to use growth charts corrected for gestational age for accurate assessment of postnatal growth. d. The F enton growth chart available at http:// peditools. org/fenton2013/ is most commonly used in the NICU and remains appropriate until the infant reaches 50 weeks postmenstrual age. Beyond that age the World Health Organization chart is rec-ommended for all infants (Billimoria, 2014). 2. Obs ervation of parent-child interactions, including holding, comforting, responsiveness, confidence, and mutual support. 3. L aboratory studies as clinically indicated, such as blood gas, electrolytes, or complete blood count. 4. C hest radiograph as clinically indicated. III. Assessment A. Determine the diagnosis Determine client's current health status and identify general health risks based on gender, age, ethnicity, and other factors. B. Severity Assess the severity of illness, as indicated. C. Motivation and ability Determine family willingness to understand and comply with the treatment plan. Iv. Goals of clinical management A. Screening or diagnosing Choose a practical, cost-effective approach to screening and diagnosis, while abiding by mandated screening pro-tocols. Post-NICU infants need careful, ongoing assess-ment related to neurobehavioral and growth risks and individualized screening based on clinical findings. B. Treatment Select a treatment plan that optimizes growth and devel-opment, is individualized for the caregiver and child, and maximizes caregiver acceptance. v. Plan A. Screening Elicit a thorough history and perform a thorough physi-cal examination, including growth and developmental assessment at all visits. B. Diagnostic tests If not already performed before discharge, these should include 1. N ewborn screen as required by individual state. 2. H earing screen. 3. V ision screen. 4. D evelopmental assessment, often done by referral to a specified neonatal follow-up clinic facility. Premature and at-risk infants may be seen as frequently as four to five times in the first year of life and are followed to school age. Typical criteria for follow-up includes birthweight, gestational age, acute illness during the NICU hospitalization, and referral request from an outpatient provider. However, there are no standardized guidelines for high-risk follow-up care (AAP Committee on Fetus & Newborn, 2004; Kuppala et al., 2012). C. Management A primary provider should be identified and accept responsibility for orchestrating care. Post-NICU patients may be managed cooperatively with a variety of consul-tant and subspecialty services, including but not limited Table 3-1 Birth W eight Classifications extremely low Birth W eight ( el BW)very low Birth W eight ( vl BW)l ow Birth Weight ( l BW) < 1,000 g at birth < 1,500 g at birth < 2,500 g at birth Data from Allen, M. D. (n. d. ). Development and follow-up of premature and low birthweight infants. Retrieved from http://mchb. hrsa. gov/chusa13/perinatal-health-status-indicators/pdf/lbw. pdf%3E. 16 CHAPTER 3 | Care of the Postneonatal Intensive Care Unit Graduate

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to nutrition services, dysmorphology and genetics, pulmo-nary, cardiology, gastroenterology, hematology, neurode-velopmental, and surgery. Specific intervals vary dependent on the complexity of the infant's history and current condi-tion (AAP Committee on Fetus & Newborn, 2008). D. Client education 1. C oncerns and feelings Assist the family with expressing concerns and feel-ings about having a complex neonatal patient in the home and coping with uncertainties related to the infant's health status or anticipated development. 2. I nformation Provide verbal and written information related toa. H ealth maintenance b. N utrition c. Gr owth and development d. Sa fety e. A nticipated referrals and follow-up plans v I. r esources and tools A. Parent-client-provider tools 1. The A AP website contains resources for caregivers, including information about high-risk neonatal growth, development, and health needs: http://www. aap. org. 2. The M arch of Dimes provides multiple neonatal and perinatal resources for providers and parents: http://www. marchofdimes. com. 3. A AP Section on Developmental & Behavioral Pediatrics. Provides recommendations for screening and assessment: https://www2. aap. org/sections /dbpeds/screening. asp. 4. A ges and Stages Questionnaire; Brookes Publishing Company: http://agesandstages. com/. referen Ces Allen, M. D. (n. d. ). Development and follow-up of premature and low birth-weight infants. Retrieved from www. hrsa. gov/. American Academy of Pediatrics. Committee on Fetus & Newborn. (2004). Follow-up care of high-risk infants. Pediatrics, 114(5), 1377-1397. American Academy of Pediatrics. Committee on Fetus & Newborn. (2008). Hospital discharge of the high-risk neonate. Pediatrics, 122(5), 1119-1126. American Academy of Pediatrics. Committee on Infectious Diseases & Bronchiolitis Guidelines Committee (2014). Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics, 134(2), 415-420. doi: 10. 1542/peds. 2014-1665Andrews, B., Pellerite, M., Myers, M., & Hageman, J. R. (2014). NICU follow-up: Medical and developmental management age 0 to 3 years. Neo Reviews, 15(4), e123-e132. Barkemeyer, B. M. (2015). Discharge planning. Pediatric Clinics of North America, 62(2), 545-556. doi: 10. 1016/j. pcl. 2014. 11. 013 Billimoria, Z. C. (2014). A pediatrician's guide to caring for the complex neonatal intensive care unit graduate. Pediatric Annals, 43(9), 369-372. doi: 10. 3928/00904481-20140825-11 Carley, A. (2008). Beyond the NICU: Can at-risk infant patients be better served? Retrieved from http://nursing. advanceweb. com/Article /Beyond-the-NICU-2. aspx. Centers for Disease Control & Prevention. (2014a). Reproductive health. Preterm birth. Retrieved from http://www. cdc. gov/reproductivehealth /maternalinfanthealth/pretermbirth. htm. Centers for Disease Control and Prevention. (2014b). Recommended immuniza-tion schedule for children from birth through 6 years old. Retrieved from http://www. cdc. gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs. pdf. Darcy, A. E. (2009). Complications of the late preterm infant. Journal of Perinatal & Neonatal Nursing, 23(1), 78-86. Farstad, T., Bratlid, D., Medbo, S., Markestad, T., & Norwegian Extreme Prematurity Study Group. (2011). Bronchopulmonary dysplasia: Prevalence, severity and predictive factors in a national cohort of extremely premature infants. Acta Paediatrica, 100(1), 53-58. doi: 10. 1111/j. 1651-2227. 2010. 01959. x. Greer, F. R. (2007). Post-discharge nutrition: What does the evidence sup-port? Seminars in Perinatology, 31, 89-95. Horvath, A., Dziechciarz, P., & Szajewska, H. (2008). The effect of thickened-feed interventions on gastroesophageal reflux in infants: Systematic review and meta-analysis of randomized, controlled trials. Pediatrics, 122(6), 1268-1277. Hynan, M. T., Mounts, K. O., & Vanderbilt, D. L. (2013). Screening parents of high-risk infants for emotional distress: Rationale and recommenda-tions. Journal of Perinatology, 33(10), 748-753. doi: 10. 1038/jp. 2013. 72. Jensen, E. A., & Schmidt, B. (2014). Epidemiology of bronchopulmonary dysplasia. Birth Defects Research. Part A, Clinical & Molecular T eratology, 100, 145-157. Kelly, M. M. (2006a). The medically complex premature infant in primary care. Journal of Pediatric Health Care, 20(6), 367-373. Kelly, M. M. (2006b). Primary care issues for the healthy premature infant. Journal of Pediatric Health Care, 20(5), 293-299. Kokotos, F. (2009). The vulnerable child syndrome. Pediatrics in Review, 30(5), 193-194. Kuppala, V. S., T abangin, M., Haberman, B., Steichen, J., & Y olton, K. (2012). Current state of high-risk infant follow-up care in the United States: Results of a national survey of academic follow-up programs. Journal of Perinatology, 32, 293-298. doi: 10. 1038/jp. 2011. 97 Loftin, R. W., Habli, M., Snyder, C. C., Cormier, C. M., Lewis, D. F., & De Franco, E. A. (2010). Late preterm birth. Reviews in Obstetrics & Gynecology, 3(1), 10-19. Shah, M. D., & Shah, S. R. (2009). Nutrient deficiencies in the premature infant. Pediatric Clinics of North America, 56(5), 1069-1083. Shaw, R. J., Bernard, R. S., Deblois, T., Ikuta, L. M., Ginzburg, K., & Koopman, C. (2009). The relationship between acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit. Psychosomatics, 50(2), 131-137. Whyte, R. K. (2012). Neonatal management and safe discharge of late and moderate preterm infants. Seminars in Fetal & Neonatal Medicine, 17(3), 153-158. doi: 10. 1016/j. siny. 2012. 02. 00References 17

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of well-being. During periodic scheduled visits, a complete his-tory is taken, an examination is performed, and potential health risks are identified. Counseling and guidance are provided in the areas of physical, behavioral, and emotional development. Cultural considerations, such as language barriers, cultural values, folk health practices, recognizing one's own personal values, and working to eliminate health disparities related to race or ethnicity, are important to incorporate into each visit (Duderstadt, 2014). For children with special needs, promot-ing self-empowerment and self-esteem as well as maximizing development and function are also important considerations. II. Database (may include, but is not limited to) A. Subjective 1. P arental concerns 2. I nterval history (if new patient include birth, patient and family medical history, and review of symptoms) a. F requency and type of illness since last visit b. M edications c. T rauma or hospitalizations d. S tatus of any chronic illness management 3. I mmunization status 4. F amily and social history a. C hanges from previous visit including new stressors b. F amily planning c. E motional support d. M eans of financial support e. C hildcare arrangements f. P eer or social interactions including siblings, other children and adults, parents 5. R eview of systems (Duderstadt, 2014)I. Intr oduction and general background The 0-3 years of age pediatric visit encompasses a wide range of physical and developmental growth. Infants go through dramatic physical growth while constantly developing gross and fine motor, language, and social skills that allow them to respond to their environment. As infants reach early childhood, their physical growth slows as they begin an intense explora-tion of their environment (Hockenberry & Wilson, 2010). This developmentally and physically diverse patient population requires additional consideration at each visit. The physical examination of infants and toddlers aged 0-3 years may need a different approach than for other age groups because they do not consistently respond to verbal instruction and developmentally may have stranger anxiety. Infants and toddlers may adjust to an examiner if they first watch the interaction between the examiner and their parent during the patient interview (Duderstadt, 2014). During this time, respecting a toddler's personal space and avoiding eye contact may help the toddler become comfortable before the exami-nation. Instead of a head-to-toe examination, a more system-focused approach may be necessary with some patients. For example, auscultation can be completed first in infants before they become more active as the examination proceeds. Indirect examination can be a useful strategy in this age group. Breathing patterns, skin characteristics, symmetry of movement, and musculoskeletal integrity are examples of assessments that can be performed noninvasively. Infants up to 6 months of age can usually be examined on the examining table, whereas infants older than 6 months and toddlers may feel more comfortable being examined in their parent's lap (Hockenberry, 2013). In addition to assessing the child, it is also important to observe the parent-child interaction (Duderstadt, 2014). These interac-tions can give the provider clues to the parent-child dynamic, which is an important element of an overall assessment. Health maintenance is a mutual goal for the patient and health provider and is aimed at potentiating the patient's state Ann Birenbaum Baker0 to 3 Ye Ars of Age Inter v A l  v I s I t© Eliks/Shutterstock; © donatas1205/Shutterstock 184Chapt Er

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iv. M eal routine: number of meals per day, where eaten and with whom v. V itamins, iron b. Or al health (American Academy of Pediatric Dentistry [AAPD], 2014) i. B rushing teeth and wiping gums with moist rag ii. P arental oral health iii. D ental visit iv. Fluor ide supplementation as indicated depending on level of fluoride in community c. S leep patterns i. D aytime and nighttime sleeping: hours and routine ii. W here sleeping: cosleeping, crib, separate bed, own room iii. S leep positioning iv. N ightmares and night terrors d. El imination pattern and, if age appropriate, toilet training history e. D evelopmental and behavioral assessment (La Rosa, 2015)i. E valuate at each well-child visit for early identification of developmental or behav-ioral disorders ii. 9 mon ths: evaluate child's vision, hearing, motor skills, early communication skills iii. 18 mon ths: evaluate motor, communi-cation, and language skills; complete M-CHAT autism screening available at https://www. m-chat. org/ iv. 24 or 30 mon ths: evaluate motor, language, and cognitive skills plus autism screening v. S tandardized developmental screening tools (see Chapter 9, Developmental Assessment: Screening for Developmental Delay and Autism) f. Be havior i. Cr ying ii. T emper tantrums iii. H ead banging iv. Body rocking v. P acifier use vi. Th umb sucking vii. S tranger anxiety viii. A pproach to discipline B. Objective 1. P hysical examination (Duderstadt, 2014) a. H eight, weight, and head circumference through 36 months of age—refer to the following link for Centers for Disease Control and Prevention Maternal infections or drug use, prenatal history, history of preterm birth, birth history, neonatal his-tory (including congenital anomalies and hospital-izations), and family medical history are important elements of the review of symptoms for this age groupa. S kin: birth skin trauma, skin tags, dimples, cysts, extra digits, birthmarks, hair, nails, diapering habits, clothing habits, behavioral history related to potential skin trauma, rashes, eczema, or skin allergies b. H ead: head growth, head trauma c. E yes: focusing, eye discharge or swelling, infant history of being shaken, vision, abnormal head positioning d. Ea rs: newborn hearing screening results, infant reaction to sound, infant vocalization, and his-tory of recurrent otitis media or effusion e. N ose, mouth, and throat: difficulty sucking or feeding, mouth sores or lesions, tooth eruption, breastfeeding, bottle use, mouthing habits, lan-guage acquisition, sucking on finger or pacifier, daycare, dental care f. R espiratory: respiratory infections, reactive air-way disease or asthma, daycare attendance, fre-quent colds, breathholding, mouthing habits g. C ardiovascular: heart murmur, cyanosis, failure to thrive h. G astrointestinal: stooling and voiding patterns, vomiting or reflux, weight gain and growth, con-stipation, toilet training, rectal bleeding i. Ge nitourinary: urinary stream, urinary tract infections, dysuria, hematuria, testes descended, vaginal discharge j. S keletal: motor milestones, toe-walking, defor-mities, gait, bowing of legs, injuries or trauma k. N eurologic: difficulty feeding, tongue thrust, developmental milestones, toe-walking, hand dominance, feeds self, poor coordination, sei-zures, staring spells, loss of consciousness, speech development, muscle tone l. L ymph and endocrine: newborn screening results, weight gain, linear growth pattern, lymphadenopathy 6. Act ivities of daily living a. N utrition i. M ilk a. T ype: breast milk, formula, cow's milk b. Amount in 24 hours c. Method: breast, bottle (held or propped), cup ii. T ype and amount of foods iii. S elf-feeding: use of utensils Database 19

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Iv. Plan A. Diagnostics A periodicity schedule for preventive pediatric health care and screening and secondary prevention tests is available through the American Academy of Pediatrics (AAP) at http://pediatrics. aappublications. org/content/133/3 /568. full?sid=84c54f2b-f79a-4830-80ca-2fdaf5c3b471 (AAP, 2014a) 1. H earing risk assessment (Hagan, Shaw, & Duncan, 2008; Harlor & Bower, 2009) a. Aud itory skills monitoring b. D evelopmental surveillance c. A ssessment of parental concern d. S tarting at 12 months, if risk factors are identi-fied by review of symptoms or risk assessment children should be referred for diagnostic audio-logic assessment. 2. V ision screen (Hagan, Shaw, & Duncan, 2008; Kelly, 2014) a. D etection of strabismus b. V ision i. I ndirect assessment of vision in infancy and early childhood as noted previously ii. Dir ect assessment of visual acuity in early childhood to comply with vision screening test (AAP, 2014a) 3. I ron deficiency (AAP, 2014a; Kelly, 2014) a. R isk assessment screening at 4, 15, 18, 24, 30, and 36 months of agei. A t 4 months, risk assessment includes histo-ry of prematurity, low birth weight, and diet. ii. A fter 1 year, risk assessment includes socio-economic status, limited access to food, diet low in iron, and exposure to lead. b. H emoglobin or hematocrit at 12 and 24 months of age 4. L ead poisoning (CDC, 2015; Kelly, 2014; Wengrovitz & Brown, 2009) a. F ollow state screening plan i. S tate-specific links can be found through the CDC: http://www. cdc. gov/nceh/lead /programs/default. htm b. I f no plan for state screening in place, consider universal screeningi. B lood lead level at 12 and 24 months of age ii. U niversal screening also recommended for recent immigrants, foreign adoptees, and ref-ugee children between 6 months and 16 years c. T argeted screening; see state-specific question-naires for suggested screening questions(CDC) growth charts: http://www. cdc. gov /growthcharts/charts. htm b. V ital signs and pain assessment: heart rate, res-pirations, temperature, blood pressure (in chil-dren who are at risk or have chronic conditions), assess pain score c. Ge neral appearance: state of alertness, nutrition d. S kin: hydration, rash, birthmark, scar, bruises, signs of trauma e. H ead: anterior fontanel size, sutures, condition of hair and scalp, asymmetry f. E yes: eyelids, discharge, reactivity of pupils, corneal light reflex, red reflex, focus and follow, cover-uncover test (perform with infant sitting in parent's lap beginning at 9 months to 1 year of age), strabismus, nystagmus g. Ea rs: external ear, external canal, tympanic mem-branes, pneumatic otoscopy h. N ose: patency, discharge, turbinates i. M outh and throat: presence and number of teeth, caries, occlusion status, tonsils j. N eck: supple, rigid, palpable lymph nodes k. C hest: work of breathing, auscultation of lungs, chest wall shape, symmetry l. H eart: rhythm, quality of heart sounds, presence of murmur, gallop or click, pulses, precordium, perfusion, color m. A bdomen: umbilicus, palpate liver and spleen, any masses, quality of bowel sounds n. Ge nitalia i. M ale: urethral meatus, foreskin, testes, inguinal canal, anus ii. F emale: appearance of perineum, clitoris, vaginal introitus, hymen, discharge, anus o. M usculoskeletal: muscle strength, range of motion, joints, extremities, spine, Ortolani and Barlow maneuvers for infants p. N eurologic: motor function, symmetry, tone, gait, language, social development, primitive reflexes, and postural reflexes III. Assessment A. Identify the child's general health risks based on age, gender, ethnicity, and specific health risks. B. Determine the child's current health status. C. Determine parent's or caregiver's motivation to promote and maintain positive health behaviors. D. Assess the child's developmental milestones and ability to accomplish and master skills. 20 CHAPTER 4 | 0 to 3 Years of Age Interval Visit

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5. Or al health screening (AAP, 2014b; AAPD, 2014) a. R isk assessment starting at 6 months of age using a caries risk assessment tool available at http:// www. aapd. org/media/Policies_Guidelines/G _Caries Risk Assessment. pdf b. D ental referral to establish a dental home at 12 months of age 6. T uberculosis (AAP, 2014a; Kelly, 2014) a. R isk assessment at 1, 6, 12, and 24 months of age, then annually b. T argeted screening with positive risk screening 7. L ipid profile (Ferranti & Newburger, 2014; Kelly, 2014) a. R isk assessment at age 2, 4, 6, 8, and 10 years b. R isk factors: family history of premature coronary artery disease, disease states associ-ated with cardiovascular disease, significant tobacco smoke exposure, hypertension, elevated BMI (> 95% for children between 2 and 8 years of age) c. H yperlipidemia screening if known risk factors B. Treatment 1. I mmunizations appropriate for age are available at http://www. cdc. gov/vaccines/schedules/ 2. Or al fluoride (if primary water source is deficient in fluoride) 3. V itamin D supplementation: breastfed infants and all children > 1 year old C. Patient and family education (Hagan, Shaw, & Duncan, 2008) 1. Di scussion of the following a. P resenting concerns b. N utrition appropriate for age c. S afety and injury prevention d. T oilet training appropriate to age e. A vailable parent and community resources f. C hildcare arrangements and preschool plans g. Gr owth and development appropriate for age with review of growth chart, physiologic development of lower extremities (bowed legs, knock knees) h. A ge-appropriate behavior of infant or toddler (including separation anxiety, fear of strangers, and sleep patterns) i. T antrums and limit setting j. V accine promotion k. P ossible reactions to immunizations D. Expected parent outcomes 1. P arents are able to: a. Be reassured about their concernsb. V erbalize knowledge of nutritional requirements appropriate for age—variable appetites, food fads, bottle habits (sleeping with bottle, juice in bottle, starting cup use), label reading c. V erbalize safety precautions appropriate for age d. V erbalize age-appropriate toilet training e. V erbalize available community resources f. V erbalize available childcare arrangements and preschools and the appropriateness for their child g. V erbalize understanding of age-appropriate growth and development including physiologic development of lower extremities h. V erbalize understanding for age-appropriate behavior including sleep patterns and separation anxiety i. V erbalize understanding of tantrums and limit setting in relation to development j. V erbalize understanding of immunizations and grant informed consent. Understand possible reactions to immunizations and treatment of possible fever including temperature taking. k. V erbalize the importance of timely immuniza-tions references American Academy of Pediatric Dentistry. (2014). Guideline on infant oral health care. Retrieved from http://www. aapd. org/media/Policies _Guidelines/G_Infant Oral Health Care. pdf American Academy of Pediatrics. (2014a). Recommendations for pedi-atric preventive health care. Retrieved from http://pediatrics . aappublications. org/content/133/3/568. full?sid=84c54f2b-f79a -4830-80ca-2fdaf5c3b471 American Academy of Pediatrics. (2014b). Maintaining and improving the oral health of young children. Pediatrics, 134(6), 1224-1229. Centers for Disease Control and Prevention (CDC). (2015). CDC's Childhood Lead Poisoning Prevention Program. Retrieved from http:// www. cdc. gov/nceh/lead/about/program. htm Duderstadt, K. G. (Ed. ). (2014). Pediatric physical examination: An illustrated handbook (2nd ed. ). St. Louis: Mosby, Inc. Ferranti, S. D., & Newburger, J. W. (2014, July 3). Definition and screening for dyslipidemia in children. Up T o Date. Retrieved from http://www. uptodate. com/contents/definition-and-screening -for-dyslipidemia-in-children?source=see_link Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds. ). (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed. ). Arlington, VA: National Center for Education in Maternal and Child Health. Harlor, A. D., & Bower, C. (2009). Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics, 124(4), 1252-1263. Hockenberry, M. J. (2013). Communication and physical assessment of the child. In M. J. Hockenberry & D. Wilson (Eds. ), Wong's essentials of pediatric nursing (9th ed., pp. 86-184). St. Louis, MO: Mosby. Hockenberry, M. J., & Wilson, D. W. (2010). Communication and physical assessment of the child. In M. J. Hockenberry & D. Wilson (Eds. ), References 21

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Wong's nursing care of infants and children (9th ed., pp. 117-226). St. Louis, MO: Mosby. Kelly, N. (2014, August 27). Screening tests in children and adolescents. Up T o Date. Retrieved from http://www. uptodate. com/contents /screening-tests-in-children-and-adolescents?source=search_result&s-earch=screening+tests+in+children+and+adolescents&selected Title =1%7E150#H16 La Rosa, A. (2015, January 8). Developmental-behavioral surveillance and screening in primary care. Up T o Date. Retrieved from http://www . uptodate. com/contents/developmental-behavioral-surveillance-and -screening-in-primary-care?source=search_result&search=developmental+screening&selected Title=2%7E18#H11 Wengrovitz, A. M., & Brown, M. J. (2009). Recommendations for blood lead screening of Medicaid-eligible children aged 1-5 years: An updated approach to targeting a group at high risk. MMWR: Recommendations and Reports, 58, 1-11. 22 CHAPTER 4 | 0 to 3 Years of Age Interval Visit

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b. T rauma, surgeries, or hospitalizations c. D ental home: date of last examination (if any); caries or dental work 4. M edication (include homeopathic or herbal supple-ments and vitamins) 5. A llergies (medication, environmental, and food) 6. I mmunization status 7. F amily history 8. S ocial history a. D aycare or preschool attendance; kindergarten b. H ousehold members c. M eans of financial support in family 9. E nvironmental health history (National Environmental Education Foundation [NEEF], 2015) a. I ndoor exposures: smoke, mold, cockroaches, rodents, damp walls, strong odors, broken win-dows, lead exposure, and parental occupation b. Out door exposures: sun, industrial smokestack, and housing proximity to heavy traffic 10. N utrition a. F oods—intake of fruits, vegetables, lean meat/ beans, iron-rich foods, whole grains; calcium sources: milk, cheese, and yogurt; and juice and water intake (source of water and fluoride) b. Ea ting habits, mealtime behavior, and family meals 11. El imination a. P otty training process and status; voiding habits b. S tooling patterns 12. S leep (quality and quantity): bedtime routine 13. D evelopmental (see Chapter 9, Developmental Assessment: Screening for Developmental Delay and Autism); evaluate overall school readiness a. S ocioemotional: self-care skills, typical play, and description of self b. L anguage (expressive and receptive)I. Intr oduction and general background Health supervision and well-child visits are opportunities for the healthcare provider to assess a child's growth and devel-opment and to promote wellness in the child and family. In addition, the provider needs to address disease detection and prevention and offer proper anticipatory guidance during the visit (Hagan, Shaw, & Duncan, 2008a). Children between 3 and 6 years of age experience an explosion of language, mastery of physical skills, sense of self and peers, an increase in independence, and endless curiosity, all in preparation for a successful school entry milestone (Hagan, Shaw, & Duncan, 2008b). They cross from early childhood into the beginning stages of middle childhood. The approach to early childhood during the well-child visit is twofold: although most of the history may still be provided by the parent or caretaker, children at this age may now partici-pate in some of the interview and actively engage with the pro-vider. Careful observation of their behavior in the examination room is also useful, including their interaction with the parent or caretaker, the environment, and the provider (Duderstadt, 2014). Healthcare maintenance visits in this age range include comprehensive history, physical examination, screening tests (as appropriate), immunizations, anticipatory guidance, coun-seling at a yearly basis, and follow-up as needed. II. Database (may include but is not limited to) A. Subjective 1. P arental and child concerns (chief complaint) a. H istory of present illness 2. I nterval history 3. P ast medical history a. B irth history Mary Anne M. Israel3 to 6 Ye Ars of Age Inter v A l  v I s I t© Eliks/Shutterstock; © donatas1205/Shutterstock 235Chapt Er

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d. S kin, hair, and nails: hydration; rashes; birth-marks; scars; nail and hair health; and infesta-tions (lice) e. H ead-eyes-ears-nose-throat: symmetry of head; external inspection of eyes and lids, extra-ocular movement assessment, pupil examina-tion, red light reflex examination, corneal light reflex, cover-uncover examination, ophthalmo-scopic examination of optic nerve and retinal vessels (in 5-and 6-year-olds); tympanic mem-brane description and mobility; nasal septal deviation, nasal discharge and turbinate status; dental condition, dental caries, gingival inflam-mation, and malocclusion; throat and tonsils f. N eck: supple, note palpable lymph nodes g. C hest and lungs: symmetry of chest, ausculta-tion of lungs h. C ardiac and heart: rhythm, murmur, gallop, click, pulses, and capillary refill time i. A bdomen: liver, spleen, masses, palpable stool, and bowel sounds j. Ge nitourinary: external genitalia and rectal status; for males, circumcision or retractable foreskin, meatus midline, testes descended bilaterally; for females, inspect urethra, vaginal introitus, labial condition k. M usculoskeletal: muscle strength, range of motion, inspect spine and back, and gait l. N eurologic: cranial nerves II-XII; deep tendon reflexes; symmetry, tone, gait, strength; observe fine and gross motor skills; m. D evelopmental: assess language acquisition, speech fluency, and clarity; thought content and ability to understand abstract thinking III. Assessment A. Summary of health, growth, and development 1. I dentify general health risks based on age, gender, past history, and ethnicity 2. D etermine child's and caregiver's motivation to promote and maintain positive health behaviors 3. I dentify ability to accomplish and master develop-mental milestones Iv. Plan A. Screening (Hagan, Shaw, & Duncan, 2008c); see resources and screening questions from http:// www. brightfutures. org 1. V ision screeningi. 3-4 y ear-old: speech is usually fluent and clear, talks about experiences and under-stands who, what, where questions ii. 5-6 y ear-old: communicates easily to adults and children, long imaginative stories, enjoys stories and understands everything that is said c. C ognitive i. 5-6 year-old: increases memory capacity, follows directions, able to listen and attend, advances pretend play d. P hysical i. 3-year-old: builds tower of cubes, throws ball, rides tricycle, walks up stairs, draws, and toilet training progress ii. 4-year-old: hops on one foot; balances for 2 seconds; copies crosses; dresses and undresses with minimal assistance; and pours, cuts, and mashes own food iii. 5-6 year-old: balances on one foot, hops and skips, ties a knot, grasps a pencil, draws a person with six body parts, recognizes letters and numbers, copies squares and triangles, and dresses and undresses without assistance 14. R eview of systems a. Ge neral b. S kin, hair, and nails: birthmarks, rashes c. H ead-eyes-ears-nose-throat: headaches; ocu-lar history (vision, eyes straight, eyelid droop, eye injury); hearing and history of otitis media; nasal congestion, allergies, and nosebleeds; oral health, dental brushing, and flossing; and sore throats and difficulty swallowing d. C hest and lungs: history of asthma or reactive air-way disease, croup, bronchitis, or persistent cough e. C ardiac and heart: history of heart murmur, cya-nosis, shortness of breath, and energy level f. A bdomen and gastrointestinal: appetite, diet, abdominal pain, constipation, vomiting, and diarrhea g. Ge nitourinary: incontinence, enuresis, urinary tract infections, dysuria, frequency, hematuria, vaginal discharge, and phimosis or balanitis h. M usculoskeletal: deformities, limb pains, inju-ries, and orthopedic appliances i. N eurologic: seizures, fainting spells, loss of con-sciousness, headache, and gait j. E ndocrine: recent weight gain or loss and linear growth patterns B. Objective 1. P hysical examination a. W eight, height, and body mass index (BMI) b. P ulse, respiratory rate, and blood pressure c. Ge neral: state of alertness and quality of interac-tion with parent and staff24 CHAPTER 5 | 3 to 6 Years of Age Interval Visit

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c. Di scuss proper nutrition for age: well-balanced diet, breakfast every day, three servings of fruits and two servings of vegetables per day, increased whole-grain consumption, two cups of milk or equivalent calcium intake per day, 3-4 oz. pro-tein daily—lean meat/beans/soy; limit high-fat and low-nutrient foods and drinks. 8. Sa fety a. C ar safety: seat or booster and safety helmets b. P edestrian safety: falls from windows, outdoor safety, swimming safety, smoke detectors and carbon monoxide detectors, and guns and weap-ons in the home c. S tranger safety: reinforce rules about talking with and going with strangers if approached d. S exual abuse prevention—review appropriate touching D. Expected outcomes 1. R eassure child and parents about health concerns 2. P romote optimal health for children and their families 3. P romote family support and acceptable discipline approach 4. P romote social development 5. E ncourage literacy activities 6. E mpower parents to provide healthy eating habits and encourage physical activities; limit amount of television and computer time 7. P romote safety parameters at home, in the car, and in the neighborhood 8. S upport school readiness E. Consultation and referral 1. D ental home if not already established 2. F urther developmental testing if indicated 3. S ubspecialty referral if indicated F. Resources for families 1. H ealthy Children (American Academy of Pediatrics): www. healthychildren. org (includes special section on preschoolers in “ Ages and Stages”) 2. Kid s Health (Nemours Center for Child Health Media): www. kidshealth. org 3. B right Futures for Families: www. brightfuturesfor families. org G. Resources for providers 1. N ational Association of Pediatric Nurse Practitioners: www. napnap. org2. Aud iometric screening 3. L ead screening and risk assessment (see Chapter 4 for lead screening recommendations) 4. A nemia screening and risk assessment 5. T uberculosis screening and risk assessment 6. D yslipidemia screening and risk assessment 7. U rinalysis (one time between 3 and 5 years of age) B. Treatment 1. I mmunizations appropriate for age are available at http://www. cdc. gov/vaccines/schedules/ 2. Or al fluoride (if primary water source is deficient in fluoride) 3. I ron supplementation: consider for children from low-income families (American Academy of Pediatrics, 2010) 4. V itamin D supplementation: breastfed infants and all children > 1 year old (Institute of Medicine, 2010) C. Anticipatory guidance and family education (Hagan et al., 2008b) 1. Addr ess child and parental-caregiver concerns 2. F amily support and routine a. F amily decisions, sibling rivalry, work balance, and discipline methods b. T emperament 3. R eading literacy and comprehension, speech and language skills 4. Pe ers a. I nteractive games, play opportunities, social interactions, and taking turns 5. S chool readiness a. P reschool: structured learning experiences; friends; socialization; and able to express feel-ings of joy, anger, sadness, fear, and frustration b. Kinde rgarten and elementary school: establish routine, after-school care and activities, parent-teacher communication, friends, bullying, matu-rity, management of disappointments, and fears 6. P hysical activity a. L imit screen time (television, computer, mobile device) to 2 hours per day of appropriate pro-gramming; no television in child's room b. E ncourage 60 minutes of physical activity per day (5-6 year-olds) 7. P ersonal health habits a. D aily routines including bedtime routine b. Or al health: daily brushing and flossing, ade-quate fluoride intake Plan 25

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2. A merican Academy of Pediatrics: www. aap. org 3. B right Futures: www. brightfutures. org references American Academy of Pediatrics. (2010). First AAP recommendations on iron supplementation include directive on universal screening. Retrieved from http://aapnews. aappublications. org/content/early/2010/10/05 /aapnews. 20101005-1. full?rss=1 Bowen, C. (2014). Ages and stages summary: Language development 0-5 years. Retrieved from http://www. speech-language-therapy. com/ Duderstadt, K. (2014). Approach to care and assessment of children & adolescents. In K. Duderstadt (Ed. ), Pediatric physical examination: An illustrated handbook (2nd ed., pp. 1-8). Philadelphia, PA: Elsevier. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds. ). (2008a). Introduction to the bright futures visits. In American Academy of Pediatrics, Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed., pp. 203-219). Elk Grove Village, IL: American Academy of Pediatrics. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds. ). (2008b). Early child-hood: 3  year visit. In American Academy of Pediatrics, Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed., pp. 439-481). Elk Grove Village, IL: American Academy of Pediatrics. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds. ). (2008c). Rationale and evidence. In American Academy of Pediatrics, Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed., pp. 221-250). Elk Grove Village, IL: American Academy of Pediatrics. Institute of Medicine. (2010). Dietary reference intakes for vitamin D and calcium. Retrieved from http://www. iom. edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Report-Brief. aspx National Environmental Education Foundation (NEEF). (2015). Pediatric environmental history primer. Retrieved from http://www. neefusa. org /pdf/primer. pdf26 CHAPTER 5 | 3 to 6 Years of Age Interval Visit

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2. I nterval history (American Academy of Pediatrics [AAP], 2014a) a. F requency and type of illness since last visit b. C hronic illnesses: current status and treatment plan c. M edications d. T rauma, hospitalizations, or emergency room visits e. D ental care status 3. I mmunization status 4. F amily and social history a. C hanges from previous visit: emotional support, means of financial support/parental employment status, childcare arrangements, and changes to family medical history b. S ibling rivalry, parental stress, living arrange-ments, and childcare c. S afety: screen for domestic violence, substance abuse in home, neighborhood safety, school bullying, Internet use, personal, and weapons in home d. E nvironmental risk factors: cigarette smoke, sun exposure, pollution, lead, and allergens 5. D evelopmental and behavioral history a. P roblems or concerns b. A ppraisal of coping styles: anxiety, anger, frus-tration, fear, and happiness c. I nteraction with peers, teachers, adults, and family d. A mount and type of screen time per day and per week, supervised versus alone, academic versus entertainment purposes e. C hild's strengths and self-esteem f. C hild's socialization skills and peer activities g. P arent's approach to sexuality and pubertal development h. E xposure to trauma, tobacco, alcohol, and drug use, history of physical or sexual abuse I. Intr oduction and general background Children in middle childhood spend less than half as much time with their parents as they did in early childhood. Although par-ents are still the most important influence in their child's emo-tional and physical development, teachers and peers become increasingly important as the child approaches adolescence. Opportunities for mastery and early identification of learning issues are critical to promoting self-esteem and academic success (Gonida & Cortina, 2014). Screening at well-child visits should include assessing peer interactions and bullying victimization in addition to academic performance and classroom behavior (Espelage & De La Rue, 2011). The influence of media in middle childhood is also increasing, with “screen time” for children ages 6-11 years averaging more than 28 hours a week (Gold, 2009). The timing of puberty varies widely between different racial and ethnic groups and genders and can start as early as 6 years in African American girls (Zuckerman, 2001). Early maturing girls are more likely to have internalizing behavior problems and exhibit more risk-taking behaviors (Zuckerman, 2001). Health maintenance is a mutual goal for the parent or guard-ian and healthcare provider. During periodic well-child visits, a complete history is taken, an examination is performed, and potential health risks are identified. Counseling and guidance are provided to the child and parent in the areas of physical, behavioral, and emotional development. Cultural consider-ations, such as language barriers, cultural values, folk remedies, recognizing child's cultural identity and values, and working to eliminate health inequalities related to race or ethnicity, are important to incorporate into each visit (Duderstadt, 2014). II. Database (may include but is not limited to) A. Subjective 1. P arent and child concerns Bridget Ward Gramkowski and Ann Birenbaum Baker6 to 11 Ye Ars of A G e Interv A l  v I s I t© Eliks/Shutterstock; © donatas1205/Shutterstock 276Chapt Er

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d. C ardiovascular: heart murmur, cyanosis, short-ness of breath, syncope, chest pain, energy level e. G astrointestinal: appetite, food restriction, weight gain or loss, abdominal pain, vomiting, diarrhea, or constipation f. Ge nitourinary: polydipsia or polyuria, enuresis, urinary tract infection, dysuria, frequency, hema-turia, penile discharge, vaginal discharge, and menstrual history g. S keletal: deformities, scoliosis, limb pains, inju-ries, orthopedic appliances, and linear growth h. N eurologic: seizures, fainting spells, loss of con-sciousness, gait, and cognitive disorders i. L ymph: lymphadenopathy, enlarged tonsils or adenoids, and enlarged spleen B. Objective 1. P hysical examination a. H eight, weight, and body mass index (BMI)— chart on Centers for Disease Control and Prevention (CDC) growth charts: http://www. cdc. gov/growthcharts/charts. htm b. V ital signs and pain assessment: Blood pressure, heart rate, pulse, and respirations, assess pain score c. V ision/hearing—AAP (2014a) guidelines d. Ge neral appearance: state of health and alert-ness, mood e. S kin: hydration, lesions or rashes, scars, nevi, and birthmarks. Assess for bruising and/or signs of nonaccidental trauma (NAD). f. H ead: hair growth and distribution, asymmetry g. E yes: reactivity of pupils, red reflexes, fundus, extraocular movements, and cover-uncover test h. Ea rs: tympanic membrane description and mobility, cerumen, and external canal i. N ose: presence or absence of discharge, color of turbinates, and swelling j. M outh: number of teeth, caries, occlusion, orthodontics, and lesions k. N eck: palpable nodes and presence of nuchal rigidity l. C hest: presence of rhonchi; coarseness; wheeze or diminished breath sounds in lung fields; breast development (females); T anner stage m. C ardiac: rate, rhythm, pulses; presence of mur-mur, gallop, or click n. A bdomen: palpable organs, masses, tenderness, and guarding o. Ge nitalia: T anner stage; circumcision, foreskin retractability, and testes (males); general descrip-tion of vaginal introitus, clitoris, labia (females)6. Act ivities of Daily Living a. N utrition i. C alcium: type and amount in 24 hours ii. M eal routine: 24-48 hour dietary recall, number of meals per day, at home and at school; frequency and type of snacks, family meal, any family meals, eating or snacking while watching TV iii. A ttitude toward body image and food iv. S ugar sweetened beverages intake, caffein-ated beverage intake v. F ast food or snack food frequency and type b. P hysical activity: frequency, type, duration, and safety (American Heart Association [AHA] et al., 2006) c. S leep patterns i. A mount of sleep, scheduled bedtime, sleep hygiene (routines and sleep-promoting hab-its), sleep environment (cosleeping, TV in room, cellphone charging next to bed) ii. S leepwalking iii. T eeth grinding, snoring, apnea, and day-time sleepiness iv. N octurnal enuresis v. N ightmares d. S chool i. N ame of school, teacher, and grade; new or continuing at previous year's school ii. S cholastic achievement or grades, other areas of achievement, changes in performance, attention concerns iii. A ttitude toward school, teachers, favorite subject, and future goals iv. P eer relationships v. S chool attendance and participation in activities vi. R eading, writing skills (have child demonstrate) vii. L earning differences, disabilities, and delays, Individual Educational Plan (IEP) or special education classes 7. R eview of systems a. S kin: birthmarks, rashes, abrasions, and bruising b. H ead-eyes-ears-nose-throat: headaches, head injuries, vision, corrective lenses or glasses, hearing, history of otitis media or effusion, nasal allergies, frequent colds, snoring, nose bleeds, dental hygiene, dentist visit, orthodontics, dif-ficulty swallowing, hoarseness, and sore throats c. R espiratory: reactive airway disease or asthma, bronchitis, persistent cough, cough at night or with exercise28 CHAPTER 6 | 6 to 11 Years of Age Interval Visit

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country with a high TB prevalence, such as Mexico, Central America, the Philippines, Vietnam, India, and China iii. C ontacts with high-risk adults, including those who are in homeless shelters, incar-cerated, infected with HIV, or intravenous drug users; and those with chronic condi-tions, such as diabetes mellitus, renal failure, malnutrition, or other immunodeficiencies 6. D yslipidemia risk assessment (AAP, 2014a; Kelly, 2014) a. R isk assessment at ages 2, 4, 6, and 8 years b. R isk factors i. F amily history of dyslipidemia, premature cardiovascular disease, or diabetes, or if family history is unknown ii. C hildren with disease states associated with cardiovascular disease iii. Body m ass index ≥ 85th percentile for age and gender, hypertension, or insulin resistance c. I f risk factors are present, test with fasting lipid profile; repeat testing in 3-5 years if results are within normal limits d. S creen all children once between ages 9 and 11, regardless of risk factors (AAP, 2014a) 7. D epression: begin screening age 11 (Hagan et al., 2008) a. S ee Chapter 13, Childhood Depression, for screen recommendations and available screening tools B. Therapeutics and treatments 1. I mmunizations appropriate for age are available at http://www. cdc. gov/vaccines/schedules/ 2. Or al fluoride supplementation (if primary water source is deficient in fluoride) 3. V itamin D supplementation-consider for all children 6 to 11 years of age C. Patient and family education (Figure 6-1 ) 1. Di scussion of parent and child concerns 2. Di scussion of nutritional requirements, physical activities appropriate for age, and limitation of entertainment screen time to 2 hours per day 3. C hild-parent discussion of safety: helmet use, car (booster seats, seatbelts), protective sports and recreational equipment, water safety, pedestrian safety, exposure to bullying through school, texting, or social media 4. Di scussion of approaches to discipline within the family 5. Di scussion of middle childhood needs for peer interaction and socializationp. M usculoskeletal: muscle strength, range of motion, and scoliosis q. N eurologic: mental status examination; cerebel-lar testing; sensory, motor (fine and gross) status; deep tendon reflexes; and cranial nerves II-XII III. Assessment A. Determine the child's current health status B. Identify the child's general health risks based on age, gender, and ethnicity and specific health risks C. Determine child and caregiver's motivation to promote and maintain positive health behaviors D. Delineate the child's ability to accomplish and master milestones of middle childhood Iv. Plan A. Diagnostics (screening and secondary prevention tests) A periodicity schedule for preventive pediatric health care is available through the AAP (AAP, 2014b) available at http://pediatrics. aappublications. org/content/133/3 /568. full. pdf. 1. H earing risk assessment (Hagan, Shaw, & Duncan, 2008; Harlor & Bower, 2009). Auditory skills monitoring annually or if indicated by parental or teacher concerns 2. V ision screen (Hagan et al., 2008; Kelly, 2014). Assess for defects in visual acuity annually or if indicated by parental or teacher concerns 3. Or al health screening (AAP, 2014b; Kelly, 2014) a. A ssessment for caries, gingival health, and orth-odontic needs b. R ecommend routine dental visit every 6 months 4. L ead poisoning (AAP, 2014a; Kelly, 2014) for recent immigrant, foreign adoptee, and refugee children between ages 6 months and 16 years 5. T uberculosis (TB) screening (AAP, 2014a; Kelly, 2014) a. T argeted screening by purified protein derivative annually for children with the following i. C ontacts with persons with active TB ii. Thos e who are foreign born; those who travel to or have household visitors from a Plan 29

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9. Di scussion of child's relationship with peers, school, and family D. Expected child-parent outcomes 1. A nticipatory guidance and reassurance when indicted in relation to parent and child's concerns6. Di scussion of child adjustment to classroom and school setting 7. Di scussion of opportunities for skill mastery and self-esteem building 8. Ages 8-11 years: discussions of child's pubertal development, hygiene, and body imagef IGure 6-1 s afety, n utrition, and Activity Guidelines for Your s chool-Aged Child Recreational activities should always be supervised and full protective sports gear used. Helmets should be used with any wheeled devices. Pedestrian safety reviewed; bicycle, scooter, and skateboard safety and pro-tective equipment; and water safety including sun exposure and protection reviewed. Teach your child to think carefully about his or her surroundings, particularly around new animals or people. Review the use of 911 and what to do if a child gets lost or separated. Model safe habits, such as seatbelt use, and instruct your child to wear his or her seatbelt appropriately for age and weight. Prepare and practice for emergency situations in the home, such as fire or natural disaster. Make sure you have a planned reunification point (a school, firehouse, and so forth) in the event of a catastrophe. Have emergency supplies for at least 3 days. Have an emergency “go bag” with essential items if you are forced to leave home quickly. Include in the bag any medical needs, emergency instructions, and contact informa-tion. Instruct all your caregivers regarding the emergency plan and location of the go bag. Computers/tablets/cellphone use or any other device allowing online access should be closely monitored. Computer use should be supervised and parents should review clear limits and enact parental controls on media as indicated. Review recommendations for limiting entertainment screen time to 2 hours daily. Nutrition Tips (U. S. Department of Agriculture, 2010): Make at least half your grains whole: whole-wheat bread, oatmeal, brown rice Vary your veggies: go dark green and orange with your vegetables Focus on fruits: fresh, frozen, canned, or dried, and go easy on the fruit juice Get your calcium-rich foods: low-fat and fat-free milk products several times a day Go lean with protein: eat lean or low-fat meat, chicken, turkey, fish, and dry beans Change your oil: fish, nuts, and liquid oils, such as corn, soybean, canola, and olive oil Avoid: Sweetened-sugared beverages and foods. Encourage water daily. Activity (CDC, 2010): 60 minutes or more EVERY day! Limit “screen time” (includes television, video games, and computer time) to 2 hours a day. Vigorous exercise at least 3 days a week including outdoor activity—running; bicycle riding; jumping rope; swimming; organized sports including soccer, basketball, baseball, tennis, martial arts, or gymnastics. Strengthen muscles by participating in sports or gymnastics or using outdoor recreational equipment at least 3 days a week. Strengthen bones with activities such as jumping rope or running at least 3 days a week. Some examples of bone strengthening activities include such games as hopscotch, hopping, skipping, jumping, jumping rope, and running and such sports as gymnastics, basketball, volleyball, or tennis. Data from Centers for Disease Control and Prevention. (2010). Physical activity for everyone. Retrieved from http://www. cdc. gov /physicalactivity/everyone/guidelines/children. html; U. S. Department of Food and Agriculture, Food and Nutrition Service. (2010). T eam nutrition: My pyramid for kids. Retrieved from http://www. fns. usda. gov/TN/kids-pyramid. html. 30 CHAPTER 6 | 6 to 11 Years of Age Interval Visit

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2. N utrition and physical activity: understands nutri-tional and physical activity recommendations appro-priate for age 3. S afety measures understood for helmet use, car boost-ers, sports and recreational equipment, pedestrian safety, social media exposure, texting, bullying and personal safety 4. Di scipline and behavior: parents agree on an approach to discipline and implement it with consistency; address any behavioral problems in home and school setting 5. D evelopmental needs: parental understanding of child's need for peer interaction, socialization, and opportunities for skill mastery 6. E ducation: parents assess child's performance in school and adjustment to current teacher/class; address parental concerns and provide anticipatory guidance 7. S exuality: developmentally appropriate discussion and anticipatory guidance on pubertal developmental stages and body image 8. A ges 8-11 years: encourage child able to verbalize “body concerns” and understanding of puberty; review available adult to talk with about issues with peers, family, teachers, and sports performance and participation referen Ces American Academy of Pediatrics. (2014a). 2014 Recommendations for pediatric preventive health care. Pediatrics, 133, 568. Retrieved from http://pediatrics. aappublications. org/content/133/3/568. full?sid =84c54f2b-f79a-4830-80ca-2fdaf5c3b471. American Academy of Pediatrics. (2014b). Maintaining and improving the oral health of young children. Pediatrics, 134(6), 1224-1229. American Heart Association, Gidding, S., Dennison, B., Birch, L., Daniels, S., Gilman, M., Lichtenstein, A., et al. (2006). Dietary recommenda-tions for children and adolescents: A guide for practitioners. Pediatrics, 117(2), 544-559. Centers for Disease Control and Prevention. (2010). How much physical activity do children need? Retrieved from http://www. cdc. gov/physical-a ctivity/everyone/guidelines/children. html. Duderstadt, K. G. (Ed. ). (2014). Pediatric physical examination: An illustrated handbook (2nd ed. ). St. Louis: Elsevier. Espelage, D. L., & De La Rue, L. (2011). School bullying: Its nature and ecology. International Journal of Adolescent Medicine and Health, 24(1), 3-10. Gold, M. (2009, October 27). Kids watch more than a day of TV each week. Los Angeles Times. Retrieved from http://articles. latimes. com/2009 /oct/27/entertainment/et-kids-tv27. Gonida, E. N., & Cortina, K. S. (2014). Parental involvement in homework: Relations with parent and student achievement-related motivational beliefs and achievement. British Journal of Educational Psychology, 84, 376-396. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed. ). Elk Grove Village, IL: American Academy of Pediatrics. Harlor, A. D., & Bower, C. (2009). Hearing assessment in infants and chil-dren: Recommendations beyond neonatal screening. Pediatrics, 124(4), 1252-1263. Kelly, N. (2014, August 27). Screening tests in children and adolescents. Up T o Date. Retrieved from http://www. uptodate. com/contents /screening-tests-in-children-and-adolescents?source=search_result&search=screening+tests+in+children+and+adolescents&selected Title =1%7E150#H16. U. S. Department of Agriculture, Food and Nutrition Service. (2010). Team nutrition: My pyramid for kids. Retrieved from http://www. fns. usda. gov/tn/team-nutrition. Zuckerman, D. (2001). When little girls become women: Early onset of puberty in girls. The Ribbon. Retrieved from http://envirocancer. cornell. edu /Newsletter/articles/v6little. girls. cfm. References 31

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picture of the youth's strengths, risks, and overall physical and psychologic health status (Ford, English, & Sigman, 2004). 2. A lthough the involvement and participation of a caring adult in the provision of adolescent services is desirable, there are situations in which a young person may not feel able to involve their parent or in which parental involvement could impair the youth's ability to seek or receive services. All states give adolescents some rights to both consent to care and maintain privacy related to care for confidential issues (Klein & Hutchison, 2012). Laws vary significantly from state to state as to the services to which youth can independently consent; therefore, it is incumbent on the healthcare provider to be familiar with consent and confidentiality laws for minors in their state. 3. Effe ctive communication with both youth and their caregivers about adolescent consent and confidentiality rights is essential to establishing rapport and eliciting pertinent information. A brief discussion of adolescent consent and confidentiality with youths and parents or caregivers, emphasizing the aspects of developing self-reliance and skills to manage their own health care, helps to set the stage. Assuring the parent or caregiver that youth are always encouraged to communicate with their parents and that their presence and participation is valued reassures them that they are not being “shut out” of their child's care. Additionally, it is important for youths to become more familiar with their own past health history as they transition into becoming the main source of their own health information. Both parents/caregivers and youths should be informed of the conditional nature of adolescent confidentiality rights because of obligations to protect adolescents in the event that they are a danger to themselves or others or have been subjected to any reportable I. Intr oduction and general background A. Developmental considerations Adolescence, generally considered to encompass ages 12-21, is a time of enormous development and change in all domains of a young person's and a family's life. Bridging and overlapping childhood and young adulthood, adolescents experience the physical changes of growth and sexual matu-ration; continued developmental changes in both structure and function of their brains (a process not completed until the mid to late 20s); and cognitive, psychologic, and social changes related to both their physical changes and roles and expectations of the culture and society in which they live. B. Adolescent consent and confidentiality 1. F or the healthcare provider, the care of the adolescent may also be a time of transition, because it is the relationship that develops between the youth and the provider that becomes the key to the efficacy with which the provider can assess what services and interventions may be appropriate (Gilbert, Rickert, & Aalsma, 2014). The provider must develop an alliance with the youth, and addressing issues of confidentiality is the cornerstone of this alliance. Without assurances of confidentiality, the most vulnerable youth in need of attention and intervention, those who engage in behaviors that present a risk to their health, who are depressed or suicidal, and who report poor communication and lack of perceived support from their parent or caregiver, may avoid health care altogether (Lehrer, Pantell, T ebb, & Shafer, 2007). For these reasons, it is recommended that providers seeing adolescents be prepared to spend time in the visit with both the parent or caregiver and adolescent together and with the adolescent alone to get a full Erica Monasterio Th E Adol Esc En T And Young Adul T (12-21 Y EA rs of Ag E ) In TE rv A l v I s IT© Eliks/Shutterstock; © donatas1205/Shutterstock 327Chapt Er

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