Lorna Schumann

Literacy in the Health Care System: A Study On Open Heart Surgery Patients

Purpose To determine if patients recovering from open heart surgery were able to read and understand written discharge instructions and further to analyze the level of difficulty of standard discharge instructions and consent forms for open heart surgery. Data Sources After screening for visual acuity and efficiency, literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine test (REALM) and comprehension was tested by a post‐test of five questions based on the discharge instructions. Flesch‐Kincaid scores were calculated on four sets of standard written discharge instructions and consent forms. Conclusions Results from the study indicated that the REALM test was more accurate than the reported grade level and that reading skills are needed to understand and comprehend information needed for post‐operative care. The study further substantiated that health care facilities are not providing wrien instructional material that is within the reading level of the patient. Implications for Practice Illiteracy can have a major impact in the health care system. Low reading skills can disempower and can prove to be costly for patients who are requiring health care services. Further investigation is needed on the impact of patients’ reading skills on the health care system.

Preventing pediatric obesity: assessment and management in the primary care setting.

Purpose To review the literature on and discuss the role of the primary care provider in assessing and managing overweight children before they become obese. Data Sources Selected research, national guidelines and recommendations, and the professional experience of the authors. Conclusions The focus of primary care involves early detectionand family interventions that are designed for lifestyle modifications, specifically for improved nutrition and an increase in regular physical activity, to achieve optimal child health. Early identification and management of children who exceed a healthy weight for height, gender, and age will prevent the increasing incidence of pediatric obesity. Early prevention and management of pediatric overweight and obesity will also decrease the potential for associated medical and psychosocial problems. Implications For Practice Pediatric obesity has risen dramatically in the United States during the last two decades; it is a significant child health problem that is preventable and largely under‐diagnosed and under‐treated. It is essential to discuss prevention of obesity with parents at every well‐child visit; treatment should be initiated when patterns of weight gain exceed established percentiles for increasing height for age and gender.

Meeting National Tobacco Challenges: Recommendations for Smoking Cessation Groups

PURPOSE To review the literature on model smoking cessation programs and provide an overview of the practice guidelines for intensive smoking cessation groups. DATA SOURCES Selected evidence‐based literature and AHCPR/AHRQ clinical practice guidelines. CONCLUSIONS Smoking is the leading cause of preventable death in our global society and is expected to kill more people than any other disease within 20 years. Data support that most smokers want to quit and are more likely to succeed with a combination of behavioral and pharmacological support. IMPLICATIONS FOR PRACTICE Smoking cessation must be a priority in the delivery of patient care. Intensive interventions are more effective than brief interventions and should be available for all smokers.

The Female Athlete Triad: A Terrible Trio Implications for Primary Care

Purpose To describe the components of the female athlete triad, including definitions and clinical criteria for diagnosis, methods of screening, and treatment options. Data Sources Selected scientific literature; standard diagnostic guidelines. Conclusions The female athlete triad is a cascading event consisting of disordered eating, amenorrhea, and osteoporosis. This disorder can occur in any sport but is seen most often in events that emphasize thinness and appearance such as gymnastics, ballet, and diving. It can often go unrecognized and result in irreversible bone loss and possible death. Implications for Practice Primary care nurse practitioners (NPs) may be the first health care professionals encountering these females; they need to recognize the risk factors and institute a multidisciplinary approach to treatment. The treatment team should be composed of the patient, the NP, a dietitian, a psychologist, psychiatrist, or psychiatric nurse specialist, and the patients family, coaches, and trainers.

Diagnosing and Treating Alzheimer's Disease: A Practitioner's Overview

Purpose To provide an overview of current diagnostic protocols of Alzheimers disease (AD), screening techniques, tests, and a review of standard and new treatments. Data Sources Selected articles from the scientific literature, online sources, and standard texts were examined. Conclusions Standard tools, such as the Geriatric Depression Scale, the Mini Mental State Evaluation, and the 7‐Minute Screen, are useful in the primary care setting for screening elderly patients. Other tools, such as the Clinical Dementia Rating (CDR) and the Global Deterioration Scale, are useful for staging and monitoring progression of disease and response to treatment. Clinical diagnostic testing is still in developmental stages, but the hope is to have a reliable and objective diagnostic tool in order to diagnose AD in the earliest stages. Implications for Practice The diagnosis and treatment of AD is becoming a more frequent challenge in the primary care office. Clinicians must keep abreast of the rapid changes in new technologies in order to make informed diagnostic and therapeutic decisions.

Early Recognition of Marfan's Syndrome

Purpose To describe the classical features of Marfans syndrome to help nurse practitioners (NPs) diagnose it in the early stages of progression and perhaps prevent many of its deleterious effects. Data Sources Selected research‐based articles in the scientific literature and classic medical texts. Conclusions The cause of Marfans syndrome is unknown, but studies have linked it with a disorder of chromosome 15. It is a degenerative connective tissue disorder that affects the musculoskeletal, ocular, integumentary, respiratory, and neurologic systems. The most lethal effect is on the cardiovascular system causing dissecting aortic aneurysms. Implications for Practice Early diagnosis is essential for a positive course of management. Marfans syndrome can have fatal consequences and is often underdiagnosed and misdiagnosed.

A perspective on chronic illness

This special issue of the Journal of the American Academy of Nurse Practitioners focuses attention on the growing population of people with chronic illness. Of particular concern is the current state of the U.S. healthcare system and its inability to provide coordinated, cost-efficient, and evidence-based care to those who need it most. Nurse practitioners (NPs) are concerned about the rising healthcare costs as providers, consumers, and employers. Throughout our history, NPs have been strong advocates for accessible, cost-effective, quality health care. Our desire is to partner with thepublic,healthcarepolicymakers, andotherhealthcare providers to optimize health care in the 21st century. This editorial overview describes some of the most salient concerns about chronic illness and is our platform for this special issue. The articles included herewere submitted and peer-reviewed through the regular submission and selection process for the journal; thus, they represent the concerns of many NPs and health professionals.

Diagnosis and Management of Chronic Prostatitis by Primary Care Providers

Purpose To describe the etiology, clinical manifesta‐tions, differential diagnosis, and treatment of chronic bacterial and chronic abacterial prostatitis (CBP and CAP respectively) in the primary care setting. Data Sources Selected research, clinical guidelines, and research‐based articles in the scientific literature. Conclusions Most cases of CBP can be appropriately diagnosed and treated in the primary care office. In the case of a diagnosis of CAP, initial therapy can be started by the nurse practitioner (NP) with referral to a urologist for refractory cases. Implications for Practice Complete eradication of pathogens in CBP is not always possible. Assisting patients to carefully follow their treatment regimens, including completion of all antibiotic therapy, will reduce the frequency and severity of symptoms. Successful management of chronic pro‐statitis symptoms can result in an improved quality of life and an increased ability to perform activities of daily living for patients. Chronic abacterial prostatitis may require referral to a urologist or mental health professional for co‐management of symptoms.

Continuing Education Forum. Diagnosing Hemochromatosis

Hereditary hemochromatosis (HHC) is the most common autosomal recessive genetic disease found in the Caucasian population. It is estimated that 1 in 10 to 20 Caucasians carry this gene and that 1 in 400 are homozygotes at risk for developing clinical problems seen with this disease (Rouault, 1993). This is a serious disease that, if untreated, will cause premature death. Fortunately, with early diagnosis, HHC is easily treated and individuals with the disease have a mortality rate equal to that of those who do not have the disease (Rouault) . Early diagnosis and treatment is necessary. With the current concern over health care costs, insurance companies will not reimburse health care providers for routine screening tests without presenting symptoms and a differential diagnosis. This means that many patients who have this disease will not be diagnosed until symptoms are present and organ failure may have begun. Another problem in diagnosing these patients early is that varying symptoms may lead primary care providers to the wrong diagnosis. It is estimated that usually more than five physicians have been consulted before the diagnosis is established and approxiognized by Europeans as “bronze diabetics” and described by von Recklinghausen in 1889. In 1935, Shelden discovered its genetic relationship, and, in 1975, HHC was linked to a human leukocyte antigen on chromosome 6 (Edwards & Kushner, 1993). Absorption occurs in the epithelial cells of the duodenal mucosa in the proximal small intestine. Due to a high absorption rate, circulating cells are overloaded with iron and transferritin (an iron-transporting protein) may become completely saturated. Normally, once this occurs, the transferrin receptor expression is down regulated, leading to a decrease in iron absorption. In persons with HHC, this regulatory mechanism is not in place (Kowdley & Tavill, 1998). After transport in the bloodstream and deposition in the liver, heart, pancreas, skin, and joints, iron is sequestered in ferritin (an iron protein complex) in individual cells of the tissue. At this point there is no mechanism for excretion other than blood loss, exfoliation of skin and mucosal epithelial cells, and small losses in sweat and urine (Rouault, 1993).

A Review of Antiphospholipid Antibody Syndrome

Purpose To review the pathophysiology, clinical presen‐tation, and management options for antiphos‐pholipid antibody syndrome (APS), a poten‐tially life‐threatening coagulation disorder. Data Sources Selected scientific literature, consensus guide‐lines, and expert opinion. Conclusions Clinical features that should alert the clinician to consider APS include recurrent fetal loss, arterial or venous thrombosis, thrombocytope‐nia and livedo reticularis. One should be sus‐picious of this diagnosis in a younger patient, one with an autoimmune disease, or family history of autoimmune disease. To confirm the diagnosis one needs both clinical and laborato‐ry abnormalities. Implications for Practice The signs and symptoms of APS are varied and could be confused with many disorders. The primary care provider needs to be aware of this syndrome in order to include it in the differ‐ential diagnosis and appropriately recognize and refer the patient in a timely manner.