WS1 Template - Family Nurse Practitioner Roberta_5-D Cove… · Web viewLymph nodes may be palpable at the cervical chain, but a common lymphatic malformation of a lymphangioma may

SCHOOL OF NURSINGPYC COVER SHEET

Title of Exhibit: Practices within an authorized scope of practice.

NONPF CORE COMPETENCY #5: Managing and negotiating health care delivery

systems.

NONPF Core Competency CATEGORY #5-D: Practices within an authorized scope of

practice.

DSGNE Program Outcome #1: Employ authentic transformational servant leadership to

influence positive change across the health care spectrum.

PYC Specialty Program Outcome #2: Utilize an evidence-based approach to initiate change

and improve primary care practice across the lifespan.

AACN Essential Standard #III: Quality improvement and safety.

AACN Element #III-5: Promote a professional environment that includes accountability and

high-level communication skills when involved in peer review, advocacy for patients and

families, reporting of errors, and professional writing.

This Exhibit Contains: Advanced Organizer for newborn assessment and Nurse Manager’s

reference indicating practice and working to improve practice over many years.

Rationale and Support:

There is much room for improvement in the professional nurse practitioner environment

such as role clarity of advanced practice nurses especially internationally (Lowe, Plummer,

O’Brien, & Boyd, 2012). The importance of nurse practitioner accountability is recognized in

the medical field and that we have comparable numbers for health indicators, but better patient

and professional satisfaction (Naylor & Kurtzman, 2010). The concerns for improved care in

pediatrics with wellness evaluations and immunizations can occur by financial incentives as

GRADUATE PORTFOLIO – GRADUATE NURSING: PYC NURSE PRACTITIONER 2

demonstrated by Massachusetts Blue Cross Blue Shield to improve childhood asthma care

(Chien et al., 2014). Then the use of wellness visits to screen for intimate partner violence and

child maltreatment as discussed by Hornor (2013). These are preventative initiatives which are

readily some of what the nursing profession is most notable for accomplishing. By starting some

screening forms and quickly using them in practice, it will decrease the some of the biggest

concerns for healthcare costs by prevention. Horner provides a number of indicators and

questions for indication of maltreatment (2013).

Reflection:

Improving the health of populations is what Florence Nightingale strived to accomplish.

Over the years, medicine has made many improvements, but getting the population to change

into a mindset of prevention is the nursing field’s forte. We were always working to achieve

improved outcomes, and assist in the education of the public. Wellness visits and patient

teaching with enhanced communication to both physicians and the general public is nursing’s

most valuable role.

I have not made it a secret of my previous marriage and being in an abusive relationship.

I also found several nurses and nurse practitioners with a similar background on the way. If we

could unite to prevent this issue as we have united on prevention at many fronts, we will have

professional acknowledgment. The prevention of maltreatment is something that is favorable.

However, I am for the taking care of all cultures, and I understand there are some cultural

variations in child discipline, but there is a fine line between discipline and maltreatment.

Maltreatment often evolves into abuse and neglect which I have a zero tolerance policy for

(Horner, 2013).

References:

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Chien, A. T., Song, Z., Chernew, M. E., Landon, B.E., McNeil, B. J., Safran, D. G., & Schuster,

M. A. (2014). Two – year impact of the alternative quality contract on pediatric health

care quality and spending. Pediatrics, 133(1), 96-104. doi:10.1542/peds.2012-3440

Honor, G. (2013). Child maltreatment: Screening and anticipatory guidance. Journal of

Pediatric Health Care, 27(4), 242-250. doi: 10.1016/j.pedhc.2013.02001

Lowe, G., Plummer, V., O’Brien, A. P., & Boyd, L. (2012). Time to clarify – the value of

advanced practice nursing roles in health care. Journal of Advanced Nursing, 63(3), 677-

685. doi: 10.1111/j.1365-2648.2011.05790.x

Naylor, M. D., & Kurtzman, E. T. (2010). The role of Nurse Practitioners in reinventing primary

care. Health Affairs, 29(5), 893-899. http://content.healthaffairs.org/content/29/5/893.full

Plagiarism Statement: I have read and understand the plagiarism policy as outlined in the

syllabus and the sections in the Catalog relating to the IWU Honesty/Cheating Policy. By

affixing this statement to the title page of my paper, I certify that I have not cheated or

plagiarized in the process of completing this assignment. If it is found that cheating and/or

plagiarism did take place in the writing of this paper, I understand the possible consequences of

the act/s, which could include expulsion from Indiana Wesleyan University.

Place the Exhibit Here:

The HEENT assessment of the newborn

There are several distinct differences in the assessment of the newborn such as the

presence of fontanels, developmental anomalies, and the possibility of birth injuries. The first

assessment is complete in 24 hours of birth and then another several hours before discharge from

the hospital (McKee-Garrett, 2014).

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The palpation of the anterior fontanel is the “pediatrician’s handshake” (Gallagher, Hing,

& Cunningham, 2013). There are six fontanels at the newborn skull which include; the diamond-

shaped anterior, two mastoids star-shaped fontanels, two sphenoid fontanels, and the triangular

posterior fontanel. The sutures are as essential to palpate due to the possibility of early closure

occurring in utero creating the condition of craniosynostosis. Craniosynostosis requires surgical

intervention for allowing proper brain growth. The six sutures are the coronal, metopic, sagittal,

lambdoid, mendosal, and squamosal. These sutures may not be totally palpable on the first exam

due to molding in passage from the birth canal (McKee-Garrett, 2014).

The concern of the size of the fontanels is variable in relation to the skull size and shape.

Fontanel sizes vary in relation to ethnicity, but gestational age at birth and gender has no

association with fontanel size (Gallagher, Hing, & Cunningham, 2013). The anterior fontanel

typically measures about 0.6-3.6 centimeters (cm). The posterior fontanel measures about less

than a 1 cm for about eight weeks before closing. There is some variance in the closure of the

anterior fontanel, but it ordinarily closes at 24 months (Gallagher, Hing, & Cunningham, 2013).

If the anterior fontanel is too small this could indicate microcephaly, hypoxia,

hyperthyroidism and craniosynostosis. If the anterior fontanel is too large or has soft areas,

known as craniotabes, there could be malnutrition involving calcium, vitamin D, and phosphate

(McKee-Garrett, 2014). Genetic trisomies and other genetic conditions have anterior fontanel

enlargement, as well as prenatal exposures to rubella and syphilis. Hydrocephalus will present

with increased cranial pressure creating bulging and fontanel enlargement (Gallagher, Hing, &

Cunningham, 2013).

The circumference of the head is useful in the consideration of the fontanel size. Noting

the symmetry of the head shape and size will help in determining if further evaluation of fontanel

size is requisite. Questionable or obvious anomaly precedes to magnetic resonance image (MRI)

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and the use of Half-Fourier Acquisition Single-Shot Turbo Spin Echo (HASTE) MRI to evaluate

fluid spaces (Gallagher, Hing, & Cunningham, 2013). The use of computed tomography (CT)

and three-dimensional (3-D CT) will help in evaluating ventricular size, subarachnoid spaces,

and masses. Dependent on the possible etiology in consideration of the exam the most common

referrals are to craniofacial, neurosurgery, or the genetics clinic for further evaluation (Gallagher,

Hing, & Cunningham, 2013).

Some other findings that could relate to birth are caput succedaneum creating edema,

cephalohematoma, and subgaleal hemorrhages. These all need further evaluation especially

subgaleal hemorrhage which could be life threating (McKee-Garrett, 2014). Facial palsies mostly

occur with the use of forceps but can happen in prolonged delivery. Similar, but different from

palsy is the asymmetric crying facies (ACF) which causes the asymmetry at the forehead and

eyes. ACF can be related to other anomalies, particularly cardiovascular (McKee-Garrett, 2014).

The symmetry on the eyes can reveal epicanthial folds, difference in the size of globes or

ptosis. The epicanthial folds where the skin is more prominent over the medial aspect of the eyes

is usually suggestive of a syndrome. Wide spacing of the eyes is suggestive of hypertelorism

and several syndromes such as trisomy 13 or Apert syndrome. Variance in the palpebral fissure

can assist in determining a syndrome by the slant to the inner canthus or spacing. Upward

slanting palpebral fissures are suggestive of Down syndrome, and downward fissures suggest

Treacher Collins or Apert syndrome (McKee-Garrett, 2014).

The eye movement should be smooth as the cranial nerves (CN) III, IV, or VI may be

affected. The sclera should be white and clear, but if deep blue then there could be a

developmental issue with the sclera collagen (McKee-Garrett, 2014). The ability to test CN II is

with the blink from a bright light but may not be present in the newborn (Burns, Dunn, Brady,

Starr, & Blosser, 2013; Fitzgerald, 2010). Corneas should be transparent, with any enlargement

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suggestive of glaucoma. The pupils should be responsive to light and round; defects in shape of

the iris could suggest colobama, heart defects, atresia of choanae, retardation, genital and ear

(CHARGE) syndromes. The absence of red reflex is concerning and should be referred to an

ophthalmologist, but a white pupil or white reflex is called leukocoria which is highly suggestive

of retinoblastoma (McKee-Garrett, 2014).

The ears need inspection for position, size, shape, and patency. If the ears are low-set or

more than 10 degrees below the outer canthus of the eye this could indicate Down’s syndrome,

trisomies, or other syndromes. A malformed pinna could reveal renal abnormalities due to the

development of the ears and kidneys co-occurring in utero development. The absence of startle

to loud noises or the Moro reflex is concerning. External ear abnormalities are also characteristic

of further ear anomalies which could include hearing loss and needs further evaluation of CN

VIII (McKee-Garrett, 2014).

Universal newborn hearing screening (UNHS) is recommended as a guideline by the

United States Preventive Services Task Force to identify congenital hearing loss early and for

early intervention (Adcock & Freysdottir, 2014). There are two tests routinely done to evaluate

for hearing loss, the auditory brainstem responses (ABR) and the otoacoustic emissions (OAE)

testing. The OAE requires less testing time but is unable to identify auditory neuropathy. More

false positives occur with the OAE, and that can be attributed to vernix in the external ear canal

(Adcock & Freysdottir, 2014). The overall costs for both tests are similar, due to the increased

referral rate of OAE testing. Further audiological testing occurs after failure of a test and

especially if failure to both tests (Adcock & Freysdottir, 2014).

Selective hearing tests are recommended after admission to the NICU for at least two

days, anomalies of the face and ear, and possible syndromes. Other reasons for further

evaluation are for congenital infection exposure such as; toxoplasmosis, other [Parvovirus,

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bacterial meningitis], rubella, cytomegalovirus, and herpes (TORCH) (Adcock & Freysdottir,

2014). Reasons for an audiology reassessment are after discharge from the hospital is the use of

extracorporeal membrane oxygenation (ECMO) treatment, mechanical ventilation,

aminoglycosides, and hyperbilirubinemia (Adcock & Freysdottir, 2014).

The nose assessment includes shape, patency and symmetric nares (McKee-Garrett,

2014). The assessment of the olfactory cranial nerve (CN I) is difficult in infancy (Burns et al.,

2013). Evaluate for septal deviation. The patency is usually assessed by placing thread or tissue

in front of the nare being evaluated. It may be useful to use a suction tube or feeding tube for the

determination of patency and possible choanal atresia (McKee-Garrett, 2014).

The size, shape and symmetry of the mouth are meaningful (McKee-Garrett, 2014). Is

the jaw small with possible micrognathia? Does the entire mouth have closure and is the infant

able to suck? The ability to suck involves CN V; gag CN IX – X; and tongue movement CN XII

(Burns et al., 2013). Evaluation of the mouth and palate are vital for feeding and determining no

clefts in the soft and hard palate. Are there any lesions or cysts at the palate? Is the tongue with

extended frenulum linguae? Are there natal teeth? These could indicate several syndromes and

necessitate referrals (McKee-Garrett, 2014).

The neck should be without hematomas and flexible without torticollis which could occur

related to trauma in birth (McKee-Garrett, 2014). The rooting reflex with the head turning to the

affected side where the face was stroked tests the facial nerve and CN XI (Burns et al., 2013).

Thyroid enlargement may create a midline mass at the neck. The neck should be present and not

unusually short. Lymph nodes may be palpable at the cervical chain, but a common lymphatic

malformation of a lymphangioma may occur at the supraclavicular nodes (McKee-Garrett,

2014).

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Overall, the HEENT assessment of the infant covers many neurological and genetic

evaluations. The assessment assists in determining the need for further examination and referral.

It may also indicate severe impairments that require immediate emergency attention. The first

impression is visual which helps to guide the evaluation of multiple organs. So much rides on

the initial assessment in the progression of care.

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References

Adcock, L. M., & Freysdottir, D. (2014). Screening the newborn for hearing loss. Retrieved from

http://0-www.uptodate.com.oak.indwes.edu/contents/screening-the-newborn-for-hearing-

loss

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric

primary care (5th ed.). Philadelphia, PA: Elsevier – Saunders.

Fitzgerald, M. A. (2010). Nurse practitioner: Certification examination and practice

preparation (3rd ed.). Philadelphia, PA: F.A. Davis.

Gallagher, E. R., Hing, A.V., & Cunningham, M. L. (2013). Evaluating fontanels in the newborn

skull. Contemporary Pediatrics, 30(11), 12-20.

McKee-Garrett, T. M. (2014). Assessment of the newborn infant. Retrieved from http://0-

www.uptodate.com.oak.indwes.edu/contents/assessment-of-the-newborn-infant

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WS1 Template - Family Nurse Practitioner Roberta_5-D Cove… · Web viewLymph nodes may be palpable at the cervical chain, but a common lymphatic malformation of a lymphangioma may