for Nurse Practitioners

THE OFFICIAL JOURNAL FOR NURSE PRACTITIONERS A Peer-Reviewed Journal WWW.WEBNP.NET

VOL. 12 NO. 10

OCTOBER 2008

The American Journal for Nurse

Practitioners

Clinical Challenges In… PRIMARY CARE Managing Chronic Liver Disease

NP PRACTICE Integrated Mental Health Practice in an NMHC

PEDIATRICS

School Programs to Reduce Obesity in Children

IN TE AW RS AR TIT Oc EN IA tob ES L C e S Y 20 r 20 WE STI 08 -2 EK TI 4, , S

Elevated BP in MexicanAmerican Youngsters: Practice Recommendations

Premarin Ad 4c

2

■

THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS OCTOBER 2008 VOL. 12 NO. 10

Premarin Ad 4/c

VOL. 12 NO. 10 OCTOBER 2008 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS

■

3

Premarin Ad b/w

4

■


L E T T E R

FROM THE EDITORIAL CO-DIRECTORS Dear Colleagues, This issue of The American Journal for Nurse Practitioners will reach you just before an important decision is made that will affect us all for the next 4 years. You may not fully agree with either party or candidate on all issues, but you do have the right to select your leaders while many people in our global community do not. We urge you, then, to exercise your franchise in the presidential election, as well as in your state and local elections. We offer four interesting feature articles in this issue of AJNP, starting with an overview of the management of chronic liver disease in primary care, by Brenda L Janotha. Many of our patients have underlying/coexisting mental health problems in addition to chronic physical problems. in their article about an integrated mental health practice in a nurse-managed health center, Kay T. Roberts, Karen M. Robinson, Chris Stewart, and John C. Wright present an innovative approach to meet these patients’ needs. Obesity is now pervasive in this country and is affecting the youngest members of our population and putting them at high risk for chronic health problems even before they leave adolescence! Brenda K. Landau, Celia S. Brinker, Debra J. Barksdale, and Julee Waldrop discuss elevated blood pressure in overweight Mexican-American children and adolescents, and Myra L. Clark and Marina Slemmons suggest that we develop school programs to reduce the prevalence of obesity in children. We are pleased to reintroduce a column called Turning the Tables: What I Learned from My Patient. Jill C. Muhrer, who practices in South Jersey, presents a patient narrative to which all of us can relate. In subsequent issues of AJNP, Jill will share other poignant stories with us. Finally, two of our regular columnists, Carolyn Buppert (Let’s Talk Money) and Tom Bartol (Promoting the NP Profession), provide useful tips and sound advice. Thanks to our authors and columnists, AJNP is the most widely read NP journal in the country, reaching more than 100,000 NPs. As editorial co-directors, we start the process by reading every manuscript submitted to us. Then our executive editor, editorial assistant, and peer reviewers get involved in the process to ensure that every article we publish is as accurate, current, and well written as possible. We invite you to be a part of our team effort. To submit your manuscript to AJNP, check out our Guidelines for Authors by logging on to the NP Communications website: www.webnp.net Finally, please remember that IC Awareness Week is October 20-24, 2008. You’ll find more information about interstitial cystitis and IC awareness activities on page 59 of this issue.

Please Write The American Journal for Nurse Practitioners welcomes your letters. Please send us your comments, ideas, and suggestions by letter, fax, or email to Dory Greene, Executive Editor, phone (908) 903-0230, fax (908) 903-0231, email: dorygreene@hotmail. com; or to NP Communications, LLC, 109 South Main Street, Cranbury, NJ 08512; phone (609) 371-5085, fax (609) 371-5086.

Charlene M. Hanson EdD, FNP-BC, FAAN

EDITORIAL

ADVISORY

Donna R. Hodnicki PhD, FNP-BC, FAAN, CLNC

BOARD

Ivy M. Alexander, PhD, C-ANP

Thomasine D. Guberski, PhD, CRNP

Beth Moran, RN, CNP

Associate Professor and Director, Adult, Family, Gerontological, and Women’s Health Primary Care Specialty Coordinator, WHNP and ANP Tracks Yale University New Haven, Connecticut

Associate Professor University of Maryland School of Nursing Baltimore, Maryland

Private Practice, Women’s Health Sag Harbor, New York

Doreen C. Harper, PhD, RN, FAAN

Donna G. Nativio, PhD, CRNP, FAAN

Carolyn Buppert, JD, NP Law Office of Carolyn Buppert, P.C. Bethesda, Maryland

Dean and Professor University of Alabama at Birmingham Birmingham, Alabama

Jean E. Johnson, PhD, RN, FAAN

Associate Professor Director of Adult, Family, and Pediatric Nurse Practitioner Programs Director of Doctorate of Nursing Practice University of Pittsburgh School of Nursing Pittsburgh, Pennsylvania

Professor, Dean, University of South Florida College of Nursing, Tampa, Florida

Senior Associate Dean for Health Sciences Program The George Washington University Washington, District of Columbia

Winifred Carson-Smith, Esq.

Mary Knudtson, DNSc, NP

CarsonCompany, LLC Washington, District of Columbia

Professor, Department of Family Medicine University of California at Irvine Irvine, California

Policy Liaison American College of Nurse Practitioners Policy Editor, NP Communications McLean, Virginia

Nancy Rudner Lugo, DrPH, NP

Susan Wysocki, RNC, NP, FAANP

Patricia A. Burns, PhD, RN, FAAN

M. Katherine Crabtree, DNSc, FAAN, APRN,BC Professor, Oregon Health & Science University Portland, Oregon

Linda Dominguez, CNP, BSN, WHNP Assistant Medical Director Planned Parenthood of New Mexico Albuquerque, New Mexico

School of Nursing, University of Central Florida President, NR Consulting, Inc. Orlando, Florida

Lucy Marion, PhD, RN, FAAN

Edward P. Gruber, PhD, RN, ARNP Assistant Dean and Clinical Professor Graduate Nursing Program Intercollegiate College of Nursing Washington State University College of Nursing Spokane, Washington

Dean and Professor, School of Nursing Medical College of Georgia Augusta, Georgia

Carolyn Montoya, MSN, CPNP Coordinator FNP Concentration University of New Mexico Albuquerque, New Mexico

Eileen T. O’Grady, PhD, RN, NP

President & CEO National Association of Nurse Practitioners in Women’s Health (NPWH) Washington, District of Columbia

Phyllis Arn Zimmer, MN, ARNP, FAAN President, Nurse Practitioner Healthcare Foundation Faculty, FNP Program University of Washington School of Nursing Partner, FnP Associates, LLP Seattle, Washington


■

5

THE OFFICIAL JOURNAL FOR NURSE PRACTITIONERS A Peer-Reviewed Journal

The American Journal for

Nurse Practitioners

VOL. 12 NO. 10

OCTOBER 2008

Clinical Challenges In… PRIMARY CARE Management of Chronic Liver Disease in Primary Care.......................... 8 NP PRACTICE Integrated Mental Health Practice in a Nurse-Managed Health Center .................................................................. 33

Page 8

PEDIATRICS Elevated BP in Overweight Mexican-American Children and Adolescents: Recommendations for Clinical Practice........................ 48 Page 33

School Programs to Reduce the Prevalence of Obesity in Children.................................................................................. 62

Other Features… Page 48

Page 62

Meetings & Events .................................................................................... 27 Turning the Tables: What I Learned From My Patient ............................ 28 Book Shelf ................................................................................................ 30 Letter to the Editor.................................................................................... 57 Let’s Talk Money........................................................................................ 58 Promoting the NP Profession .................................................................. 60

The American Journal for Nurse Practitioners Editorial Co-Directors

Charlene M. Hanson EdD, FNP-BC, FAAN

Donna R. Hodnicki PhD, FNP-BC, FAAN, CLNC

Executive Editor Policy Editor and Columnist

Victoria Baum

Advertising Sales

Jim Arsenault

Editorial Assistant

Dawn Citron

CEO Columnists

■

Eileen T. O’Grady, PhD, RN, NP

Art Director

Publisher

6

Dory Greene

www.webnp.net

The American Journal for Nurse Practitioners™ is published by NP Communications, LLC. It is indexed in CINAHL. Contents of the articles are determined by the authors and do not reflect the views or opinions of the publisher or advertisers. ©2008 NP Communications, LLC

The American Journal for Nurse Practitioners is offered free of charge to all licensed nurse practitioners. Annual paid subscriptions to The American Journal for Nurse Practitioners are also available at $59 (US) per year. To receive a paid subscription, send name, address, and speciality, along with a check for $59, to NP Communications, LLC, 109 South Main Street, Cranbury, NJ 08512.

Louise K. Young George R. Young Tom Bartol, NP, CDE Carolyn Buppert, JD, NP Loretta C. Ford, RN, PNP, EdD Susan Kellogg-Spadt, PhD, CRNP Donna G. Nativio, PhD, PNP, FAAN Linda J. Pearson, MSN, DNSc, APRN,BC, FAANP Nancy Rudner Lugo, DrPH, NP Mary Ann E. Zagaria, PharmD, MS, RPh, CGP

ADDRESS CHANGE: Please send your new information and address label to: The American Journal for Nurse Practitioners (AJNP) 800 Township Line Road, Suite 125, Yardley, PA 19067 or email information and label code # to [email protected]

NP Communications, LLC 109 South Main Street • Cranbury, NJ 08512 Postmaster: Address Correction Requested Phone: 609-371-5085 • Fax: 609-371-5086 • Website: www.webnp.net


C,M & F Ad


■

7

PRIMARY CARE

Management of Chronic Liver Disease in Primary Care Brenda L. Janotha, DrNP(c), MSN, ANP-C

A large proportion of patients in primary care have a chronic illness. By 2020, with the “graying” of America, nearly half of the population is likely to have at least one chronic illness.1 With this trend, chronic liver disease (CLD), including cirrhosis, is becoming a more common entity in primary care practice. Patients with CLD represent a unique challenge for nurse practitioners (NPs) because such patients are susceptible to a mul-

The most common causes of cirrhosis in the United States are alcoholism and hepatitis C virus infection.

titude of complications and have a

significantly

reduced

expectancy. This article discusses the main objectives of care for patients with CLD—including psychosocial aspects associated with the condition.

8

■

life


T

he term chronic liver disease generally encompasses all noncurable liver diseases. The impact of CLD on society is vast, and includes loss of productivity, increased healthcare expenditures, diminished quality of life (QoL), and reduced life expectancy. The terms, CLD, cirrhosis, and endstage liver disease (ESLD) are sometimes used interchangeably, depending on the source. In 2005, according to the Centers for Disease Control and Prevention, CLD/cirrhosis was the 12th leading cause of death in the United States.2 Approximately 513,000 hospital discharge records in 2004 listed a diagnosis of CLD/cirrhosis.2

Cirrhosis of the liver is characterized by progressive hepatic fibrosis, disorganization of hepatic lobular and vascular architecture, and development of regenerative nodules.4 Hepatocyte necrosis leads to collapse of the supporting reticulin network with subsequent connective tissue deposition, distortion of the vascular bed, and nodular regeneration of the remaining liver parenchyma.6 These fibrotic changes progressively replace normal liver tissues, causing distortion of hepatic architecture. Resultant impairment in the synthetic, metabolic, and hemodynamic functions of the liver defines the clinical course of cirrhosis.6

Pathophysiology

Etiology of Cirrhosis and CLD

Hepatitis, an inflammation of the liver caused by an infectious or toxic agent, is considered a form of acute or early-stage liver disease. Acute liver disease encompasses infection (with one of the five hepatitis viruses), drug-induced hepatitis, alcoholic hepatitis, ischemic hepatitis, and acute duct obstruction. Patients with acute hepatitis rarely develop scarring unless the disease progresses to a chronic state; reasons for disease progression are unknown.3 Fibrosis of the liver is mediated by the same molecular signals and cellular processes that govern the normal wound healing response.4 Hepatic fibrosis is the development of extracellular matrix or scar tissue that encapsulates the damaged regions of the liver. All patients with chronic liver injury eventually develop fibrosis.5 The rate of fibrosis development varies, depending on the cause of the liver disease and host factors. Early fibrosis is thought to be reversible, whereas progressive fibrosis leads to cirrhosis.5

The most common causes of cirrhosis in the United States are alco-

TABLE 1

holism and hepatitis C virus (HCV) infection.2 Causes of CLD are categorized by the insult or injury leading to the pathologic state (Table 1).7

Clinical Manifestations of Cirrhosis The clinical course for patients with advanced cirrhosis is unpredictable. Complications are independent of the cause of the underlying liver disease. The liver is resilient and can operate with little functional capacity. Most patients with cirrhosis exhibit no symptoms of liver disease and have normal liver enzyme levels.8 Clinically silent cirrhosis inevitably compromises hepatocyte function and hepatic circulation, leading to a host of complications.6 Progression of cirrhosis invariably leads to liver failure. When cirrhosis causes hepatic

COMMON CAUSES OF CHRONIC LIVER DISEASE 7

Autoimmune

Autoimmune hepatitis

Biliary

Chronic obstruction: ■ Primary biliary cirrhosis ■ Primary sclerosing cholangitis ■ Chronic cholestasis Byler disease

Drug/Toxin

Alcohol Amiodarone Methotrexate Vitamin A

Idiopathic

Cryptogenic cirrhosis

Infectious

Chronic viral hepatitis Schistosomiasis

Metabolic and Genetic

Nonalcoholic steatohepatitis Hereditary hemochromatosis Alpha-1 antitrypsin deficiency Wilson’s disease Glycogen storage disease Cystic fibrosis

Vascular

Severe right-sided heart failure Hepatic vein occlusion Budd-Chiari syndrome


■

9

PRIMARY CARE

decompensation, the prognosis is poor and warrants immediate referral for orthotopic liver transplantation (OLT).8 As liver function deteriorates, specific clinical manifestations of impairment arise. Symptoms of CLD, when they do appear, reflect the severity of hepatic damage. The first signs of advanced cirrhosis are laboratory abnormalities such as thrombocytopenia, prolonged prothrombin time (PT), hyperbilirubinemia, and hypoalbuminemia.6 Loss of functioning hepatocellular mass may lead to jaundice, edema, coagulopathy, and a variety of metabolic abnormalities. As liver disease progresses, fibrosis and distorted vasculature may lead to portal hypertension and its sequelae, including gastroesophageal varices and splenomegaly. Ascites and hepatic encephalopathy result from both hepatocellular insufficiency and portal hypertension.9

Assessment CLD eventually leads to multisystem failure; therefore, NPs need to perform a detailed, comprehensive physical examination at every patient visit. Conducting a review of systems helps identify early and manageable signs of liver failure. On physical exam of patients with CLD, NPs should assess for specific clinical features listed in Table 2 and Table 3.10 Frequency of followup depends on a patient’s disease severity and should be coordinated with consulting specialists’ scheduling and recommendations. NPs are usually the ones coordinating communication efforts among the patient, the specialists, and themselves. Telephone consultations, facsimiles of records, and written communications should be routinely shared among practitioners involved in each case. 10

■

TABLE 2

ASSESSMENT OF PATIENTS WITH CHRONIC LIVER DISEASE 10

Review of Systems General

Fever Muscle wasting Weight loss

Respiratory

Orthopnea Shortness of breath

Cardiovascular

Swelling or edema

Gastrointestinal

Anorexia Bowel movements: color and consistency

Genitourinary

Voiding: color, odor, frequency

Neurologic

Change in personality Change in sleep patterns Confusion Disorientation Irritability Mental dullness

Integumentary

Itch Jaundice

Physical Examination Head, eyes, ears, nose, throat Mucous membrane sublingual (jaundice) Sclera (icterus) Respiratory

Orthodeoxia (oxygen saturation decrease with change in position from lying to sitting) Platypnea (shortness of breath with change in position from lying to sitting) Tortuous arterioles on upper torso

Abdomen

Caput medusae (collateral veins radiating from umbilicus) Hepatomegaly Right-upper-quadrant tenderness on palpation Splenomegaly Testicular atrophy Umbilical hernia Unusual firmness, irregular surface, frank nodules on palpation of liver border

Hands

Seven hand signs (see Table 3)

Skin

Gynecomastia Jaundice Skin hemangiomas Spider angiomas Superficial tortuous arterioles on arms and face

Neurologic

Drawing tests or signature comparisons Mental status exam


Laboratory tests can be used as markers of liver injury and synthetic liver function. Serum alanine transaminase (ALT) and aspartate transaminase (AST) are released in greater than normal levels from damaged hepatocytes in response to necrosis or inflammation. With inflammation, the ALT level—more specific to the liver—will rise more than AST. However, in alcoholismrelated liver injury, the ratio of AST to ALT is 2:1.11 Elevations of hepatic alkaline phosphatase (ALP) and direct and total serum bilirubin are indicative of cholestatic conditions. ALP is also elevated with infiltrative liver disease such as a tumor or a granuloma.11 Albumin level and PT are markers of hepatic synthetic function. A normal gamma-glutamyl transpeptidase (GGT) value in the presence of an elevated ALP level usually suggests bone disease, as opposed to liver disease or bile duct disease, in which both ALP and GGT are elevated.11 Hepatitis serologies and autoimmune markers are used to confirm the cause of disease. Frequency of lab testing is usually directed by the treating hepatologist. CLD encompasses a vast array of disorders, as outlined in Table 1, so laboratory markers used to evaluate individual patients vary

TABLE 3

greatly. Several serologic disease markers are used for specific disorders. Liver biopsy is useful for diagnostic purposes and for managing and assessing CLD progression.12 Liver biopsy is the most accurate means of evaluating the stage of liver disease by providing a direct measure of pathology.12 However, biopsy is an invasive procedure and not without complications, and should be used only when it can contribute substantially to management and therapeutic decisions. Several options are available with regard to imaging the liver. Noninvasive methods include ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure offering diagnostic and therapeutic potential. The likelihood of complications of ERCP, including acute pancreatitis, depends at least in part on the skill and experience of the operator. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive alternative to ERCP. MRCP is sensitive but does not allow for direct intervention (eg, stenting).7 NPs need to remember that patients with CLD must still be

screened for other diseases/disorders/conditions according to health guidelines and recommendations for the general population. In addition, some health concerns are specific to patients with CLD. For example, patients with CLD may have hypogonadism, vitamin D deficiency, malabsorption, and low body mass index.13 When combined with excessive alcohol intake and corticosteroid use, these factors increase the risk for the development of osteoporosis, which is associated with significant morbidity through fractures and related pain, deformity, and immobility. Therefore, patients with CLD should be evaluated for osteoporosis at a younger age than that recommended for the general population.13

Staging of Cirrhosis Cirrhosis staging is based on the quantitative degree of hepatic fibrosis. The gold standard for diagnosis of cirrhosis is examination of the entire explanted liver following a transplant or at autopsy. In clinical practice, definitive diagnosis of cirrhosis is by liver biopsy wherein a sample of hepatic tissue is obtained by a percutaneous, transjugular, laparoscopic, or radiographically-guided fine

SEVEN SIGNS OF CIRRHOSIS IDENTIFIED ON THE HAND 10

1. Palmar erythema: reddening of the palms at the thenar and hypothenar eminences 2. Dupuytren’s contracture: painless thickening and contracture of tissue beneath the skin on the palm of the hand and fingers 3. Telangiectasias: small enlarged blood vessels near the surface of the skin, usually measuring only a few millimeters 4. Thenar wasting: atrophic flattening most prominently seen in the thenar and hypothenar muscles 5. Leukonychia or Terry’s nails: white discoloration appearing on nails 6. Clubbing: bulbous fusiform enlargement of the distal portion of a digit 7. Asterixis: flapping tremor of the wrist with dorsiflexion, sometimes referred to as “liver flap”


■

11

Evamist Ad

12

■


Evamist Ad


■

13

Evamist Ad

14

■


Evamist Ad


■

15

PRIMARY CARE

needle approach.14 Staging is helpful in making a prognosis and guiding management of complications, and is the basis for screening recommendations. However, these patients need not be screened for esophageal varices or hepatocellular carcinoma unless they have advanced fibrosis.15 Multiple scoring systems have been created to categorize cirrhosis severity. The two systems most commonly used are the ChildTurcotte-Pugh (Child-Pugh) score and the Model for End-stage Liver Disease (MELD) score. The ChildPugh score is based on five factors: serum albumin, bilirubin, PT/international normalized ratio, presence of ascites, and degree of encephalopathy.7 The Child-Pugh score is calculated based on these lab and clinical findings, each of which receives a numeric assignment. The score, which ranges from 5 to 15, is an established measure of disease severity and prognosis; interpretation of the score is outlined in Table 4.10 The MELD model predicts liver disease severity based on specific lab values and is useful in predicting mortality.15 This model is used by the United Network for Organ Sharing (UNOS) as the national standard for determining liver transplantation eligibility. UNOS provides universal access to an online MELD calculator at www.unos.org/resources/

Preventive Care In general, CLD cannot be cured; therefore, NPs need to prevent exacerbation and prolong the time between hepatitis and progression to cirrhosis.8 Several recommendations are aimed at preserving liver function. Alcohol avoidance is considered the most important measure in keeping CLD from progressing 16

■

to cirrhosis.8 Abstinence from alcohol may reverse some of the deleterious effects of alcohol and may improve response to certain hepatitis treatments. Vaccinations to prevent superinfections are recommended for patients with CLD. Strong evidence supports hepatitis A and B vaccinations for patients without immunity. Infection with hepatitis A or B carries a higher mortality rate and a higher risk of fulminant hepatic failure in this group.8 Streptococcal pneumonia is common in patients with cirrhosis; a single dose of polyvalent pneumococcal vaccine is recommended.15 In addition, annual influenza vaccines are recommended for this patient population.15 The liver is the central organ of the body for clearance, detoxification, excretion, and activation of most medications. Potential drug toxicity is a threat to remaining liver function in patients with CLD. As a general rule, patients with mild liver impairment can be treated with medications used to treat minor ailments in otherwise healthy patients. As liver function worsens, however, the potential for adverse events increases because of alterations in hemodynamics, pharmacokinetics, portosystemic shunting, reduced cytochrome P450 activity, and possibly impaired oxygen uptake caused by changes in the liver sinusoids.16 Medications for patients with

TABLE 4

CLD must be prescribed with caution. Common drugs with potential for hepatotoxicity include antidepressants, nonsteroidal antiinflammatory drugs (NSAIDs), muscle relaxants, psychotropics, anticonvulsants, lipid-lowering agents, oral anti-diabetic agents, estrogens, anabolic steroids, and antibiotics.8 Pain management is particularly challenging; certain medications must be avoided in all patients with cirrhosis. NSAIDs are associated with an increased risk of variceal hemorrhage, impaired renal function, and development of diuretic-resistant ascites,17 and should be avoided in patients with hepatic impairment. Long-term use of opioids for pain management may lead to tolerance, requiring escalating doses and raising the potential for hepatic encephalopathy; these agents should also be avoided.17 Low-dose acetaminophen is effective and safe in patients with CLD who do not drink alcohol. For those with cirrhosis and chronic alcohol ingestion, up to 2 grams of acetaminophen (half the daily recommended dose) may be used daily.17 Use of herbal remedies and over-thecounter medications should be strongly discouraged unless NPs undertake a serious review of possible adverse events related to these agents. Medication management entails the coordination of acute treat-

INTERPRETATION OF THE CHILD-PUGH SCORE 10

Class

Score Points 1-Year Survival 2-Year Survival

A (well compensated disease)

5-6

100%

85%

B (significant functional compromise)

7-9

80%

60%

10-15

45%

35%

C (decompensated disease)


TABLE 5

SURGICAL RISK ASSESSMENT IN PATIENTS WITH CHRONIC LIVER DISEASE 18-21

Absolute Contraindications

Relative Contraindications

Minimal Risk

■

Acute or fulminant hepatitis

■

Cardiac surgery

■

Autoimmune hepatitis

■

Alcoholic hepatitis

■

Hepatic surgery

■

Hemochromatosis

■

Severe chronic hepatitis

■

Obstructive jaundice

■

Mild chronic hepatitis

■

Trauma surgery

■

Nonalcoholic steatohepatitis

■

Wilson’s disease

ment for minor conditions with long-term regimens for chronic disease. To prevent potential adverse drug reactions in patients with CLD, NPs need to carefully prescribe medications based on patients’ level of hepatic function and response to treatment. NPs should perform a thorough review of medications and possible side effects at every patient visit.

Presurgical Optimization Patients with liver disease are at substantial risk for adverse events following any surgical intervention.18 Surgical risk can be determined by conducting a thorough preoperative evaluation. Coordination with team members in surgery, anesthesiology, hepatology, and other disciplines will optimize safety and postoperative outcomes. Several specific aspects of surgery must be stratified to estimate a given patient’s risk. For example, the effects that anesthesia has on a patient depend on the type of surgery, the hemodynamic effects of anesthesia, the functionality of hepatic metabolism, the use of mechanical ventilation, and the specific anesthetic used.18-20 The Child-Pugh score is the best predictor of surgical mortality and morbidity.19 Child-Pugh scores should be used to determine a patient’s

preoperative status and should be included on the preoperative evaluation documentation. Also, the urgency of the surgery and co-existing illnesses should be included and documented in the pre-surgical assessment. Table 5 lists aspects of CLD that are absolute or relative contraindications for surgery or that constitute minimal risk for surgery.18-21 NPs conducting the preoperative comprehensive evaluation should make appropriate recommendations and ensure optimization of patients’ health status. In each case, estimation of operative risk can be determined based on the assessment performed by the NP and the expertise of the surgical team and specialists involved in the patient’s care. When risk is excessive, consideration of alternative approaches should be contemplated.21

Management of End-stage Liver Disease Cirrhosis inevitably results in portal hypertension. Normal portal vein pressure is 5-10 mm Hg. Consequences of portal vein pressures exceeding 10 mm Hg include increased collateral circulation between the high-pressure portal venous system and the low-pressure systemic venous system, increased lymphatic flow, in-

creased plasma volume, ascites, splenomegaly, and portosystemic shunting. Complications of cirrhosis and treatments for these complications are outlined in Table 6.7 Ascites is the most common and difficult to manage complication of ESLD. Abdominal paracentesis with ascetic fluid analysis is the most rapid and cost-effective method of diagnosing and treating ascites in patients with CLD.22 Therapeutic paracentesis and serial paracentesis are common procedures performed to improve QoL, although these procedures carry risk of infection and are often only temporary solutions. A transjugular intrahepatic portosystemic stent shunt (TIPSS) procedure is most often used as a bridge to liver transplant. TIPSS is a radiologically placed device that relieves portal hypertension by shunting blood between the portal vein and the hepatic vein. The TIPSS procedure, which is recommended once ascites requires large volume paracentesis, provides much greater control of ascites, improves survival, and has not been shown to cause a significant increase in encephalopathy.22 OLT may be the only viable therapeutic option for patients with advanced cirrhosis. In fact, OLT remains the sole definitive treatment of cirrhosis.23 Referral


■

17

PRIMARY CARE

and coordination with a transplant center is the responsibility of the primary care practitioner. Timing of referral for OLT is debatable and arbitrary, due in part to the insidious progression of CLD. Contraindications for transplantation include high preoperative risk, malignancies, and active alcohol or substance abuse.23 Each transplantation center sets its own eligibility criteria, which vary greatly from one center to the next. Following OLT, NPs need to monitor for a host of complications. Allograft rejection—cellular and ductopenic rejection of the transplanted liver24—is T cell mediated and is

TABLE 6

the reason for prophylactic treatment with immunosuppressant medications. Infectious complications include cytomegalovirus (CMV) infection, which occurs in 15% - 25% of transplants and may be fatal.24 CMV infection increases patients’ risk for superinfection and chronic rejection. Other possible post-OLT infections are viral hepatitis, bacterial infections, and fungal infections. Biliary complications post-transplantation include anastomotic leaks, anastomotic strictures, and non-anastomotic strictures.24 NPs should also be aware of the potential for pulmonary, neurologic, and renal complications.

Psychosocial Aspects of Chronic Liver Disease The physical, emotional, and financial difficulties associated with chronic illness, including CLD, affect patients, their families, their communities, and society as a whole. CLD threatens the integrity of a patient’s body and organ systems, as well as his or her personal, intimate, and family relationships. CLD affects family members, whose roles change, depending on the health status of the ill member and the developmental stage of the family.25-27 Regardless, CLD places great stress on a family unit. A fundamental task for the family

COMPLICATIONS OF CIRRHOSIS 7

Complication

Description

Treatment

Ascites

Occurs in 50% of causes of compensated cirrhosis within 10 years of diagnosis

Sodium restriction Diuretics Therapeutic paracentesis TIPPS OLT

Esophageal/gastric varices

Evaluate with EGD

Endoscopic sclerotherapy; beta blockers, possibly nitrates; emergency management: balloon tamponade, vasopressin; TIPSS; OLT

Hepatic encephalopathy

Manifested by altered mental status, neuropsychiatric abnormalities

Tx of precipitating factors: lactulose, metronidazole, neomycin, rifaximin, vancomycin, low-protein diet

Hepatocellular carcinoma

10%-15% of patients with cirrhosis develop hepatocellular carcinoma after 10 years, with a median survival of 6-20 months

Surgical resection, OLT, chemoembolization, radiofrequency irradiation

Hepato-pulmonary syndrome

Increase in the alveolar-arterial gradient on room air, manifested by hypoxia, intrapulmonary vascular dilations

OLT (the only treatment)

Hepato-renal syndrome I

Evidenced by a decreased creatinine clearance of ≥50% or a doubling of serum creatinine in 15% of the overall disease burden.1 Persons with a chronic illness tend to have at least one chronic mental disorder, with each problem compounding the other.3

Challenge: Addressing Physical and Mental Healthcare Needs Despite the high acceptance of primary care by patients with MH needs, their MH problems may not be adequately addressed by PCPs.7 Most PCPs receive minimal education in MH care and are unprepared to intervene in the vast range of MH problems experienced by their patients.8 In many cases, the practitioners do not even recognize their patients’ MH needs. And if they do recognize the MH problem, they may be unable to manage it properly.8 Therefore, they refer patients to an MH practitioner at a separate, distant MH site. Unfortunately, the well-intentioned referral creates an unintended series of barriers to access to care, as follows: ■ Time delay in securing an appointment: This delay often results in patients’ failure to keep their appointment. The University of Louisville Health Science Psychiatry Clinic reported a 50% no-show rate for scheduled appointments.9 Community residents participating in focus groups reported that the delay (2-3 months) in obtaining MH appointments resulted in many patients forgoing care that they needed at the time. In some cases, the problem leading residents to seek MH 34

■

care may have resolved on its own, but, in other cases, the problems were merely deferred until life permitted patients to handle them.10 The time barrier also delays, if not prevents, communication between referring practitioners and MH practitioners. As a result, the interplay of physical and MH needs remains unaddressed.4,11,12 ■ Need to travel to a distant location: This need incurs additional cost and complexity. Over 50% of individuals with MH problems reported at least one barrier to care, such as transportation, compared with 19% of the general population.13 ■ Need to keep two separate appointments: This need requires that patients expend extra energy and adds complexity and cost. To simplify the situation, many patients keep only one of the scheduled appointments—usually that with the PCP.6,12-15 ■ Stigma of mental illness: This stigma is greater for patients who receive care at a stand-alone MH site than at an integrated care site, further deterring them from making/keeping appointments. On the other side of the continuum, many patients seen at standalone MH sites do not receive adequate care for physical problems.11,13 MH practitioners lack sufficient skills, time, and service delivery mechanisms to meet patients’ physical health needs. The outcome of this fragmented healthcare delivery structure is delayed/untreated MH and physical health needs and increased disease severity.11,16 Improved health service models that encompass patients’ physical and MH needs are needed.16

An Emerging Trend Inclusion of MH specialists in pri-

mary care practices is an emerging trend that can improve patient access to high-quality MH services.5,17 In the authors’ IMH practice, MH specialists work at the practice site alongside PCPs. In a well-structured practice, an IMH facility provides patients with highquality care delivered in a unified and holistic manner, with timely coordination and information sharing among practitioners.16-19 NPs can be at the forefront of this movement to shape and lead IMH teams. Therefore, they must be informed about IMH models and be able to evaluate, adapt, and/or create models. This article presents a model of IMH care used in a community-based, academic nursing center—the Harambee Nursing Center (HNC). Best-practice strategies for developing the model are also described.

The Setting The HNC, operated by the University of Louisville School of Nursing (http://www.louisville. edu/nursing/), is led by a nursing faculty director and driven by nursing philosophy. The center is located in the Presbyterian Community Center, which is based in the heart of a low-income, primarily AfricanAmerican, urban community of about 9000 persons. The HNC mission is to promote health equity for the community. The HNC is staffed with 4 part-time family/adult NPs, 1 family practice MD (who provides care and acts as a medical consultant for patients with health problems outside the NPs’ scope of practice), and 1 psychiatrist (who is also certified as an addiction specialist). Selected NP faculty practice on a part-time basis and NP students are regularly placed at the nursing center for clinical experiences. In addition to community


Vagifem ad


■

35

Vagifem ad

36

■


health promotion programs, the HNC operates a primary care clinic that is open 5 days a week for patients with acute and chronic health problems and/or in need of preventive health services. Although the HNC provides care to persons of all ages, most primary care patients are adults aged ≥20 years. About 6-8 patients present during each 4-hour clinic session (staffed by an NP or an MD). During IMH practice, a psychiatrist is on site and provides MH care to 4-6 patients during this same time period (some patients may be the same ones seen for primary care).

IMH Project In 2005, the Foundation for a Healthy Kentucky awarded funds to the HNC to improve access to MH services for the underserved HNC community. Residents in this community have a high rate of acute and chronic diseases, sexually transmitted infections, substance abuse, substantiated child abuse and neglect, and crime and violence, and have multiple unmet physical and MH needs.20 Residents obtain fewer preventive health services than do persons living in more affluent areas and their lifestyle behaviors place them at risk for increased morbidity and mortality. Adding MH specialists to primary health care would offer a viable way to intervene with MH issues resulting from these stressful health and life situations. A project team, consisting of 2 family NPs (FNPs)/faculty members, 1 family practice MD, 1 psychiatrist, and 1 psychiatric MH nursing faculty member guided development of the IMH project. Students from the FNP and psychiatric MH NP programs also participated. During an 18-week period, the team provided care for 68

unduplicated patients who presented at the HNC on the IMH practice day. Three fourths of the patients were female and one fourth were male. The mean age was 40 years (32 years for males, 44 years for females). Sixty-one percent of the group identified themselves as African American, 36% as Caucasian, and 3% as Hispanic. About 96% of the patients were single and 4% were separated. Most (71%) were unemployed and most (86%) had no insurance. Patients with insurance were covered by Medicaid. Among the 68 patients who presented at the IMH for primary care, 28 (41%) were seen by the psychiatrist and an NP or MD. The most common MH disorders identified by screening with the PRIME-MD were somatoform disorder (86%), anxiety disorder (79%), mood disorder (68%), eating disorder (25%), and substance abuse disorder (18%). Practice Algorithm—The Figure presents key elements of the IMH practice model. The core IMH practice team consists of an NP and a psychiatrist (or any qualified MH specialist such as a psychiatric NP). The psychiatrist provides counseling and medication management. At the HNC, a family practice MD provides on-site primary care on a different day than when the psychiatrist is on site. The MD functions as a distant member of the IMH team, providing medical consultation for physical health problems, seeking consultation from the psychiatrist regarding MH care for patients as needed, and referring selected patients with physical and/or MH needs to the IMH team. An HNC assistant helps with screening and scheduling of patients into the IMH practice. An NP student (family, adult, psychiatric, or other specialty) frequently

participates on the team. The algorithm is based on the project team’s belief that IMH practice should increase patients’ access to holistic health care by providing multiple, flexible pathways culminating in appropriate interventions matched to their needs and readiness for care. Hence, no single gatekeeper approves entry into the practice. The Figure depicts patients’ entry into IMH care and the flow thereafter. Initial entry into the IMH practice may occur in one of several ways. Patients may contact the HNC program assistant or HNC practitioner by telephone or through a walk-in visit, and may schedule an appointment with an NP, an MD, and/or the psychiatrist. Any practitioner or layperson outside the IMH practice may refer a patient directly to any IMH practitioner. If a patient’s chief complaint is clearly an MH issue that requires an MH specialist, then the patient is scheduled to see the psychiatrist. The most common scenario is for a patient to first schedule an appointment with a PCP (NP or MD) who then identifies the need for intervention for an MH problem during a clinical visit. At this point, the PCP may choose to treat and manage the MH issue independently, to consult with the psychiatrist, and/or to refer the patient to the psychiatrist, thereafter engaging in collaborative team care as long as needed. The complexity and needs of each patient, as well as the expertise of each PCP, dictate which path is chosen. Because practitioners are located in the same unit, “just in time” consultation occurs frequently. For example, practitioners meet briefly in the clinical unit to discuss patient situations and decide on appropriate care. As previously mentioned, entry


■

37

NP PRACTICE

FIGURE

Integrated Mental Health Practice Algorithm Intake (includes MH screenng data)

Contact with HNC Phone, walk-in, referral

NP or MD

Schedule based on chief complaint

MH provider

➡ Refer to MH provider

Assess MH problem

Consult & collaborate with MH/NP/MD provider

Treat the disorder

Treat & Refer for additional support Refer to appropriate provider & provide prn consultation

Support Group (eg, chronic illness group) Psychoeducational Support (eg, parenting classes) HNC = Harambee Nursing Center; MH = mental health; NP = nurse practitioner; MD = medical doctor; prn = as needed.

into IMH practice may occur through direct referral or a patient’s request to see the psychiatrist. In this instance, the psychiatrist can request consultation regarding a physical health problem and/or refer the patient to the NP or the MD for unmet physical health care needs at any point of care. The psychiatrist may also refer the patient to a specialized standalone MH site. The team recognized that the IMH primary care practice is one of several service sub-systems that comprise the national MH service delivery system. Through referral and collaboration, HNC practitioners connect patients with other MH care services as appropriate. As good citizens in the community they serve, HNC practitioners also contribute to community MH through 38

■

Assess MH problem

Treat the disorder

NP or MD for possible physical problems Outside agency (based on complexity)

outreach MH promotion programs. One example is the distribution of a video about depression in African Americans to area churches, with offers to be guest speakers. Best-practice Case Scenario— Mrs D, a 60-year-old, AfricanAmerican woman and her daughter presented at the HNC with the following chief complaint: “I want refills of the medicine for the sores in my mouth. Also, I have a really bad cough that won’t go away.” During the intake history, the NP learned that Mrs D was HIV positive but stopped attending a comprehensive HIV clinic. Because of Mrs D’s continuing alcohol and cocaine addiction, her PCP at the HIV clinic would not prescribe antiviral medications. (Most patients with addictions do not follow necessary medication proto-

cols, likely rendering medications ineffective and possibly dangerous. Also, significant adverse interactions between alcohol or other substances and anti-HIV medications may occur.) Therefore, Mrs D’s addiction precluded the use of effective interventions that might halt disease progression. The NP addressed Mrs D’s immediate physical problems. She prescribed an antibiotic to treat the respiratory infection and an antifungal medication for the mucosal candidiasis. However, without resolution of the alcohol and cocaine addiction, Mrs D would most likely continue to deteriorate physically. Because the psychiatrist was on site, the NP asked Mrs D if she would be willing to talk with him. Mrs D initially hesitated, but the NP explained that the psychiatrist was


a specialist in helping people with addictions. Her daughter also gently urged Mrs D to talk with him. The NP asked Mrs D if she would be willing to meet the psychiatrist and find out whether she thought it might be helpful to talk with him in the future. Mrs D agreed to meet the psychiatrist. She said that she liked talking with him, and asked to make a follow-up appointment. The NP also collaborated with the practitioner at the HIV clinic, who agreed to continue to provide care to Mrs D if she addressed the addiction. Over time, Mrs D entered an addiction recovery program and was able to resume her medication for the HIV infection, which improved. Mrs D has continued to receive MH support and primary preventive care and other physical care at the HNC. Immediate access to an MH practitioner permitted a spontaneous clinical interaction that decreased multiple access barriers. Without making a larger commitment, Mrs D was able to meet the psychiatrist and develop personal comfort with him. The psychiatrist was able to begin a therapeutic relationship with the patient. Given Mrs D’s ambivalence at seeing an MH practitioner, the likelihood that she would keep an off-site appointment with an unknown practitioner was low. Presence of an expert in the treatment of addiction—at the point of this patient’s readiness—was important. Other Examples—The IMH team found that almost all patients could benefit from the IMH collaboration. The Table lists examples of patient situations demonstrating the value of IMH care. The team agreed that the IMH process of collaboration strengthened the knowledge base and competency of both PCPs and MH practitioners.

Best Practices and Lessons Learned—The IMH team considered several strategies best practices, including reflective team meetings, community assessment of MH needs, IMH case conferences, screening primary care patients for mental illness, a continuous quality improvement (QI) process, and stigma-sensitive marketing strategies. Reflective team meetings. Over two academic semesters, one full day each week was dedicated to team meetings. During the first 2-4 hours, the team discussed the IMH practice, their professional values, and ways to function as a cohesive, effective team. Presentations to meet learning needs were incorporated. Meetings also included discussions with about 20 MH practitioners to learn about services available in the community and to obtain IMH practice recommendations, a process the team identified

TABLE

as highly valuable for team development. Presence of the full team on a regular basis built cohesion and led to enhanced analysis and development of the model. Community assessment of MH needs. Assessment was conducted concurrently with development of the IMH practice. The first step was to give the team a direct view of the community through a windshield tour, conducted by community leaders and residents. Afterwards, the team viewed a video created by community residents. Team members highly valued these strategies. The rich history, expression of values, and strong pride described by residents personalized the issues and provided a new view of the community. Through residents’ voices, the strengths that lay beneath visible problems became apparent, and the struggle for health was personalized. The video had a powerful

PATIENT SITUATIONS DEMONSTRATING THE BENEFITS OF INTEGRATED MENTAL HEALTH CARE

■

Chronically ill patients with depression

■

Obese patients with unresolved psychological issues and/or inadequate coping mechanisms

■

Patients with chronic pain

■

Patients with compulsive behaviors

■

Patients with multiple unresolved psychosomatic complaints without evidence of physical illness

■

Patients experiencing post-traumatic stress disorders

■

Collaboration regarding medication management

■

Handling emergency situations (eg, patients with high risk of suicide)

■

Patients with severe mental illness requiring further evaluation

■

Patients with bipolar disorders

■

Families with multiple problems


■

39

NP PRACTICE

effect on the practitioners and motivated them to succeed. The community assessment also included dialogues with residents through three focus groups. The dialogues helped the IMH team understand the residents’ beliefs about MH, the barriers they faced in accessing MH care, their desires for community-based MH services, and acceptable interventions. For example, residents estimated the incidence of depression in their community as 50%-90%. They described crisis as a normal way of life—driven by drug abuse, violence, low income, unemployment, lack of travel, and the breakdown of traditional family life. Traditional community support systems had been replaced with well-meaning but formal social agency services (eg, Meals on Wheels). Many residents did not recognize the early stages of mental illness—depression seemed “normal” to them. Many residents lacked information about available and affordable MH services. IMH case conferences. These conferences included presentations of patient situations, discussions, and critiques by the team. Case conferences were among the most effective strategies to clarify the IMH practice model. Case examples helped team members identify the desired flow of patients from one practitioner to another. The conferences provided insight into learning needs and helped clarify interprofessional values and practices. For example, one MH practitioner described the concept of “supervision”— required by all MH professionals— which is a process of professional support and learning that enhances clinicians’ knowledge and competence. Practitioners met with MH supervisors to discuss 40

■

cases and learn within the context of the practice experience.21 The NP faculty supervisor served as an expert resource to the team, and to ensure that the psychiatric NP students were learning and implementing nursing philosophy, roles, and competencies. The psychiatric faculty supervisor was unable to be onsite at all times, but through participation in development of the practice model, intermittent onsite observation, participation in the case conferences, and direct debriefing with students, she was able to accomplish the supervisory goals. An FNP faculty member was onsite at all times. Another example of team learning was when the psychiatrist discussed “splitting,” a common phenomenon experienced by practitioners when patients with MH disorders (eg, borderline personality disorder) create conflict and dissention among practitioners about care management. Team members learned to recognize splitting and to pursue more therapeutic patient interventions without creating undue conflict among practitioners. Case conferences led to more holistic and coordinated care by creating awareness of the potentially adverse interaction of separate interventions prescribed by PCPs and MH practitioners. For example, medications could cause or exacerbate a physical problem or the MH problem (eg, psychotropic medications can increase diabetes risk).22 Case conferences also helped identify appropriate IMH patients and those who needed to be referred outside the IMH practice (eg, those with psychosis). However, the NP or the MD could continue to provide physical care to these patients. Screening primary care patients for MH problems. Because some

PCPs may not immediately recognize mental illness, especially when a patient with coexisting physical symptoms presents for care, the team incorporated a screening instrument into the IMH protocol. During the first semester, the team used the Prime-MD Clinical Evaluation Guide to screen patients for symptoms of mental disorders (based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic guidelines).23 This 25-item questionnaire asks patients to check Yes or No for signs and symptoms experienced during the past month that are related to (1) somatoform, (2) eating, (3) mood, (4) anxiety, or (5) substance abuse problems.23 Depending on a patient’s responses, certain modules may be triggered that correspond to these problems. The triggered modules provide more detailed assessment questions. The team found this tool helpful at the beginning of the project, primarily as an educational tool. However, the process was time consuming and the embedded assessment protocol was duplicative with the follow-up assessment conducted by the psychiatrist. To simply screening without sacrificing validity, the team ultimately selected the Patient Health Questionnaire-2 (PHQ-2), a twoitem questionnaire that demonstrated acceptable construct and criterion validity.24 Kroenke et al administered the PHQ-2 to 6000 patients attending primary care or OB/GYN clinics.24 They assessed construct validity by comparison with the 20-item short-form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. The Mental Health Professional Interview, in a sample of 580 patients, was used to determine


Gynazole Insert


■

41

Gynazole Insert

42

■


criterion validity. A PHQ-2 score ≥3 had a sensitivity of 83% and a specificity of 92% for major depression. Collection of patient data at the HNC is in progress. Continuous QI process. “Plan, Do, Study and Act,” a continuous QI process, was implemented. At the end of each IMH practice session, practitioners anonymously completed a questionnaire asking them to (1) rate their level of satisfaction with the IMH process and the quality of care patients received, (2) list three best and three worst practices of the day, (3) list benefits and costs of the IMH practice, and (4) recommend changes in the process. The research assistant summarized the responses and gave a copy to the team. During the team meeting on the following week, the members reviewed the summary and decided on changes in practice processes. The regular practice of team reflection and analysis of the IMH practice led to a multiplicity of benefits: enhanced organization, improved forms and structured processes, and heightened collaboration among team members. Patient satisfaction was evaluated using the 12-item Medical Outcomes Study Visit-Specific Questionnaire.25-27 This instrument asks patients to rate their satisfaction with the length of time it took to get an appointment, the convenience of the location, the length of time spent waiting at the clinic, the length of time spent with the practitioner, the quality of the explanation of what was done, the technical skills of the practitioner, the personal manner of practitioner, the overall visit, the confidentiality of personal health information, satisfaction with the practitioner, the belief that the practitioner would be able to dis-

cuss an MH issue, and satisfaction with discussions of MH, feelings, and health behavior. Twelve of the 28 patients who were asked to complete the questionnaire did so. The overall visit was rated by patients as excellent or good. Most patients rated basic clinic interactions, practitioner skills, personal manner, and explanation of procedures as excellent. Patients were satisfied with the confidential manner of handling personal information and the manner of dealing with MH issues. The instrument not only helped provide feedback about practitioners’ performance but also kept the team focused on creating a positive environment for the patients. Stigma-sensitive marketing strategies. The best interventions are useless if they are unacceptable to patients. Before the community focus groups met, the team advertised widely that MH care was available through the HNC. Few patients showed up. As the team learned about the strong community stigma against mental illness, they realized that the intensive marketing strategies deterred residents from seeking IMH care. Thereafter, they became more subtle in engaging patients in IMH care. They continued to place educational materials about MH illnesses in the clinic, but they also looked for ways to normalize MH needs and interventions to minimize the stigma. For example, they incorporated information about MH in educational materials about physical diseases such as diabetes, hypertension, asthma, and obesity. At community health fairs, they included MH booths alongside booths related to physical diseases. MH practitioners paid casual visits to areas where community residents gathered and developed

informal relationships with them. They advised patients who were concerned about being stigmatized that they could schedule an appointment through the IMH practice, without others in the community knowing whether they had an appointment for physical or MH needs. One of the best marketing practices was for PCPs to introduce patients to the psychiatrist to give them an opportunity to become comfortable with him. Accepting a referral to the psychiatrist became less of an “unknown” for the patient. The combination of these practices led to an increased number of patients seeking MH care through the IMH practice. Summary—The HNC team valued the IMH practice. Patients were engaged in MH care at the point of readiness, onsite in their community and with decreased barriers to access. One year later, the psychiatrist has a full schedule of patients each week, with a pattern of increasing requests for appointments. Patient satisfaction has been high. All team members believe that the IMH model has enhanced their practice competency. Of note, numerous reimbursement barriers still deter IMH practice. For example, some insurers prohibit same-day payment for dual services. In the author’s situation, all billing is done by the department of psychiatry and reimbursement rates are too low to maintain the MH personnel. The reimbursement issues, plus the fact that most HNC patients are uninsured, create a need for private funding or volunteer services essential to sustainability. Although not true in all states, Kentucky practice regulations require NPs to have a collaboration practice agreement with a psychiatrist for prescriptive privileges. Availability of consulta-


■

43

NP PRACTICE

tion with psychiatrists is valued, but unnecessary practice restrictions limit access to care, especially for underserved populations.

Conclusion Despite the barriers, the authors found the IMH practice model to be clinically effective and to significantly improve timely access to MH care. Although the HNC model incorporated a psychiatrist, a highly qualified psychiatric NP or other MH specialist could serve as the MH expert within the IMH team and be more cost effective. To date, the authors have been successful in maintaining private funding support. However, they participate actively in advocacy at a state level to improve reimbursement practices and continue to explore creative solutions for sustainability. ■ Kay T. Roberts, project investigator, is a professor of nursing and director of the Harambee Nursing Center. Karen M. Robinson, co-investigator, is professor of nursing and coordinator of the Psychiatric Mental Health Nurse Practitioner program. Christopher Stewart, co-investigator, is an assistant professor in the department of psychiatry at the School of Medicine. John C. Wright, project medical consultant, is a professor emeritus; former chair of the Department of Family and Community Medicine; and Harambee Nursing Center medical consultant and project consultant. All authors are affiliated with the University of Louisville School of Nursing, Harambee Nursing Center, in Louisville, Kentucky. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article. 44

■

Acknowledgments Other team members who contributed to the Integrated Mental Health Practice model are Felicia Smith, PhD; Robert Topp, PhD, RN; Gwendolyn Hayes, MSN, ARNP; Jamie Newman, MSN, RN; and Toni Thomas, PhD applicant. The Harambee Nursing Center is funded by the Good Samaritan Foundation, a ministry of the Kentucky Annual Conference of the Methodist Church.

References 1. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville. Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. 2. Bower P, Gilbody S. Managing common mental health disorders in primary care: conceptual models and evidence base. BMJ. 2005; 330(7495):839-842. 3. Dyer JG, Hammill K, Regan-Kubinski MJ, et al. The psychiatric-primary care nurse practitioner: a futuristic model for advanced practice psychiatricmental health nursing. Arch Psychiatric Nurs. 1997;11(1):2-12. 4. Kathol RG, McAlpine D, Kishi Y, et al. General medical and pharmacy claims expenditures in users of behavioral health services. J Gen Intern Med. 2005;20(2):160-167. 5. Swindle RW, Rao JK, Helmy A, et al. Integrating clinical nurse specialists into the treatment of primary care patients with depression. Int J Psychiatry Med. 2003;33(1):17-37. 6. Blount S, Schoenbaum M, Kathol R, et al. Economics of behavioral health services in medical settings. 2008. Available at: www.integratedprimarycare.com/economics.htm 7. Schulberg HC, Block MR, Madonia MJ, et al. The 'usual care' of major depression in primary care practice. Arch Fam Med. 1997;6(4):334-339. 8. Marion LN, Braun S, Anderson D, et al. Center for Integrated Health Care: primary and mental health care for people with severe and persistent mental illnesses. J Nurs Educ. 2004;43(2):71-74. 9. Personal communication with C. Stewart, MD, Louisville, Ky; 2006. 10. Phoenix Hill Focus Group Communication, November 28, 2006. Communication with Phoenix Hill focus group members designed to obtain direct information from the intended recipients of care about their perceptions of access barriers to mental health care. Louisville, Ky; 2006. 11. Rust MT. The trend to integrate physical and mental care. Kentucky Hosp Assoc. 2007;May(3):11.

12. Hogg Foundation for Mental Health. Integrated Health Care Grant Program. 2007. Available at: http://www.hogg.utexas.edu/pro grams_ihc_program.html 13. Koyanagi CCL. Get It Together: How to Integrate Physical and Mental Health Care for People with Serious Mental Disorders. Washington, DC: Bazelon Center for Mental Health Law; 2004. 14. Bartels SJ, Coakley EH, Zubritsky C, et al. Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry. 2004;161(8):1455-1462. 15. Lasser KE, Himmelstein DU, Woolhandler SJ, et al. Do minorities in the United States receive fewer mental health services than whites? Int J Health Serv. 2002;32(3):567-578. 16. President’s New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. July 2003. Available at: http://www.mentalhealthcom mission.gov/reports/FinalReport/toc.html 17. Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836-2845. 18. Funk M, for the World Health Organization. Organization of Services for Mental Health. Geneva, Switzerland: World Health Organization; 2003. 19. Katon W, Unützer J. Collaborative care models for depression: time to move from evidence to practice. Arch Intern Med. 2006;166(21):2304-2306. 20. Roberts K, Robinson K, Stewart C, et al. A Summary of Three Focus Groups in the Harambee Community: University of Louisville. 2005. 21. Hines-Martin V, Robinson K. Supervision as professional development for psychiatric mental health nurses. Clin Nurse Specialist. 2006; 20(6):293-297. 22. Lean ME, Pajonk FG. Patients on atypical antipsychotic drugs: another high-risk group for type 2 diabetes. Diabetes Care. 2003;26(5):15971605. 23. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272(22):1749-1756. 24. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: validity of a twoitem depression screener. Med Care. 2003;41 (11):1284-1292. 25. Rubin HR, Gandek B, Rogers WH, et al. Patients' ratings of outpatient visits in different practice settings: results from the Medical Outcomes Study. JAMA. 1993;270(7):835-840. 26. Howard PB, El-Mallakh P, Kay Rayens M, Clark JJ. Consumer perspectives on quality of inpatient mental health services. Arch Psychiatric Nurs. 2003;17(5):205-217. 27. Jerrell JM. Psychometrics of the MHSIP Adult Consumer Survey. J Behav Health Serv Res. 2006;33(4):483-488.


Aldara Ad


■

45

Aldara Ad

46

■


Aldara Ad


■

47

PEDIATRICS

Elevated BP in Overweight Mexican-American Children and Adolescents: Recommendations for Clinical Practice Brenda K. Landau, MSN, RN, FNP; Celia S. Brinker, MSN, RN, FNP; Debra J. Barksdale, PhD, RN, CFNP, CANP; and Julee Waldrop, MSN, RN, CFNP, CPNP

This state-of-the-science article has two goals: to review the current literature on blood pressure (BP), including prehypertension (pre-HTN) and hypertension (HTN), in Mexican-American children and adolescents; and to make recommendations for clinical practice. Over the years, BP has risen substantially in all groups of children in the United States, but MexicanAmerican children are particularly vulnerable because of the link between overweight/ 48

■

obesity and elevated BP. Although weight loss is a frequently recommended intervention for BP management, the authors found no specific studies evaluating the treatment of HTN in MexicanAmerican youth. Because of limited evidence-based literature on this topic, nurse practitioners (NPs) should use clinical judgment and modify current management guidelines so that they are culturally relevant and appropriate for this population.

B

lood pressure has been rising substantially in US children and adolescents in recent years.1 At the same time, overweight and obesity in children have reached epidemic proportions across racial and ethnic groups.2 According to Sorof et al, although the prevalence of HTN and obesity is high in all groups of children, minority children are particularly vulnerable.3 Among minority children, Mexican Americans are particularly susceptible to the deleterious health effects of HTN and associated cardiovascular conditions. Compared with their white, black, and Asian counterparts, Hispanic children had the highest rates of HTN (25%) and overweight (31%).3 In addition, HTN was 3 times more


common in overweight adolescents than in non-overweight adolescents. Furthermore, according to findings from the National Health and Nutrition Examination Survey (NHANES), 16.3% of Mexican Americans aged 12-19 years exceeded the 95th percentile for body mass index (BMI).2 Several studies have suggested that the reduction of risk factors related to HTN—specifically, overweight and obesity—should be the first step in managing elevated BP in children and adolescents of any racial or ethnic group.3-10 Srinivasan et al analyzed data from the Bogalusa Heart Study, a longitudinal investigation conducted from 1976 to 1994.9 This study assessed BP and levels of cholesterol, triglycerides (TG), and plasma glucose in 3255 non-Hispanic white and black schoolchildren through young adulthood.9 Findings indicated that body weight, systolic BP (SBP), diastolic BP (DBP), and TG were consistently higher from childhood through adulthood in pre-hypertensive and hypertensive subjects than in normotensive subjects. Researchers also found that pre-hypertensive and hypertensive subjects were overweight since childhood, and suggested that overweight, not hyperinsulinemia, may be an early cause of essential HTN. Although no Hispanic subjects were included in the sample, the study provides compelling evidence that HTN risk factor identification and weight management are crucial in the care of children and adolescents at risk for pre-HTN and HTN.

Defining the Terms The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood

TABLE 1

CLASSIFICATION OF BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS 13

Blood Pressure Category

Definition

Normal

95th percentile). Overweight children and those with AN were at least twice as likely to present with high BP after controlling for confounding factors. Therefore, obesity and ethnicity were independent markers for increased likelihood of HTN in children.

Management Strategies NPs need to recognize pre-HTN as a modifiable independent risk factor to reduce Mexican-American youth’s risks of developing HTN and CVD as young adults. Current strategies to manage pre-HTN in children and adolescents include weight loss, weight management, nutrition management, and increased physical activity. These interventions should include culturally relevant education on lifestyle modification and behavior change, not only for the patient but also for the whole family. Opportunistic Approach to Assessment and Monitoring— NPs should use each office visit as an opportunity to assess BP in every pediatric patient. This opportunistic approach is key to early detection of pre-HTN and HTN in Mexican-American children and adolescents, who are at high risk for these conditions. This approach also allows for verification of ele-

NPs should measure children’s BP at every office visit. vated BP on multiple occasions before diagnosing a child as having pre-HTN or HTN.3 A thorough history (including family history, sleep history, risk factors, diet, and physical activity), a complete review of systems and identification of co-morbidities, and a physical examination are essential. Use of appropriately sized equipment and proper technique for children are necessary to measure BP correctly. Weight and height should be determined, growth charts updated, and BMI calculated.10 Up-to-date, accurate data enable NPs to make proper decisions related to the treatment and management of pre-HTN and HTN. All children or adolescents in whom high BP is identified should be re-evaluated in 6 months. Those exhibiting stage 1 hypertension (Table 1) are re-checked in 1 to 2 weeks or sooner if symptomatic. If BP is persistently elevated on two additional occasions, then further evaluation is warranted. Children who have stage 2 hypertension (Table 1) and are symptomatic should be promptly referred to a specialist in pediatric HTN for evaluation and treatment. The Figure provides recommendations for BP assessment and management. Recognizing and Managing Risk Factors—In addition to identifying pre-HTN and HTN in their pediatric patients, NPs need to

address one of the main underlying causes—overweight and obesity. Therefore, NPs must encourage patients to follow a healthful diet and get a sufficient amount of exercise. To increase the likelihood that therapeutic lifestyle changes are implemented, NPs need to convey these recommendations in a culturally relevant manner. The aforementioned Fourth Report recommends that a fasting lipid panel and glucose level be ordered in overweight or obese children with elevated BP to identify hyperlipidemia and metabolic abnormalities.13 Monitoring lipid levels in adolescents with a BMI >85th percentile or who are at risk for overweight or have elevated BP may be helpful in preventing CVD.8 Diet and nutrition. Nutrition education for Mexican Americans is needed, particularly as they become further removed from their traditional diets. Hispanics who have lived in the United States for more than one generation or who speak English report a higher intake of fat and a lower average intake of fiber than do first-generation Hispanics.19 Parents should be encouraged to provide nutritious snacks (eg, vegetables, fruits, lowfat dairy foods, whole grains). Children and adolescents need to learn to self-regulate their food intake and make appropriate food choices.20 Families may lack money and access to grocery stores to buy healthful foods. In this situation, NPs should encourage patients’ parents to carpool to larger stores weekly for better selections and prices. NPs should also provide sample grocery lists of healthful food choices to make the shopping process easier. On a broader level, schools should be encouraged to provide healthful meal choices.


■

53

PEDIATRICS

Physical activity. At each clinic visit, NPs should ascertain the type and amount of physical activity in which their Mexican-American pediatric patients engage. They should ask parents to limit the amount of television viewing, video gaming, and other sedentary activities to a maximum of 2 hours a day.20 For patients who are spending little time engaging in physical activity, NPs need to provide suggestions, support, and positive reinforcement. Physical activity, including unstructured play at

home, in childcare settings, at school, and in the community, should be encouraged. Children who reside in neighborhoods that are unsafe for outdoor play can use video games such as Dance Dance Revolution by Konami. These games promote physical activity with music and dance, entertain, allow competition, and provide an intense workout for the entire family. Finding resources. Children and family members can learn more about nutrition and healthful

eating habits from the Internet (at school or in a public library if necessary). For example, the National Dairy Council,21 the Nemours Foundation,22 and the Dole Food Company23 have child-friendly websites that provide information about nutrition (Table 2). The National Heart, Lung, and Blood Institute (NHLBI)24 and the American Heart Association (AHA)25 offer patient information that may be helpful in educating Mexican-American patients and their families about healthful

FIGURE. Blood Pressure Management in Children 13 Measure BP and height and calculate BMI: determine BP category for gender, age, and height*

*Stage 2 hypertension

*Stage 1 hypertension Repeat BP 90%-