Current Issues For Advanced Practice Nurses

Today people are living longer than ever. The discovery of new technology, innovative medicines, science, and research all play apart of that. An increase in aging population is one of the most dramatic demographic trends in the world today. Many elders present many complex diseases and require complex care and disease management. The challenge also presents many opportunities in the healthcare field and a shortage of providers in rural areas. The roles for advanced practice nursing (APN) have been introduced since the late nineteenth century till the present (Hamric, Spross, and Hanson, 2009, p. 3). These roles include certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), and nurse practitioners (NPs) (Hamric, Spross, and Hanson, 2009, p. 3). Building credibility and defining practice of APN roles did not firmly establish until in late 1970s (Hamric, Spross, and Hanson, 2009, p. 17).

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In 1992, the American Nurse Association (ANA) established Healthcare Reform which focused on restructuring the United States healthcare system to reduce costs and improve access to care (Hamric, Spross, and Hanson, 2009, p. 23). Today APNs face many challenges as they strive to be recognized by members of the society. The current issues faced by APNs are discussed below and this information is based on Advanced Practice Nursing: An Integrative Approach (4th ed.).

The Key Issues
The identified key issues are education, scope of practice, specialty practice, reimbursement, titling, prescriptive authority, legal status, regulation, and credentialing issues. The similarities among these issues are all embedded in regulatory languages which make it difficult for APNs to benefit from development of nursing role. The differences occur when one failed to collaborate and to address these above issues as a whole and to promote collaborative relationships with other regulated health disciplines both at the national and state level. And, indeed these issues are still importance to the practice of advanced practice nurses.

Three Chosen Issues
The three chosen issues are scope of practice/specialty practice, reimbursement, and prescriptive authority. Like never before, the profession for APNs has emerged into different era which presents many different opportunities and challenges for newcomers. Today APNs can be found working anywhere from the family practice, cardiology office, urgent care always to emergency medicine. As a new graduate APN, the role can present many challenges and obstacles especially when she or he tries to adjust to the new role while attempting to comply with several clinical practice guidelines.

Even though the title of APN is recognized as a valuable asset to the community and other healthcare team member, many of them are still struggled to get reimbursed properly. The holistic caring approach provided by APNs is not inferior to the medical model provided by physicians. The education requirement for both professions will be soon about the same especially with the new requirement of a doctoral degree for APNs. This is the reason APNs still debate for equal pay for equal service when care is compared between both health providers.

After reading Advanced Practice Nursing: An Integrative Approach (4th ed.) page 606 and 607, the reality becomes clear that APNs have to prove so much in order to gain sole authority in scope of practice. The Board of Medicine continues to find ways to limit the scope of practice for APNs. According to Lugo, O'Grady, Hodnicki, & Hanson (2007), 23 states possess sole authority from the board of nursing; whereas other states possess joint authority with the board of medicine, the board of pharmacy, or both (Hamric, Spross, and Hanson, 2009, p. 606). The outcome of this disagreement affects the role and practice of APNs greatly especially when they attempt to provide the best care possible in a timely manner.

Top Two Issues
The chosen top two issues are reimbursement and prescriptive authority. As a new graduate APN, she or he must get educated well about different payment options such Medicare and Medicaid, third party payers, and more to ensure proper reimbursement. The second strategy is to encourage schools throughout the country to incorporate this valuable lesson as part of the standard curriculum. The nursing profession as a whole should continue to flight aggressively for equal service for equal pay because nursing profession should not be assumed as inferior to other independent health providers despite different styles of caring approach. As an individual APN, one must continue the education to doctorial level in order to try to resolve the unfair disadvantage of prescriptive authority across the nation. The second strategy is APNs should continue to promote the recognition of APN as safe and cost-effective alternative provider throughout the healthcare systems.

Regulatory Barriers
The current regulatory barriers for APNs are prescriptive authority, reimbursement schemes, nursing education, and scope of practice and titling. The variance in board regulations from state to state is a problem facing APNs who highly mobile (Hamric, Spross, and Hanson, 2009, p. 610). Even though prescriptive authority exists over the years and becomes fairly standard for APN prescribers, but the requirements still vary from state to state (Hamric, Spross, and Hanson, 2009, p. 607). For those APNs who love to travel and work at another state to make sure to check the scope of practice for that state as it varies significantly (Hamric, Spross, and Hanson, 2009, p. 607). The professional nursing organizations and the National Council of State Boards of Nursing (NCSBN) have been working on a new regulatory model for APNs in order to promote some uniformity on credentialing and licensure (Hamric, Spross, and Hanson, 2009, p. 610). A system of mutual regulatory recognition between states is needed and remains to be done.

Conclusion
Even though most of the hard work was done to promote the path to independency and uniformity for advanced practice nursing, but several issues remain to be solved especially in the areas of credentialing and regulation. Many nursing organization is working aggressively to put a new regulatory model in place to promote a system of mutual regulatory recognition. The field in advanced practice nursing is evolving and changing rapidly, especially in the areas of advanced practice nursing specialties. As a result of this complex change, policymakers and regulators face many challenges and obstacles to ensure development of broad-based practice standards. At the same time this challenge also presents many new opportunities for advancing practice nursing; thus APNs continue to prove themselves as safe and cost-effective providers to the members of society and to move forward to a better professional future.

Reference

Hamric, A. B., Spross, J. A., & Hanson, C. M. (2009). Advanced practice nursing: An integrative approach (4th ed.). St. Louis, MO: Elsevier.

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Dental Case Study - Ms sick person

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Primary Care Providers - Dental Case Study - Ms sick person

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49 year old married female with complicated sclerosis. She is very open to discuss her disease and the impact it has on her life. She practises yoga and leisure therapy. A friend of hers mentioned that Ms was caused by mercury toxicity from dental amalgam fillings. Her chief complaints were sensitivity to hot, cold in her upper left lower right quadrant, bleeding gums, possible amalgam dismissal and dry mouth. Client used to see her dentist normally for dental check ups but stopped all of a sudden. Her last dental visit was at a Dental Hygiene College 3 years ago. In 1976 She reported to have trigeminal neuralgia that lasted about 2 months, and previous use of cigarettes and marijuana from (1974 to 1988). She also reported to have problems with urine leakage. She sees her doctor and neurologist bi-annually. Her vital signs were within normal limits, she was hospitalized two times due to acute Ms episodes one in 1978 and the other in 1992. She reported taking medication to prevent the progression of Ms, and gets injected every other day with Betaseron 5mg and Copaxone 20mg; diazepam 1mg twice daily; ibuprofen 800mg three times a day and baclofen 10 mg four times a day. Dry mouth is a frequent side effect of these medications. Client is disabled she must use a walker to walk. Fatigue has affected her oral hygiene before bedtime so she often brushes only in the morning. This client lacks manual dexterity and coordination due to the deadness and pain in her hands. Her diets consist of fried foods and lots of soda.

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Clinical appraisal Data

On the first appointment the following things were completed. Extra and intraoral, periodontal hard tissue examination, a full mouth serious, intraoral photographs were taken and homecare practices were observed and discussed. Considerable findings included the following.

Extraoral: Unilateral swelling on the right side of the face; bilateral firm masseter muscles; Tmj crepitation; occasional pain upon opportunity mouth in the morning and nocturnal bruxing.

Intraoral: Linea Alba bilateral 6mm on both sides; small tori on the palate and decreased salivary flow. Moderate subgingival calculus with grayish extrinsic stains.

Periodontal: Generalized 2-6 mm probing depth and localized 5mm readings on the posterior interproximal areas; furcations placed on 16,14,47,46. Bleeding upon probing on all posterior teeth.

Hard Tissue: Generalized itsybitsy attrition. Multi exterior restorations on most posterior teeth.

Plaque operate Record: Plaque-free score 75%; Radiographs: Generalized bone loss 10 to 30% horizontal bone loss; localized itsybitsy vertical bone loss in posterior; graphic calculus spicules; suspected caries on #15 under restoration.

Nutrition: Meal pattern consist of breakfast, snack, lunch, snack, dinner, snack. Calorie intake is inadequate. Food Groups consumed daily are generally Meat and alternatives. Fat intake high. Body weight above healthy. Performance level low.

Social: Regardless of having Ms client feels her widespread health is good. The client has no insurance, so that's why she has been avoiding dental care but she is ready to make a lifestyle change. She has a withhold theory to aid her with transportation

Dental hygiene treatment care plan

1. Take vital signs at each appointment to ensure that V/S are Wnl

2. Update healing history for any possible contraindication to treatment.

3. Recap her medication intake to settle any side effect that might compromise the treatment.

4. Book the sick person at morning appointments since morning appointments tempt to be less stressful to patients with neurological problems.

5. Ensure a quite and relaxant environment for the sick person during the appointment.

6. Allow complicated brakes during the appointment to help relaxing her facial muscles and allow Considerable frequent urination.

7. Minimize fatigue by complying with the sick person daily regime and comfort during treatment (positioning the chair in the most comfortable position for the patient).

8. Monitor oral conditions that are related with client at every appointment and make referral if necessary, (to settle any intra extra oral changes that might compromise treatment or sick person health).

9. Use clorhexidine prior to treatment to sacrifice bacterial flora within the oral cavity.

10. Debridement of calculus and plaque by ultrasonic (One quadrant at the time) to sacrifice the scaling time. 1-2 appointments.

11. Debridement by hand scaling ( one quadrant at the time) to make sure that all the calculus and dental plaque left after using ultrasonic is removed. 1-2 appointments

12. Selective polishing to selectively remove intristic stain. (Whiter teeth are related with attractiveness and a healthier lifestyle)

13. Use fluoride rinse Neutral sodium 2% to help re mineralize clients teeth.

14. Take an impression on lower anteriors to produce a mouthguard that will prevent added attrition on the lower anteriors due to buxism.

15. Referral to Dds for recovery due to clients invite to replace old amalgam fillings with white recovery material

16. Diet counseling to increase salivary flow. ( during intra oral examination xerostomia was clear perhaps from medication side effects)

17. Reconsider Local anesthetic ( Lidocaine 2% in case Topical anesthetic 2% is not adequate in production client comfortable during the appointment.

Osc planning

1. Designate antisensitivity toothpaste to eliminate sensitivity to hot and cold.

2. Propose addition of H2o consumption to increase salivary flow in the oral cavity.

3. Client will be educated in the relationship that Ms has on her oral cavity to increase her cognitive knowledge towards Osc (for example bruxism, subluxation, crepitation, xerostomia).

4. Discuss the relation in the middle of Ms patients and the high risk of caries activity.

5. Demonstrate floss and brushing aids to the client. ( proxy brush, floss aid, modified brush handles.) to improve patients Osc skills.

6. Use disclosing agent to show to the client the problematic areas that are missed during at home oral self care. This will increase the awareness of the client to the gift oral situation.

7. Propose powered toothbrush to increase the brushing time due to clients compromised plaque dismissal skills.

8. Propose separate modifications to the Osc aids that client will feel comfortable with, to increase comfort in grasping oral aid handles

9. Propose water pick to allow a inescapable degree of independence in cleaning interproximal areas from plaque.

10. Propose separate corporeal activities ( like yoga) to improve the dexterity that will help client with self oral care.

Multiple Sclerosis and Dental Hygienist

Treating patients with Ms provides dental hygienists with many opportunities to learn. The complicated links in the middle of oral conditions and Ms symptoms enable dental hygienists to fulfill their roles as primary holistic health care providers. Ms is the most prevalent demyelinating disease of the Cns, and the third foremost cause of neurological disability in the United States. For patients presenting with Ms, the dental hygienist can contribute by promoting both corporeal and oral comfort. Appointments that adapt special corporeal needs and treatment plans that offer meaningful health promotion and disease arresting plans are ways to bring up Ms sick person compliance. Current knowledge about Ms symptoms, etiology, corporeal limitations, treatments, and Cam will aid the dental hygienist in providing optimal care.

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