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Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
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Family Practice Guidelines | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Jill C. Cash, MSN, APRN, FNP-BC, a family nurse practitioner for over 20 years, currently practices as a family nurse practitioner at the Vanderbilt Medical Group, Westhaven Family Practice, in Franklin, Tennessee. Her past experience includes teaching as an instructor for the School of Nursing, Southern Illinois University in Edwardsville and Carbondale, Illinois, in the undergraduate BSN program and the graduate NP program. She has been a clinical preceptor for a variety of programs. Her previous experience includes high risk obstetrics as a clinical nurse specialist in maternal-fetal medicine at Vanderbilt University Medical Center, rheumatology in the outpatient setting, women's health in the outpatient setting, and providing wound care in skilled nursing facilities. She has served as a member and officer on numerous boards which include Hospice of Southern Illinois, the Marion Memorial Health Foundation, the American Cancer Society, and Women for Health and Wellness in Southern Illinois. Ms. Cash has authored several chapters in other textbooks and is the co-author of Family Practice Guidelines, first, second, third, and fourth editions, and Adult-Gerontology Practice Guidelines. Most recently, she was awarded the 2017 AANP Nurse Practitioner State Award for Excellence from Illinois. Cheryl A. Glass, MSN, WHNP, RN-BC, is a women's health nurse practitioner who currently practices as a clinical research specialist for KEPRO in Tenn Care's Medical Solutions Unit in Nashville, Tennessee. She is also adjunct faculty at Vanderbilt University School of Nursing. Previously, Ms. Glass was a clinical trainer and trainer manager for Healthways. Her previous nurse practitioner practice was as a clinical research coordinator on pharmaceutical clinical trials at Nashville Clinical Research. She also worked in a collaborative clinical obstetrics practice with the director and assistant directors of maternal-fetal medicine at Vanderbilt University Medical Center Department of Obstetrics-Gynecology. Ms. Glass is the author of several book chapters and is coauthor of Family Practice Guidelines, second, third, and fourth editions, and Adult-Gerontology Practice Guidelines. She has published five refereed journal articles. In 1999, Ms. Glass was named Nurse of the Year by the Tennessee chapter of the Association of Women's Health, Obstetric and Neonatal Nurses. | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
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Family Practice Guidelines Fourth Edition Jill C. Cash, MSN, APRN, FNP-BC Cheryl A. Glass, MSN, WHNP, RN-BC Editors | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Copyright © 2017 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright. com or on the Web at www. copyright. com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www. springerpub. com Acquisitions Editor: Margaret Zuccarini Compositor: Newgen Knowledge Works ISBN: 978-0-8261-7711-7 e-book ISBN: 978-0-8261-7712-4 Patient Teaching Guide: 978-0-8261-7713-1 Patient Teaching Guides are available for download at springerpub. com/familypracticeguidelines4e 17 18 19 20 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research and specific institutional policies before performing any clinical procedure. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers' use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Names: Cash, Jill C., editor. | Glass, Cheryl A. (Cheryl Anne), editor. Title: Family practice guidelines/[edited by] Jill C. Cash, Cheryl A. Glass. Description: Fourth edition. | Danvers, MA: Springer Publishing Company, LLC, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016048484 | ISBN 9780826177117 (paperback) | ISBN 9780826177124 (e-book) | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Subjects: | MESH: Family Practice—methods | Primary Nursing—methods | Diagnostic Techniques and Procedures | Nurse Practitioners | Physician Assistants | Handbooks Classification: LCC RT120. F34 | NLM WY 49 | DDC 610. 73—dc23 LC record available at https://lccn. loc. gov/2016048484 Special discounts on bulk quantities of our books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well. For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY 10036-8002 Phone: 877-687-7476 or 212-431-4370; Fax: 212-941-7842 E-mail: sales@springerpub. com Printed in the United States of America by Bradford & Bigelow. | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
This book is dedicated to all of our families, friends, and colleagues who have influenced our lives, careers, and dreams. We greatly appreciate our colleagues, Margaret Zuccarini and Joanne Jay at Springer Publishing, and Ashita Shah and the Newgen Knowledge Works staff for keeping us on track for deadlines and understanding that life happens! Jill C. Cash and Cheryl A. Glass | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Contents Contributors Reviewers for the Third and Fourth Editions Preface Share Family Practice Guidelines, Fourth Edition I. GUIDELINES 1. Health Maintenance Guidelines Cultural Diversity and Sensitivity Health Maintenance During the Life Span Pediatric Well-Child Evaluation Anticipatory Guidance by Age Nutrition Exercise Planning an Exercise Program Patient Education Before Exercise Other Collaborating Providers Adult Risk Assessment Form Adult Preventive Health Care Immunizations Immunizations for Travel Immunization Links: 2016 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Beers Criteria for Medication Use in Older Adults 2. Public Health Guidelines Homelessness Obesity Post—Bariatric Surgery Long-Term Follow-Up Substance Use Disorders Violence Children Intimate Partner Violence Older Adults 3. Pain Management Guidelines Acute Pain Chronic Pain Lower Back Pain 4. Dermatology Guidelines Acne Rosacea Acne Vulgaris Animal Bites, Mammalian Benign Skin Lesions Candidiasis Contact Dermatitis Eczema or Atopic Dermatitis Erythema Multiforme Folliculitis | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Hand, Foot, and Mouth Syndrome Herpes Simplex Virus Type 1 Herpes Zoster or Shingles Impetigo Insect Bites and Stings Lice (Pediculosis) Lichen Planus Pityriasis Rosea Precancerous or Cancerous Skin Lesions Psoriasis Scabies Seborrheic Dermatitis Tinea Corporis (Ringworm) Tinea Versicolor Warts Wound Care Lower Extremity Ulcer Pressure Ulcers Wounds of the Skin Xerosis (Winter Itch) 5. Eye Guidelines Amblyopia Blepharitis Cataracts Chalazion Conjunctivitis Corneal Abrasion Dacryocystitis Dry Eyes | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Excessive Tears Eye Pain Glaucoma, Acute Angle-Closure Hordeolum (Stye) Strabismus Subconjunctival Hemorrhage Uveitis 6. Ear Guidelines Acute Otitis Media Cerumen Impaction (Earwax) Hearing Loss Otitis Externa Otitis Media With Effusion Tinnitus 7. Nasal Guidelines Allergic Rhinitis Epistaxis Nonallergic Rhinitis Sinusitis 8. Throat and Mouth Guidelines Avulsed Tooth Dental Abscess Epiglottitis Oral Cancer | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Pharyngitis Stomatitis, Minor Recurrent Aphthous Stomatitis Thrush 9. Respiratory Guidelines Asthma Bronchiolitis: Child Bronchitis, Acute Bronchitis, Chronic Chronic Obstructive Pulmonary Disease Common Cold/Upper Respiratory Infection Cough Croup, Viral Emphysema Obstructive Sleep Apnea Pneumonia (Bacterial) Pneumonia (Viral) Respiratory Syncytial Virus Bronchiolitis Shortness of Breath Tuberculosis 10. Cardiovascular Guidelines Acute Myocardial Infarction Arrhythmias Atherosclerosis and Hyperlipidemia Atrial Fibrillation Chest Pain Chronic Venous Insufficiency and Varicose Veins | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Deep Vein Thrombosis Heart Failure Hypertension Lymphedema Murmurs Palpitations Peripheral Arterial Disease Superficial Thrombophlebitis Syncope 11. Gastrointestinal Guidelines Abdominal Pain Appendicitis Celiac Disease Cholecystitis Colic Colorectal Cancer Screening Constipation Crohn's Disease Cyclosporiasis Diarrhea Diverticulosis and Diverticulitis Elevated Liver Enzymes Gastroenteritis, Bacterial and Viral Gastroesophageal Reflux Disease Giardiasis intestinalis Hemorrhoids Hepatitis A Hepatitis B Hepatitis C | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Hernias, Abdominal Hernias, Pelvic Hirschprung's Disease or Congenital Aganglionic Megacolon Hookworm Irritable Bowel Syndrome Jaundice Malabsorption Nausea and Vomiting Peptic Ulcer Disease Pinworm Roundworm Ulcerative Colitis 12. Genitourinary Guidelines Benign Prostatic Hypertrophy Chronic Kidney Disease in Adults Epididymitis Hematuria Hydrocele Interstitial Cystitis Prostatitis Proteinuria Pyelonephritis Renal Calculi or Kidney Stones (Nephrolithiasis) Sexual Dysfunction Male Erectile Dysfunction Premature Ejaculation Testicular Torsion Undescended Testes or Cryptorchidism Urinary Incontinence | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Urinary Tract Infection (Acute Cystitis) Varicocele 13. Obstetrics Guidelines ANTEPARTUM Preconception Counseling: Identifying Patients at Risk Routine Prenatal Care Anemia, Iron Deficiency Gestational Diabetes Mellitus Preeclampsia Preterm Labor Pyelonephritis in Pregnancy Vaginal Bleeding: First Trimester Vaginal Bleeding: Second and Third Trimesters POSTPARTUM Breast Engorgement Endometritis Secondary Postpartum Hemorrhage Mastitis Postpartum Care: 6 Weeks Postpartum Examination Postpartum Depression Wound Infection 14. Gynecologic Guidelines Amenorrhea Atrophic Vaginitis Bacterial Vaginosis (or Gardnerella) Bartholin's Cyst or Abscess | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Breast Pain Cervicitis Contraception Dysmenorrhea Dyspareunia Emergency Contraception Endometriosis Female Sexual Dysfunction Infertility Menopause Pap Smear Screening Guidelines and Interpretation Pelvic Inflammatory Disease Premenstrual Syndrome and Premenstrual Dysphoric Disorder Vulvovaginal Candidiasis 15. Sexually Transmitted Infections Guidelines Chlamydia Gonorrhea Herpes Simplex Virus Type 2 Human Papillomavirus Syphilis Trichomoniasis 16. Infectious Disease Guidelines Cat Scratch Disease Cytomegalovirus Encephalitis H1N1 Influenza A (Swine Flu) Influenza (Flu) | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Kawasaki Disease Lyme Disease Meningitis Mononucleosis (Epstein—Barr) Mumps Parvovirus B19 (Fifth Disease, Erythema Infectiosum) Rheumatic Fever Rocky Mountain Spotted Fever Roseola (Exanthem Subitum) Rubella (German Measles) Rubeola (Red Measles) Scarlet Fever (Scarlatina) Toxoplasmosis Varicella (Chickenpox) West Nile Virus Zika Virus Infection 17. Systemic Disorders Guidelines Chronic Fatigue Syndrome (Systemic Exertion Intolerance Syndrome) Fevers of Unknown Origin Human Immunodeficiency Virus (HIV) Idiopathic (Autoimmune) Thrombocytopenic Purpura Iron-Deficiency Anemia (Microcytic, Hypochromic) Lymphadenopathy Pernicious Anemia (Megaloblastic Anemia) 18. Musculoskeletal Guidelines Neck and Upper Back Disorders Plantar Fasciitis | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Sciatica Sprains: Ankle and Knee 19. Neurologic Guidelines Alzheimer's Disease Bell's Palsy Carpal Tunnel Syndrome Dementia Guillain—Barré Syndrome Headache Migraine Headache Mild Traumatic Brain Injury Multiple Sclerosis Myasthenia Gravis Parkinson's Disease Restless Legs Syndrome Seizures Seizure, Febrile (Child) Transient Ischemic Attack Vertigo 20. Endocrine Guidelines Addison's Disease Cushing's Syndrome Diabetes Mellitus Galactorrhea Gynecomastia Hirsutism Hypogonadism | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Metabolic Syndrome/Insulin Resistance Syndrome Polycystic Ovarian Syndrome Thyroid Disease: Hyperthyroidism Thyroid Disease: Hypothyroidism Thyrotoxicosis/Thryoid Storm 21. Rheumatological Guidelines Ankylosing Spondylitis Fibromyalgia Gout Osteoarthritis Osteoporosis/Kyphosis/Fracture Polymyalgia Rheumatica Pseudogout Psoriatic Arthritis Raynaud's Phenomenom Rheumatoid Arthritis Systemic Lupus Erythematosus Temporal Arteritis/Giant Cell Arteritis Vitamin D Deficiency 22. Psychiatric Guidelines Anxiety Attention-Deficit Disorder/Attention-Deficit/Hyperactivity Disorder Bipolar Disorder Depression Failure to Thrive Grief Sleep Disorders | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Suicide 23. Assessment Guide for Sport Participation II. PROCEDURES Canalith Repositioning (Epley) Procedure for Vertigo Cervical Evaluation During Pregnancy: Bimanual Examination Clock-Draw Test Cystometry Cystometry: Bedside Foreign Body Removal From the Nose Hernia Reduction (Inguinal/Groin) Intrauterine Device Insertion Neurologic Examination Nonstress Test Oral Airway Insertion Pap Smear and Maturation Index Procedure Pregnancy: Estimating Date of Delivery Prostatic Massage Technique: 2-Glass Test Rectal Prolapse Reduction Sprain Evaluation Tick Removal Trichloroacetic Acid/Podophyllin Therapy Wet Mount/Cervical Cultures Procedure III. PATIENT TEACHING GUIDES Abdominal Pain: Adults | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Abdominal Pain: Children Acne Rosacea Acne Vulgaris Acute Otitis Media Addison's Disease ADHD: Coping Strategies for Teens and Adults ADHD: Tips for Caregivers of a Child With ADHD Adolescent Nutrition Alcohol and Drug Dependence Allergic Rhinitis Amenorrhea Ankle Exercises Aphthous Stomatitis Asthma Asthma: Action Plan and Peak Flow Monitoring Asthma: How to Use a Metered-Dose Inhaler Atherosclerosis and Hyperlipidemia Atrial Fibrillation Atrophic Vaginitis Back Stretches Bacterial Pneumonia: Adult Bacterial Pneumonia: Child Bacterial Vaginosis Basal Body Temperature Measurement Bell's Palsy Bipolar Disorder Bronchiolitis: Child Bronchitis, Acute Bronchitis, Chronic Cerumen Impaction (Earwax) Cervicitis | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Chickenpox (Varicella) Childhood Nutrition Chlamydia Chronic Obstructive Pulmonary Disease Chronic Pain Chronic Venous Insufficiency Colic: Ways to Soothe a Fussy Baby Common Cold Conjunctivitis Constipation Relief Contraception: How to Take Birth Control Pills (for a 28-Day Cycle) Cough Crohn's Disease Croup, Viral Cushing's Syndrome Deep Vein Thrombosis Dementia Dermatitis Diabetes Diarrhea Dysmenorrhea (Painful Menstrual Cramps or Periods) Dyspareunia (Pain With Intercourse) Eczema Emergency Contraception—Levonogestrel Emergency Contraception—Ulipristal Acetate Emphysema Endometritis Epididymitis Erythema Multiforme Exercise Eye Medication Administration | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Febrile Seizures (Child) Fibrocystic Breast Changes and Breast Pain Fibromyalgia Folliculitis Gastroesophageal Reflux Disease Gestational Diabetes Gonorrhea Gout Grief Head Injury: Mild Hemorrhoids Herpes Simplex Virus Herpes Zoster, or Shingles HIV/AIDS: Resources for Patients Human Papillomavirus Infant Nutrition Influenza (Flu) Insect Bites and Stings Insulin Therapy During Pregnancy Iron-Deficiency Anemia (Pregnancy) Irritable Bowel Syndrome Jaundice and Hepatitis Kidney Disease: Chronic Knee Exercises Lactose Intolerance and Malabsorption Lice (Pediculosis) Lichen Planus Lyme Disease and Removal of a Tick Lymphedema Mastitis Menopause | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Migraine Headache Mononucleosis Myasthenia Gravis Nicotine Dependence Nosebleeds Oral Thrush in Children Osteoarthritis Osteoporosis Otitis Externa Otitis Media With Effusion Parkinson's Disease Management Pelvic Inflammatory Disease Peripheral Arterial Disease Pernicious Anemia Pharyngitis Pityriasis Rosea Pneumonia, Viral: Adult Pneumonia, Viral: Child Polymyalgia Rheumatica Postpartum: Breast Engorgement and Sore Nipples Premenstrual Syndrome Preterm Labor Prostatic Hypertrophy/Benign Prostatitis Pseudogout Psoriasis Respiratory Syncytial Virus RICE Therapy and Exercise Therapy Ringworm (Tinea) Rocky Mountain Spotted Fever and Removal of a Tick Roundworms and Pinworms | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Scabies Seborrheic Dermatitis Shortness of Breath Sinusitis Skin Care Assessment Sleep Apnea Sleep Disorders/Insomnia Superficial Thrombophlebitis Syphilis Systemic Lupus Erythematosus Testicular Self-Examination Tinea Versicolor Tinnitus Toxoplasmosis Transient Ischemic Attack Trichomoniasis Trigeminal Neuralgia Ulcer Management Urinary Incontinence: Women Urinary Tract Infection (Acute Cystitis) Urinary Tract Infection During Pregnancy: Pyelonephritis Vaginal Bleeding: First Trimester Vaginal Bleeding: Second and Third Trimesters Vaginal Yeast Infection Varicose Veins Warts Wound Care: Lower Extremity Ulcers Wound Care: Pressure Ulcers Wound Care: Wounds Wound Infection: Episiotomy and Cesarean Section Xerosis (Winter Itch) | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Zika Virus Infection Appendices Appendix A. Normal Laboratory Values Appendix B: Diet Recommendations Bland Diet DASH Diet: Dietary Approaches to Stop Hypertension Foods to Avoid While Taking Warfarin (Coumadin, Jantoven) Gluten-Free Diet High-Fiber Diet Lactose-Intolerance Diet Low-Fat/Low-Cholesterol Diet Nausea and Vomiting Diet Suggestions (Children and Adults) Vitamin D and Calcium Handout Appendix C: Tanner's Sexual Maturity Stages Appendix D: Teeth Index | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Contributors Julie Adkins, DNP, APN, FNP-BC, FAANP Certified Family Nurse Practitioner Adkins Family Practice, LLC West Frankfort, Illinois Rhonda Arthur, DNP, CNM, WHNP-BC, FNP-BC, CNE Associate Professor Frontier Nursing University Hyden, Kentucky Amy C. Bruggemann, MSN, APRN-BC, CWS Director of Clinical Operations Specialized Wound Management Chesterfield, Missouri Beverly R. Byram, MSN, FNP Clinical Instructor Vanderbilt University School of Nursing Director, Ryan White Part D Comprehensive Care Center Nashville, Tennessee Jill C. Cash, MSN, APN, FNP-BC Vanderbilt Medical Group Westhaven Family Practice | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Franklin, Tennessee; and Vanderbilt University Medical Center Nashville, Tennessee Moya Cook, APN, CNP Morthland College Health Services West Frankfort, Illinois Susan Drummond, RN, MSN, C-EFM Associate in Obstetrics Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, Tennessee Cheryl A. Glass, MSN, WHNP, RN-BC Clinical Research Specialist KEPRO Peer Review Medical Solutions Unit Nashville, Tennessee Debbie Gunter, APRN, FNP-BC, ACHPN Nurse Practitioner Emory University Atlanta, Georgia Mellisa A. Hall, DNP, APN-BC, FNP-BC, ACHPN University of Southern Indiana Evansville, Indiana Audra C. Malone, DNP, FNP-BC Assistant Professor Frontier Nursing University Hyden, Kentucky Robertson Nash, Ph D, ACNP, BC Director, PATHways Clinic | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Nurse Practitioner, Medicine/Infectious Diseases Comprehensive Care Clinic Vanderbilt University Medical Center Nashville, Tennessee Laura A. Petty, MSN, GNP-BC Gerontological Nurse Practitioner Lebanon, Tennessee Bunny Pounds, DNP, FNP, BC Frontier Nursing University Hyden, Kentucky Angelito Tacderas, APN Marion, Illinois Nancy Pesta Walsh, DNP, CNP Frontier Nursing University Hyden, Kentucky Kimberly D. Waltrip, Ph D(c), APRN-BC Instructor of Nursing Southeast Missouri State University Cape Girardeau, Missouri Alyson Wolz, DNP, APN, PMHCNS, BC Harrisburg Medical Center Harrisburg, Illinois | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Reviewers for the Third and Fourth Editions Julie Adkins, DNP, APN, FNP-BC, FAANP Certified Family Nurse Practitioner Adkins Family Practice, LLC West Frankfort, Illinois Rhonda Arthur, DNP, CNM, WHNP-BC, FNP-BC, CNE Associate Professor Frontier Nursing University Hyden, Kentucky Leanne Busby, DSN, RN, FAANP Certified Nurse Practitioner Adjunct Faculty Gordon E. Inman School of Health Sciences and Nursing Belmont University Nashville, Tennessee Andrew W. Hull, PA-C Director, Chair, and Assistant Professor of Physician Assistant Studies Milligan College Physician Assistant Program Milligan College, Tennessee Heather C. Justice, MSPAP, PA-C | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Assistant Professor Milligan College Milligan College, Tennessee David Knechtel, MPAS, PA-C Pulmonary Associates of East Tennessee Clinical Coordinator, Milligan College PA Program Johnson City, Tennessee Maureen Knechtel, MPAS, PA-C Assistant Professor of Physician Assistant Studies Milligan College Milligan College, Tennessee Keith A. Lafferty, MD, FAAEM Codirector of Emergency Medicine Gulf Coast Regional Medical Center Atlanticare Regional Medical Center Atlantic City, New Jersey Ethel M. Robertson, Ed D, FNP-BC, WCC Certified Nurse Practitioner Harmony Family Health Care/Physicians Services Nashville, Tennessee Lucy W. Kibe, Dr PH, MS, MHS, PA-C Director of Doctoral Education Assistant Professor Department of Physician Assistant Medicine School of Graduate Health Sciences Lynchburg College Lynchburg, Virginia | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Preface We are excited to collaborate again on the new fourth edition of Family Practice Guidelines. The guidelines have been written and updated by experienced nurse practitioners in their fields of expertise. This valuable resource is designed to assist novice and experienced nurse practitioners in organizing and using the content in a quick-reference format. Emphasis is placed on history taking, physical examination, and key elements of the diagnosis. Useful website links have also been incorporated, along with updated patient teaching guides to offer to patients. This book is organized into chapters using a body-system format. The disorders included within each chapter are organized in alphabetical sequence for easy access. Disorders that are more commonly seen in the primary care setting are included. Patient teaching guides are also organized in alphabetical order. Bold text or italic text highlights alerts for practitioners and educational clinical pearls are easily found. Organization The book is now organized into three major sections: Section I: Guidelines presents 23 chapters containing the individual disorder guidelines. Section II: Procedures presents procedures that commonly are conducted within the office or clinic setting. Section III: Patient Teaching Guides presents patient teaching guides that are easy to distribute to patients as a take-home teaching guide. The teaching guidelines are arranged in alphabetical order for ease of reference | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
and the pages are perforated for easy pull-out and photocopying. The Patient Teaching Guides are also available for download at springerpub. com/familypracticeguidelines4e New to This Edition New guidelines have been added to the fourth edition, and include the following: The newest up-to-date Centers for Disease Control and Prevention (CDC) guidelines on health maintenance and immunization schedules for adults and children. An entire chapter is dedicated to the sports pre-participation examination. A new chapter on Public Health Guidelines, including the subchapter Homelessness. The Dermatology Guidelines include the newest guidelines for wound care management. The Respiratory Guidelines include a new subchapter on shortness of breath and the newest updated treatment guidelines for chronic obstructive pulmonary disease (COPD) and pneumonia. The Cardiovascular chapter includes the newest guidelines for heart failure and hypertension. The Genitourinary Guidelines include an updated subchapter on erectile dysfunction and a new sub-chapter on premature ejaculation. The Gynecologic Guidelines have been updated with a new subchapter, female sexual dysfunction. New subchapters have been added to the Infectious Disease chapter, including the new CDC guidelines for the Zika virus. Updated guidelines are included in the Neurologic chapter, together with the newest treatment options for stroke and trigeminal neuralgia. A brand new Rheumatological Guidelines chapter includes the most common rheumatic conditions encountered in primary care, including fibromyalgia, psoriatic arthritis, gout, and many others. The section concludes with the newest treatment recommendations in psychiatric conditions including the new subchapters bipolar disorder, | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
depression, sleep disorders, and others. New Patient Teaching Guides Chapter 4, Dermatology Guidelines: Wound Care: Lower Extremity Ulcers; Wound Care: Pressure Ulcers; Wound Care: Wounds Chapter 6, Ear Guidelines: Tinnitus Chapter 10, Cardiovascular Guidelines: Atrial Fibrillation, Chronic Venous Insufficiency, Superficial Thrombophlebitis, and Varicose Veins Chapter 12, Genitourinary Guidelines: Kidney Disease: Chronic Chapter 19, Neurologic Guidelines: Migraine Headache Chapter 22, Psychiatric Guidelines: Sleep Disorders/Insomnia Procedures Three of the procedures have been updated: Clock-Draw Test, Cystometry, and Prostatic Massage Technique: 2-Glass Test. We hope you find this fourth edition of Family Practice Guidelines easy to access and a valuable resource during your clinical practice. We appreciate your support for our first three editions and hope you find the fourth edition as rewarding as the others. Jill C. Cash Cheryl A. Glass | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Share Family Practice Guidelines, Fourth Edition 1 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
I Guidelines 1. Health Maintenance Guidelines 2. Public Health Guidelines 3. Pain Management Guidelines 4. Dermatology Guidelines 5. Eye Guidelines 6. Ear Guidelines 7. Nasal Guidelines 8. Throat and Mouth Guidelines 9. Respiratory Guidelines 10. Cardiovascular Guidelines 11. Gastrointestinal Guidelines 12. Genitourinary Guidelines 13. Obstetrics Guidelines 14. Gynecologic Guidelines 15. Sexually Transmitted Infections Guidelines 16. Infectious Disease Guidelines 17. Systemic Disorders Guidelines 18. Musculoskeletal Guidelines 19. Neurologic Guidelines 20. Endocrine Guidelines 21. Rheumatological Guidelines 22. Psychiatric Guidelines 23. Assessment Guide for Sport Participation 2 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1Health Maintenance Guidelines Cultural Diversity and Sensitivity Angelito Tacderas Culture is more than nationality or race. Culture influences a person's reasoning, decisions, and actions. It is the accumulation of learned beliefs, values, habits, and practices. Culture influences decision making, thoughts, what is approved or disapproved, what is normal or not, which are all acquired from close personal relations (family/members of society) over time. Cultural diversity exists when groups of different cultures must coexist within an environmental area (family, neighborhood, township, city, or country). Knowing that there are differences in cultures and not assigning values among different cultures reflects cultural sensitivity. However, significant differences may exist in the way health care is perceived and practiced because of the differing values and beliefs regarding health and illness inherent among people of varying cultural backgrounds. Factors Contributing to Cultural Diversity Fewer White non-Hispanic children Increase in immigration Efficiency in transportation and travel Increase in the homeless and the poor populations Increase in divorce rate Increase in single parenting Grandparents raising grandchildren 3 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Substance abuse Violence Transgender sex changes Homosexual acceptance Information explosion/high technology Illiteracy Increase in non-English-proficient health care providers Federal regulations Cultural sensitivity is the responsibility of all health care providers. Each office visit is an opportunity to gain more knowledge about a client's health beliefs and practices. Inadequate awareness of the client's health beliefs and practices influenced by culture may lead to mistrust. This may result in barriers, including inappropriate delivery of care, increased cost, noncompliance, and seeking care elsewhere. Thus, this may eventually lead to even more barriers to health care access, resulting in unfavorable health care outcomes. Title VI of the Civil Rights Act is very specific about providing services that are less than the existing standard of care to anyone based on race, age, sex, or financial status. According to this document, “No person in the United States shall, on the grounds of race, color or national origin be excluded in the participation in, be denied the benefits of, or be discriminated under any programs or activity receiving federal financing assistance” (U. S. Department of Justice [USDJ], n. d. ). Thoughtful Consideration Providing care without being sensitive to the cultural needs of a client may suggest that the health care provider's values and beliefs are superior to those of the client and may lead to disparity of care. The limited patient involvement in care may result in noncompliance, placing patients at greater risk of health-related complications. The delay in provision of health care can result in life-threatening complications. Numerous cultural resources are available throughout the literature and the Internet. Preference as to which educational/assessment tools to use are within the health care provider's prerogative. The following are guidelines for promoting cultural sensitivity in the 4 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
clinical setting: A. Provide a cultural diversity self-assessment/practice organization. 1. Consult online Internet self-assessment tools, for example, Centers for Disease Control and Prevention (CDC) website (see the next section). 2. Download self-assessment tools from public sites (see Exhibit 1. 1). 3. Use existing self-assessment tools and make necessary changes to fit the need of your community (see Exhibit 1. 1). B. Identify the need of the population served. 1. Understand the community and its health status. 2. Evaluate resources, attitudes, and barriers inside the community and practice location. a. Access to resources b. Notification of assistance c. Range of assistance options i. Transportation ii. Communication; consider an interpreter (personal vs. automated) 1)Identify bilingual staff. 2)Use family members or personal acquaintances as interpreters (adults only). 3)Provide multilingual written materials. iii. Education (meaningful/multilingual) 1)User friendly 2)Friendly technology C. Educate staff to cultural diversities. 1. Assessments should include the patient's health values and beliefs (see Exhibit 1. 2). 2. Communication should be meaningful. a. Be precise and clear. b. Maintain eye contact when speaking. c. Use plain language. d. Observe facial expressions and body language. e. Use short sentences to explain lengthy information. f. Avoid medical jargon g. Use repetition for emphasis h. Ask questions to confirm understanding 5 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Schedule longer appointments if needed. E. Health care providers should clarify the limitations of a health care provider's role. F. Clearly identify alternatives offered by health care provider. EXHIBIT 1. 1 Cultural Diversity and Sensitivity Self-Evaluation Form Using a scale of 1 to 5, with 1 = never and 5 = always, please answer the following questions: Question Response Value 1. I am comfortable with my culture and can compromise on situations without sacrificing my integrity. 2. I think about what I say and how it may affect people with different beliefs and practices. 3. I am aware that others may stereotype me, and I am willing to proactively get involved and share my beliefs and practices. 4. I evaluate what the real reasons are when I encounter a conflict with persons of a different culture. 5. I am aware of sensitive issues when I am around women and persons of different beliefs and races. 6. I ask for clarification when I do not understand what others mean. 7. I am aware of my assumptions about others who are culturally or racially different from me and I am okay with it. 8. I object when others tell ethnic jokes. 9. I listen without interrupting when someone is speaking. 10. I am comfortable forming friendships with people of different cultures. 11. I find ways to learn more about different cultures and to communicate effectively. 12. I realize that flexibility and empathy allow me to evaluate persons of different cultures without imposing any judgments, which allows me to collaborate effectively. 13. I recognize that there are other ways to do things than mine. 14. I accept people for who they are regardless of color, educational achievement, 6 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
financial status, or gender. 15. I do not mind apologizing if I have wronged or offended someone. 16. I respect that others may have a different interpretation of personal space than I do. 17. I treat people differently than suggested by the biases and prejudices of members of my culture. 18. I do not look down on people who do not speak English fluently or may have an accent. 19. I understand that there are other ways to communicate than I do. 20. I use simple and common phrases when around someone of diverse culture who may not speak my language proficiently. Add up all of the numbers to get a total score. Total score: Outstanding: 95-100 Good: 85-94 Average: 75-84 Needs improvement: 74 or less (This tool is intended for personal use only. It is designed to be performed as a personal self-assessment. No reliability test that measures stability, equivalence, and homogeneity has been performed. ) Source: American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine (2010). Copyright © 2010 American Academy of Pediatrics. Reproduced with permission. EXHIBIT 1. 2 Sample History Form 7 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
8 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Source: American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine (2010). Copyright © 2010 American Academy of Pediatrics. Reproduced with permission. Health Maintenance During the Life Span Jill C. Cash and Debbie Gunter Health maintenance involves identifying individuals who are at risk of health problems and encouraging behaviors that reduce these risks. An important aspect of health maintenance is patient education, including teaching individuals about their risk factors for disease and ways to modify their behaviors to reduce their risks of comorbidities. This book contains Patient Teaching Guides that the practitioner may use for patient education; these forms are found in Section III: Patient Teaching Guides. They may be photocopied by the practitioner, filled in according to the patient's evaluation and needs, and given to the patient. This chapter describes tools that the practitioner can use in preventive health care assessment, which include websites, screening guidelines, and suggestions for patient education and counseling. Pediatric Well-Child Evaluation The Well-Child Care chart (Exhibit 1. 3) is designed for use with newborns 9 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
and young children up to 5 to 6 years old. When complications arise, a detailed Subjective, Objective, Assessment, and Plan (SOAP) note is required for documentation. The documentation should be kept in the front of the child's chart for easy reference. The growth charts for children are available in English; metric versions and charts in multiple languages, including Spanish and French, are available on the Centers for Disease Control and Prevention (CDC) website (www. cdc. gov/growthcharts). Anticipatory Guidance by Age The anticipatory guidance tool (Exhibit 1. 4) provides a quick reference for the practitioner from the child's initial visit at 1 month throughout his or her well-child visits until age 15 years. It lists topics that the practitioner should discuss with the caregiver. This information should be supplemented with booklets, teaching guides, and brochures for the caregiver. EXHIBIT 1. 3 Well-Child Care 10 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Source: American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine (2010). Copyright © 2010 American Academy of Pediatrics. Reproduced with permission. 11 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
EXHIBIT 1. 4 Anticipatory Guidance Immunizations: Please see the Centers for Disease Control and Prevention (CDC) Immunization chart for the recommended vaccination schedule for each visit: www. cdc. gov/vaccines/schedules. Initial Visit: 2 Weeks to 1 Month A. Safety 1. Review sleeping position: Back or side-lying. 2. Avoid placing newborn on top of tables, counters, bed, and so forth. Discuss risk of fall. 3. Avoid toys, pillows in crib. 4. Discuss car seat safety. Use rear-facing car seat. B. Nutrition 1. Breast/bottle feeding 2. Feeding patterns/frequency 3. Regurgitation 4. Avoid propping bottles C. Development 1. Handling fussy periods 2. Soothing techniques: Music, reading 3. Reaction to pain D. Health Care Management 1. Use of thermometer 2. Fever 3. Vomiting 4. Diarrhea 5. Skin: Sun protection E. Family Dynamics 1. The new role of parenting 2. Exhaustion 3. Sleeping patterns of the newborn and parents 4. Sibling reactions, anticipated jealousy 2 Months A. Safety 1. Review sleeping habits. 2. Use rails on cribs. 3. Do not leave child unattended on bed, changing table, and so on. 4. Discuss car seat safety. B. Nutrition 1. See Section III: Patient Teaching Guide for this chapter, “ Infant Nutrition” 2. Breastfeeding/formula intake 12 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Development 1. Head control 2. Eyes follow moving object to midline D. Health Care Management 1. Skin care, infant acne 2. Use of thermometer E. Family Dynamics 1. Child care 2. Relaxation and personal time for the parents 3. Sleeping patterns of infant and parents 4. Sibling rivalry/relationships 4 Months A. Safety 1. Car seat safety 2. Choking, suffocation 3. Ways to assist in an emergency 4. Water safety: Tubs, buckets, pools, and so on 5. Use of safety gates 6. Poison control: Provide poison control number for parent 7. Covering electrical outlets B. Nutrition 1. Begin solids (infant cereal) 2. Breastfeeding/formula intake C. Development 1. Sits with support 2. Follows moving object past midline 3. Social smile, squeals 4. Lifts head up 5. Rolls over supine to prone D. Health Care Management 1. Patterns of sleep 2. Digestive changes E. Family Dynamics 1. Parents' time away 2. Child care 3. Sibling rivalry 6 Months A. Safety 1. Review of 4-month information 2. Car seat safety 3. Reinforce home safety 4. Security of chemicals, toxins, detergents 5. Use of cabinet and door locks, or gates for stairs 6. High-chair safety 13 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
7. Poison control phone number B. Nutrition 1. Breastfeeding/formula intake 2. Cereals/fruits/vegetable introduction C. Development 1. No head lag 2. Turns to rattle noise 3. Reaches toward object 4. Sits without support 5. Transfers object from hand to hand 6. Rolls over prone to supine 7. Shows stranger anxiety D. Health Care Management 1. Dental care 2. Footwear 3. Laboratory: Hematocrit/hemoglobin E. Family Dynamics 1. Parents' time away 2. Child care 3. Sibling rivalry 9 Months A. Safety 1. Childproofing the home 2. Use of gates, locks, cabinet locks 3. Poison control phone number B. Nutrition 1. See Section III: Patient Teaching Guide for this chapter, “ Childhood Nutrition” 2. Breastfeeding/formula intake 3. Solid foods and choking hazards 4. Easy snacks (Cheerios, crackers) C. Development 1. Takes two cubes, pincer grasp 2. Verbalizes “mama” 3. Crawls, cruises 4. Weight-bearing legs 5. Imitates sound 6. Setting limits with “no” D. Health Care Management 1. Elimination patterns 2. Sleeping habits 3. Dental care E. Family Dynamics 1. Sibling interactions 2. Child care 12 Months 14 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Safety 1. Accident prevention (poison control, windows, outlets, water) 2. Poison control phone number B. Nutrition 1. Introduction to cow's milk 2. Use of cup 3. Solid food intake C. Development 1. Read books with caregiver 2. Playtime 3. Praising behavior 4. Stranger and separation anxiety 5. Encourage speech 6. Walking D. Health Care Management 1. Exercise 2. Elimination patterns 3. Sleeping habits 4. Dental care E. Family Dynamics 1. Sibling relationships 2. Child care 15 Months A. Safety 1. Accident prevention review 2. Water safety 3. Choking hazards 4. Plastic bags 5. Electrical safety B. Nutrition 1. Feeding patterns and habits 2. Dental care C. Development 1. Socialization skills changing 2. Goes up steps in childlike manner 3. Bedtime routines 4. Looking/reading books 5. Establishing hand preference D. Health Care Management 1. Treating small injuries at home (abrasions, falls, etc. ) 2. Exercising/activities 3. Elimination patterns 4. Sleeping habits E. Family Dynamics 1. Child care 2. Parent relaxation/time alone 15 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Extended family 18 Months A. Safety 1. Review 12 months 2. Window safety 3. Falls B. Nutrition 1. Feeding patterns and habits 2. Dental care C. Development 1. Pretend play 2. Temper tantrums 3. Reinforce self-care 4. Self-comforting behavior 5. Peer interactions/sharing skills 6. Kick, throw a ball D. Health Care Management 1. Exercise/activity 2. Sleeping habits 3. Elimination patterns E. Family Dynamics 1. Child care 2. Parent relaxation/time alone 3. Extended family 24 Months A. Safety 1. Review 12 months 2. Crib-to-bed transition 3. Car seat and helmet safety 4. Water safety 5. Storage of hazardous household supplies 6. Poison control 7. Street safety 8. Playground (slides, swings, bikes, and so on) 9. Firearm safety 10. Climbing 11. Lighters and matches 12. Motorized toys B. Nutrition 1. Fun foods to eat 2. Feeding habits/daily intake 3. Dental care C. Development 1. Peer interaction 16 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Toileting habits 3. Common routines for eating 4. Bedtime routines 5. Story time 6. Praising good behavior 7. Two-word sentences, knowledge of approximately 250 words D. Health Care Management 1. Laboratory studies: Hematocrit/hemoglobin 2. Urinalysis 3. Lead screening 4. Skin care 5. Elimination and voiding habits E. Family Dynamics 1. Day care/child care 2. Extended family interactions 3. Sibling rivalry 3 to 4 Years A. Safety 1. See topics at 24 months B. Nutrition 1. Daily dietary intake 2. Healthy snacks C. Development 1. Pretend play 2. Fears 3. Fantasy 4. Sleeping habits (night terrors) 5. Setting realistic limits 6. Praising good behavior 7. Reading 8. Music 9. Child care D. Health Care Management 1. Dental 2. Vision 3. Hearing 4. Speech evaluation 5. Laboratory studies: Hematocrit/hemoglobin 6. Tuberculosis (TB) skin test 7. Lead screen E. Family Dynamics 1. Sibling rivalry 2. Child care 3. Parent time alone/relaxation 5 to 6 Years 17 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Safety 1. Review as discussed at previous visits 2. Safety with strangers B. Nutrition 1. Healthy eating habits 2. Healthy snacks C. Development 1. School readiness 2. Sexual curiosity 3. Peer interactions 4. Good health habits (dental, diet, exercise, sleep) 5. Praise good behavior 6. Adult role models 7. Fears 8. Lying D. Health Care Management 1. Dental 2. Vision 3. Hearing E. Family Dynamics 1. Family traditions 2. Changes in the family household (pets, moving, divorce) 3. Sibling rivalry 4. Extended family interactions 10 Years A. Safety 1. Car and cycle safety 2. Pedestrian safety B. Nutrition 1. Daily intake 2. Healthy snacks 3. Healthy nutrition for athletes C. Development 1. School adjustments 2. Social interactions 3. Communications skills 4. Health habits (same topics as ages 5-6) D. Health Care Management 1. Laboratory studies: Hemoglobin, hematocrit, urinalysis 2. Vision 3. Hearing 4. Scoliosis 5. TB skin test E. Family Dynamics 1. Sibling rivalry 2. Extended family 18 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Parenting 4. Family responsibilities/chores 5. Family rituals 6. Changes in family household (pets, moving, divorce) 15 Years A. Safety 1. Stranger awareness 2. Car and cycle safety B. Nutrition 1. Diet, healthy habits 2. See Section III: Patient Teaching Guide for this chapter, “ Adolescent Nutrition” C. Development 1. Relationships with peers 2. Body image 3. Sexuality 4. Self-esteem 5. Peer pressure 6. Decision making 7. Role models 8. School adjustments 9. Extracurricular activities: Sports, hobbies, exercise 10. Drug, alcohol, tobacco use 11. Suicide D. Health Care Management 1. Cardiopulmonary resuscitation (CPR) 2. Emergency numbers 3. Skin care 4. Vision 5. Hearing 6. Scoliosis 7. TB skin test 8. Hemoglobin, hematocrit E. Family Dynamics 1. Change in family household (pets, moving, divorce) 2. Family responsibilities/chores 3. Identifying role models 4. Family events 5. Earning an allowance Source: American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine (2010). Copyright © 2010 American Academy of Pediatrics. Reproduced with permission. Nutrition Proper nutrition is an essential part of maintaining health and preventing 19 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
diseases. Promote well-balanced diets for all patients with an emphasis on the prevention of obesity. Diet modification is an important part of disease or disorder management. The U. S. Department of Agriculture (USDA) provides a variety of interactive educational tools on nutrition, weight management, and physical activity. It is recommended that patients use these tools for family education on healthy diet and lifestyle. Diet information is found in Appendix B: Diet Recommendations (see also Tables 1. 1-1. 3 for more specific information). TABLE 1. 1 Nutrition for Kids: Guidelines for a Healthy Diet TABLE 1. 2 Recommended Number of Food Servings per Day 20 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
TABLE 1. 3 Food Sources for Common Vitamin and Mineral Deficiencies Common Nutritional Deficiencies Food Sources Calcium Dairy sources of calcium include, yogurt, and cheese. Nondairy sources of calcium are vegetables, including kale, broccoli, and Chinese cabbage. Calcium is also found in fortified sources, including breakfast cereals, fruit juices, and tofu. Folate Found naturally in vegetables (especially dark green leafy vegetables), fruits, fruit juices, nuts, beans, peas, dairy products, poultry and meat, eggs, seafood, and grains. In January 1998, the U. S. Food and Drug Administration began requiring manufacturers to add folic acid to enriched breads, cereals, flours, cornmeal, pasta, rice, and other grain products. Iron Heme iron is found in animal foods that originally contained hemoglobin, including red meat, fish, and poultry. Nonheme iron is found in plant foods, including lentils and beans. Iron is also found in fortified ready-to-eat cereals. Magnesium Widely distributed in plant and animal foods, including green leafy vegetables, legumes, nuts (almonds, peanuts, and cashews), seeds, and whole grains. Magnesium is also found in fortified breakfast cereals. Vitamin A Concentrations of preformed vitamin A are highest in liver, fish oils, leafy green vegetables, orange and yellow vegetables, tomato products, fruits, and some vegetable oils. 21 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Vitamin A is also found in fortified breakfast cereals. Vitamin B6 Richest sources include fish; beef, liver, and other organ meats; potatoes and other starchy vegetables such as chickpeas; and fruit (except for citrus). Vitamin B6 is also found in fortified breakfast cereals. Vitamin B12 Found naturally in animal products, including fish, meat, poultry, eggs, and milk and milk products. Generally not present in plant foods. Vitamin B12 is found in fortified breakfast cereals. Vitamin D Very few foods in nature contain vitamin D; it is found primarily in fortified foods. Almost all of the U. S. milk supply is voluntarily fortified with vitamin D. Both the United States and Canada mandate the fortification of infant formula with vitamin D. Vitamin E Found in nuts and seeds (sunflower seeds, almonds, hazelnuts, and peanuts), green leafy vegetables, and vegetable oils. Vitamin E is found in fortified breakfast cereals. Zinc Red meat and poultry provide the majority of zinc in American diets; however, oysters contain more zinc per serving than any other food. Other food sources include beans, nuts, seafood (crab and lobster), and dairy products. Zinc is also found in fortified breakfast cereals. Source: National Institutes of Health, Office of Dietary Supplements (2015) (https://ods. od. nih. gov/factsheets/Mvms-Health Professional). The obesity epidemic is the responsibility of all health care providers. Each office visit is an opportunity to evaluate the patient's weight and to discuss exercise programs. As the pain assessment becomes the “fifth vital sign” in the hospital setting, the body mass index (BMI) becomes the fifth vital sign in the outpatient setting. Teaching parents the correct serving sizes for children will help guide their children's eating habits for life. Dr. Debby Demory-Luce (2004) notes the rule of thumb for measuring portion sizes for fruits and vegetables is “one tablespoon per year of life” for children aged 1 to 6 years. Serving sizes for older children and adults are based on the food pyramids. Use the food pyramid to teach and reinforce proper nutrition. Some helpful websites about 22 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
nutrition are as follows: A. The USDA resources for nutrition and health are located at www. choosemyplate. gov B. My Plate kids' place is located at https://www. choosemyplate. gov/kids C. Nutrition Expedition Games for children are available at www. nutritionexplorations. org/kids. php D. The Childhood Nutrition website is located at www. nourishinteractive. com. This informative website gives helpful information such as: 1. Controlling portion sizes 2. Parent tips tool 3. Interactive nutrition tools 4. A fun area for children with interactive nutrition games 5. Healthy living tips ready to print Height and weight are used to calculate BMI. The mathematical calculation is BMI = kg/m2; however, the Internet provides easy-to-use BMI calculators. A. The National Heart, Lung, and Blood Institute (NHLBI, n. d. ) includes a calculator in its Obesity Education Initiative: www. nhlbi. nih. gov/health/educational/lose_wt/BMI/bmicalc. htm. This support site also includes patient information on risk assessment, weight control, and helpful recipes. B. The CDC provides an online source for the calculation of BMI for children and teens: https://nccd. cdc. gov/dnpabmi/calculator. aspx The CDC's website also provides information on weight loss, physical activity, and parental tips. Malnutrition and vitamin and mineral deficiency are commonly seen in the elderly population. Vitamins B6, B12, D, E, folic acid, zinc, calcium, and iron are often deficient in the elderly diet, along with protein and calorie deficiencies. Using Zawada's (1996) acronym WEIGHT LOSS can help you easily identify common causes of weight loss in the elderly. W: Wandering and not eating, because of forgetting to take time to eat E: Emotional problems, including depression I: Impecuniosity (finances do not meet the needs to buy food and other things) 23 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G: Gut problems H: Hyperthyroidism or other endocrine abnormalities T: Tremor or neurologic problems that make eating and holding utensils difficult L: Low-salt, low-cholesterol diets avoided, often because of disliking the taste of recommended diets O: Oral problems: edentulous, poor dental care, dentures not fitting, mouth disorders such as oral ulcers S: Swallowing problems, difficulty swallowing or chewing food because of stroke or other impairment S: Shopping or food preparation barriers, inability to purchase or prepare food, and no resources for assistance Identification of factor(s) contributing to an elderly patient's malnutrition assists you, the patient, and the patient's family in resolving them. Utilize your state's Area Agencies on Aging (AAA) for information on elder care resources in your area (websites not provided because they are state specific). Exercise Physical exercise is a vital component of health maintenance. Exercise provides cardiovascular fitness and weight control, prevents osteoporosis through weight-bearing exercise, and decreases lipids. Exercise is important for flexibility, strength, and coordination. Exercise can also be used for both weight control and reduction. Approximately 3,500 calories must be burned to lose 1 pound of fat. Therefore, along with exercise, caloric intake must remain the same or decrease to result in weight loss. Planning an Exercise Program Exercise plans should be started after a health provider screens a patient, because heavy physical exertion may trigger an acute myocardial infarction. Factors most likely to influence risk are age, medical conditions, hypertension, and the intensity of the exercise planned. The medical history screening identifies individual and family history of problems such as coronary heart disease, hypertension, and diabetes. Review health habits such as previous exercise or sedentary lifestyle, diet, and smoking. Providers need to evaluate the patient using screening tests before prescribing an exercise program. Consider the patient's age and all comorbidities for additional tests. 24 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Complete blood count B. Blood glucose C. Cholesterol screening D. EKG (in patients older than 40 years) E. Holter monitoring for arrhythmias Persons with a heart murmur or other abnormal physical finding should defer exercise until the full nature of the disorder is evaluated. The best measure of an exercise work capacity is the determination of oxygen consumption at maximal activity, which is measured with a stress test. Hypertension, elevated resting blood pressures, and chronic obstructive lung disease are other factors that require attention before participation in exercise. Persons with hypertension should undergo a thorough evaluation, have antihypertensive agent(s) prescribed, and be monitored periodically during their prescribed graded exercise program. Physical exercise should be strictly monitored in the following conditions and may need to be curtailed, or even stopped, based on the condition: A. Congestive heart failure B. Uncontrolled hypertension C. Uncontrolled epilepsy D. Uncontrolled diabetes E. Atrioventricular (AV) heart block F. Aneurysms G. Ventricular instability H. Aortic valve disease Measurement of the heart rate during exercise is an easy and inexpensive method to evaluate cardiovascular fitness. Target heart rates vary by physical condition and a person's age. The following formula is used to evaluate target heart/aerobic activity level: [220-(age of individual)] × 0. 65 = Maximum heart rate range Maximum heart rate × 0. 65 = Minimum aerobic effect Maximum heart rate × 0. 85 = Maximum aerobic effect Patient Education Before Exercise All exercise program prescriptions should include frequency, duration, intensity, and time to abort the exercise. Persons should be educated on the 25 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
signs and symptoms of heat exhaustion and should be advised when to seek first aid. Exercise programs with aerobic activity at least three times a week on nonconsecutive days is the minimal amount of exercise individuals should set as a goal. The target heart rate should be sustained for 20 to 30 minutes for maximal cardiovascular effect. Women engaged in regular physical exercise before pregnancy may safely continue exercise throughout pregnancy. The target heart rate for a pregnant woman during exercise should not exceed 140 beats per minute. Activities should also be limited to low-impact aerobics and activities that do not require agility, because a woman's center of balance changes throughout pregnancy, leaving the woman at risk of falling and injury. Swimming is ideal for upper and lower body conditioning, with low impact on joints. Swimming is not well suited for women at risk of osteoporosis, because it is not a weight-bearing exercise. Examples of weight-bearing exercise to help prevent osteoporosis include dancing, impact aerobics, and resistance training. For exercise to benefit individuals, it must be continued lifelong. The health care provider should evaluate individual lifestyle and preferences in designing an exercise program. One exercise program can become boring over a period and probably will not be continued. A variety of activities, class participation, and positive reinforcement help to keep physical activity fun as an integral part of a health maintenance program. See Section III: Patient Teaching Guide for this chapter, “Exercise. ” Health care professionals who will be monitoring and prescribing exercise plans for large numbers of individuals are encouraged to seek special training and certification. The American College of Sports Medicine has a program that includes training for health care professionals. Other Collaborating Providers Jill C. Cash and Debbie Gunter The role of the primary care provider is to ensure that the patient becomes a partner in preventive health measures to avoid disease comorbidities. The practitioner should refer the patient to other health care providers to continue 26 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
health maintenance. A. Dental care 1. Dental care should be routinely discussed. 2. Once teeth emerge, brushing should begin with a small soft brush. 3. In children, dental care should begin with soft, rubber brushes for gum care. 4. Encourage the child to brush teeth twice daily to promote healthy habits. 5. Refer the patient to a dentist at 3 years, unless problems arise earlier. 6. Older child should be encouraged to use mouth guards with contact sports. 7. Encourage flossing when the child has the cognitive and developmental dexterity to use dental floss. B. Vision care 1. Begin initial vision screening for children at 3 years of age using the age-appropriate eye chart. 2. School screening should include a vision-screening component. 3. Refer patients to an optometrist for routine evaluation. Adult Risk Assessment Form Jill C. Cash and Debbie Gunter The Adult Risk Assessment Form (Exhibit 1. 5) should be used for all adult patients. It is used to evaluate a patient's risk for particular diseases. The practitioner should interview the patient, assessing for the risk factors listed on the Risk Assessment Form. The family history of first-degree relatives (parents, siblings, and children) should also be discussed, as many diseases are related to genetic factors. Keep a copy of the Risk Assessment Form in the front of the patient's chart, and update yearly or as needed. When complete, this tool can guide the practitioner in determining the assessment needs of each patient. 27 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
EXHIBIT 1. 5 Adult Risk Assessment Form Name _________ DOB _________ Chart # _________ Allergies _________________________________ Occupation ________________________________ Assess the patient for the following risk factors: Family History First-degree relatives with remarkable diseases (e. g., hypertension, diabetes mellitus, coronary artery disease [CAD], cancer, and thyroid) 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. A. Coronary heart disease 1. High-fat/high-cholesterol diet 2. Obese 3. Elevated cholesterol level 4. Stroke 5. Hypertension 6. Tobacco use B. Lung cancer 1. High-fat/high-cholesterol diet 2. Tobacco use C. Cervical cancer 1. Early age of first intercourse 2. Multiple sexual partners D. Breast cancer 1. Nulliparous 2. Primigravida after age 35 years 3. High-fat diet E. Colon cancer 1. History of polyps 2. High-fat diet F. Osteoporosis 1. Less than 1 g of calcium per day 2. History of tobacco or alcohol use 3. Sedentary lifestyle 28 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
4. Thin, Caucasian 5. Female gender G. Glaucoma/visual impairment 1. Family history of glaucoma 2. Diabetes mellitus H. Sexually transmitted infections (STIs)/HIV 1. Alcohol and drug use or abuse 2. Multiple sexual partners 3. Homosexual or bisexual partner 4. History of intravenous drug use 5. History of blood transfusion 6. Exposed to or past history of STI I. Substance abuse 1. Alcohol or drug use history 2. Family history of substance abuse 3. Stress or poor coping mechanisms 4. Administer the CAGE assessment: Have you ever tried to Cut down on your alcohol/drug use? Do you get Annoyed if someone mentions your use is a problem? Do you ever feel Guilty about your use? Do you ever have an “Eye-opener” first thing in the morning after you have been drinking or using the night before? J. Accidents and suicide 1. Family history of suicide 2. Alcohol or tobacco use 3. History of depression 4. High-stress or “hot-reactor” personality 5. Male gender 6. Alcohol use 7. Previous suicide attempt 8. Poor coping mechanisms or stress K. Safety 1. Does not use seat belt or car seat 2. Drinks and drives 3. Drives over the speed limit 4. Does not wear safety helmet if driving motorcycle 5. Inadequate number of smoke detectors or none in the home 6. Firearms in the home 7. Feels safe at home/at risk for domestic violence Adult Preventive Health Care Jill C. Cash and Debbie Gunter The flow sheet given in Exhibit 1. 6 helps the practitioner identify changes in 29 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
the adult patient's risk factor status, make recommendations for health maintenance (e. g., immunizations, laboratory work, physical examinations), and educate patients in prevention (Exhibit 1. 7). Screening guidelines for each of these can be found in the associated chapters in this book, according to the national association recommendations (e. g., screening recommendations for mammograms were obtained from the American Cancer Society). The Adult Health Maintenance Guide in Exhibit 1. 7 can be used as a quick reference for the practitioner to evaluate the patient's adherence to preventive measures. Keep a copy of this flow sheet and guide in the front of the patient's chart where they can be reviewed routinely and updated as necessary. If using electronic medical records, a special section should be identified as routine health maintenance. EXHIBIT 1. 6 Adult Preventive Health Care Flow Sheet 30 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
EXHIBIT 1. 7 Adult Health Maintenance Guide 31 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Immunizations The CDC is the primary source for the current immunization schedules. Consult the CDC's website for pocket-sized schedules, printable versions, and versions for mobile devices. The download information for your smartphone is available on the CDC website at www. cdc. gov/vaccines/schedules/hcp/child-adolescent. html Immunizations for Travel The CDC recommends certain vaccines to protect travelers from illnesses present in other parts of the world and to protect others on return to the United States. The CDC's Travelers' Health website is located at 32 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
www. cdc. gov; it is an interactive website to individualize the needs of travelers to their specific destination. Vaccinations required are dependent on several factors: A. Travel destination B. Travel season C. Age D. Pregnancy or breastfeeding E. Traveling with infants or children F. Immunocompetent secondary to diabetes or HIV The CDC also has a Health Education sheet for travelers at www. cdc. gov/travel/page/traveler-information-center Immunization Links: 2016 Recommended immunization schedule for persons aged 0 through 18 years —2016 is available at: www. cdc. gov/vaccines/schedules/downloads/child/0-18yrs-schedule-bw. pdf Catchup immunization schedule for persons aged 4 months through 18 years who started late or who are more than 1 month behind—United States— 2016 is available at: www. cdc. gov/vaccines/schedules/downloads/child/catchup-schedule-bw. pdf Recommended adult immunization schedule—United States—2016 is available at: www. cdc. gov/vaccines/schedules/downloads/adult/adult-schedule-bw. pdf Recommended vaccination of persons with primary and secondary immunodeficiencies is available at: www. cdc. gov/mmwr/preview/mmwrhtml/rr6002a1. htm ; www. cdc. gov/vaccines/schedules/hcp/imz/child-adolescent. html ; www. cdc. gov/vaccines/schedules/hcp/imz/catchup. html Beers Criteria for Medication Use in Older Adults Check the Beers list for harmful drugs in the geriatric population. The 2015 33 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is available at https://www. guideline. gov/summaries/summary/49933/american-geriatrics-society-2015-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults. Bibliography Allender, J. A., Rector, C., & Warner, K. D. (2013). Community health nursing (8th ed. ). Philadelphia, PA: Kluwer/Lippincott Williams & Wilkins. American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine. (2010). Preparticipation physical evaluation (4th ed. ). Elk Grove Village, IL: American Academy of Pediatrics. Andrews, M. M., & Boyle, J. S. (2015). Transcultural concepts in nursing care (7th ed. ). Philadelphia, PA: Lippincott Williams & Wilkins. Benton, J. (2003). Making schools safer and healthier for lesbian, gay, bisexual, and questioning students. Journal of School Nursing: The Official Publication of the National Association of School Nurses, 19(5), 251-259. Bernhardt, D. T. (2015). Concussion. Medscape. Retrieved from www. medscape. com Centers for Disease Control and Prevention. (2015, March 11). Cultural competence. Retrieved from https://npin. cdc. gov/pages/cultural-competence Centers for Disease Control and Prevention. (2016a). CDC catchup immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind—United States 2016. Retrieved from https://www. cdc. gov/vaccines/schedules/hcp/imz/catchup. html Centers for Disease Control and Prevention. (2016b). CDC recommended adult immunization schedule —United States 2016. Retrieved from https://www. cdc. gov/vaccines/schedules/hcp/adult. html Centers for Disease Control and Prevention (CDC). (2016c). CDC recommended immunization schedule for persons aged 0 through 6 years—United States 2016. Retrieved from https://www. cdc. gov/vaccines/schedules/hcp/imz/child-adolescent. html Centers for Disease Control and Prevention. (2016d). Information for travelers. Retrieved from www. cdc. gov/travel/page/traveler-information-center Centers for Disease Control and Prevention. (n. d. a). BMI percentile calculator for child and teen: English version Retrieved from https://nccd. cdc. gov/dnpabmi/calculator. aspx Centers for Disease Control and Prevention. (n. d. b). Growth charts. Retrieved from https://www. cdc. gov/growthcharts Centers for Disease Control and Prevention. (n. d. c). Immunization applications for PC/handhelds. Retrieved from https://www. cdc. gov/vaccines/pubs/vis/vis-downloads. htm Childhood Nutrition. (n. d. ). Serving sizes. Retrieved from http://www. nourishinteractive. com/parents_area/healthy_family_nutrition_newsletter/portion_control_childhood_easy_weight_management_tips_reducing_kids_food_serving_sizes Douglas, M. K., Rosenkoetter, M., Pacquiao, D. F., Callister, L. C., Hattar-Pollara, M., Lauderdale, J.,... Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society/Transcultural Nursing Society, 25(2), 109-121. Health Canada. (2007). How much food you need every day. Retrieved from http://www. hc-34 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
sc. gc. ca/fn-an/food-guide-aliment/basics-base/quantit-eng. php Huber, D. L. (2013). Leadership and nursing care management (5th ed. ). St. Louis, MO: Saunders. Mayo Foundation for Medical Education and Research. (2016, January). Nutrition for kids: Guidelines for a healthy diet. Retrieved from http://www. mayoclinic. com/health/nutrition-for-kids/NU00606 Miller, N., Reicks, M., Redden, J. P., Mann, T., Mykerezi, E., & Vickers, Z. (2015). Increasing portion sizes of fruits and vegetables in an elementary school lunch program can increase fruit and vegetable consumption. Appetite, 91, 426-430. Mirabelli, M. H., Devine, M. J., Singh, J., & Mendoza, M. (2015). The preparticipation sports evaluation. American Family Physician, 92(5), 371-376. Muronda, V. (2016, July). The culturally diverse nursing student: A review of the literature. Journal of Transcultural Nursing, 4, 400-412. National Heart Lung and Blood Institute. (n. d. ). Obesity education initiative: BMI calculator. Retrieved from http://www. nhlbi. nih. gov/health/educational/lose_wt/BMI/bmicalc. htm National Institutes of Health, Office of Dietary Supplements. (2015). Food sources for common vitamin and mineral deficiencies. Retrieved from https://ods. od. nih. gov/factsheets/Mvms-Health Professional/ Pigozi, P. L., & Jones Bartoli, A. (2016). School nurses' experiences in dealing with bullying situations among students. Journal of School Nursing: The Official Publication of the National Association of School Nurses, 32(3), 177-185. Purnell, L. D., & Paulanka, B. J. (2013). Transcultural health care: A culturally competent approach (4th ed. ). Philadelphia, PA: F. A. Davis. Ritchie, C. (2015, October 22). Geriatric nutrition: Nutritional issues in older adults. Up To Date. Retrieved from http://www. uptodate. com/contents/geriatric-nutrition-nutritional-issues-in-older-adults Sanders, B., Blackburn, T. A., & Boucher, B. (2013). Preparticipation screening: The sports physical therapy perspective. International Journal of Sports Physical Therapy, 8(2), 180-193. Sharma, S., Merghani, A., & Gati, S. (2015). Cardiac screening of young athletes prior to participation in sports: Difficulties in detecting the fatally flawed among the fabulously fit. JAMA Internal Medicine, 175(1), 125-127. Spector, R. E. (2012). Cultural diversity in health and illness (8th ed. ). Upper Saddle River, NJ: Prentice-Hall. Stepler, R. (2016). World's centenarian population projected to grow eightfold by 2050. Washington, DC: Pew Research Center. Retrieved from http://www. pewresearch. org/fact-tank/2016/04/21/worlds-centenarian-population-projected-to-grow-eightfold-by-2050 U. S. Census. (n. d. ). Quickfacts. Retrieved from https://quickfacts. census. gov/qfd/staes/oooo. html U. S. Department of Agriculture. (n. d. ). Food pyramid. Retrieved from https//:www. choosemyplate. gov U. S. Department of Agriculture. (n. d. ). My Plate kids' place. Retrieved from https://www. choosemyplate. gov/kids Zawada, E. (1996). Malnutrition in the elderly: Is it simply a matter of not eating enough? Postgraduate Medicine, 100(1), 208. 35 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2Public Health Guidelines Homelessness Robertson Nash Overview Homelessness is a multifaceted structural problem that has a syndemic effect on people. The term syndemic refers to situations in which the net effect of multiple physical and social comorbidities is worse than the sum of the individual effects (Merrill, 2009). In the case of people experiencing homelessness, consider all of the possible interactions among unmanaged chronic diseases (diabetes mellitus type 2, hypertension, hyperlipidemia), multiple caries and gingival abscesses, chronic soft tissue infections, and untreated depression and anxiety. For people without the support of stable housing and nutrition, these interactions can be overwhelming. Data show that, on average, people who are chronically homeless live approximately 20 years less than their housed peers. Definition (Federal) A. The U. S. Department of Housing and Urban Development (HUD) is responsible for defining the criteria by which an individual's housing status is assessed. The required criteria for the determination of homelessness include the following (HUD, 2011): 1. Individuals and families who lack a fixed, regular, and adequate nighttime residence OR an individual residing in an emergency shelter or place not fit for human habitation OR an individual exiting an institution that provided temporary residence 2. Individuals and families at imminent risk of losing their primary 36 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
nighttime residence 3. Unaccompanied youth and families with children not otherwise qualifying as homeless 4. Individuals and families fleeing or attempting to flee dating/domestic violence, sexual assault, stalking, or other dangerous or life-threatening situations B. In order to meet the criteria of “chronically homeless,” an individual has to be determined to have been homeless either continuously for at least 12 months, or on at least four separate occasions in the past 3 years, with a total experience of homelessness greater than 12 months. Both families and individuals may meet this definition (HUD, 2015). Incidence A. According to data published by the HUD, on a given night in January 2013, an estimated 610,042 people were homeless. Of these, an estimated 394,698 were sheltered and 215, 344 were unsheltered (Henry, Cortes, & Morris, 2013). According to this same source, total homelessness in the United States has declined by more than 9% between 2007 and 2013 (Henry et al., 2013). Pathogenesis A. Homelessness is a catastrophic experience at the individual level. However, most of the factors that contribute to homelessness are structural in nature and are beyond the control of any one patient or provider. For example, cities with an inadequate supply of Section 8 housing will not be able to provide people experiencing homelessness with a place to live. Furthermore, the disparity between federal and state minimum wages and the living wage translate into people who work 40 or more hours a week who are often unable to secure housing. Predisposing Factors A. Chronic illnesses: People who are homeless suffer from chronic illnesses at rates that exceed those in the general population. In many cases, overlapping and negatively interacting manifestations of illness exacerbate each other, leading to several complicated comorbidities whose management may tax the resources available to both patient and provider. 37 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Common Complaints A. Cough/upper respiratory infection B. Sinusitis C. Soft tissue infections D. Dental abscesses/gingivitis E. Tinea pedis F. Pest infestations G. Mental health-related complaints Other Signs and Symptoms A. Does the patient smell of smoke, as if he or she has been sleeping outdoors by a fire? If so, this would trigger a chest x-ray and detailed pulmonary examination. B. Does the patient smell of urine, suggesting a possible urinary tract infection? If so, this would trigger a genitourinary skin examination, urinalysis, and social work consult regarding access to clean clothing. C. Unilateral lower extremity pitting edema, pain, and tenderness suggest the presence of a deep vein thrombosis, which is considered a medical emergency. D. Bilateral lower extremity pitting edema may be a sign of heart failure. This finding would trigger a thorough clinical examination for the following: S3, S4 heart sounds, jugular venous pulse, and jugular venous distension. E. Brawny edema and venous stasis ulcerations would trigger a thorough peripheral vascular examination and a sensory examination of the plantar surfaces of both feet. F. Itchiness suggests pest infestation, needs treatment, shower, wash cloth, new clothes, and contact shelter to treat the environment G. Unusual behavior; for example, hallucination, visible depression, intoxication and so on refer to mental health Subjective Data: Factors to Consider When Evaluating People Experiencing Homelessness A. Where did the patient sleep last? Does the patient have a safe place to sleep tonight? B. When was the last time the patient was able to bathe? 38 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. When was the last time the patient ate? D. Is the patient able to find bathrooms when needed? E. Are symptoms of depression and anxiety interfering with survival? F. Is the patient being physically, sexually, or emotionally abused? G. Is the patient being forced to engage in behaviors against his or her will in exchange for food and shelter? H. Does the patient have a safe way to manage medications on the street, such as, insulin? I. Assess/discuss current substance abuse. See Section III: Patient Teaching Guide for this chapter, “ Alcohol and Drug Dependence. ” Physical Examination Providers should be aware that, due to past trauma, many people experiencing homelessness are reluctant to touch. Take your time with the physical examination, ask permission for each step of the physical examination, and explain what you are doing and why. A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Scalp—assess for nits. 2. Oral cavity—assess for caries, or active oral abscesses. 3. Assess skin for burns, abrasions, trauma, and evidence of accidental or intentional injury. Visualize both feet for infection and trauma. C. Palpate the abdomen for tenderness or masses. Perform pelvic examination as appropriate. This may not be possible on the first examination. For some females, intentionally poor hygiene is viewed as protection against male assault. D. Auscultate heart, lungs, and abdomen. E. Neurologic examination 1. Assess for neuropathy in feet. 2. Assess hearing and vision, as these faculties are central to survival when living on the street. F. Mental health examination 1. Perform depression/anxiety screening. See depression/anxiety in Chapter 22: Psychiatric Guidelines, for screening. 2. Evaluate suicidal ideation. See Chapter 22: Psychiatric Guidelines, for assessment/screening. 39 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Assess for active audio/visual hallucinations. 4. Assess for paranoia. Diagnostic Tests A. Complete blood count (CBC) B. Comprehensive metabolic panel (CMP) C. B12/folate D. Urine: Urinalysis for protein/glucose and Neisseria gonorrhea/Chlamydia E. Rapid plasma reagin (RPR) F. HIV G. HAV/HBV profile, hepatitis C virus antibody H. Glycosylated hemoglobin A1c I. Purified protein derivative (PPD)/T-SPOT Differential Diagnoses A. Homelessness B. Substance use/abuse C. Depression D. Malnutrition E. Schizophrenia Plan A. General interventions 1. There are no disease-based standards of care that specifically address people who are homeless. Rather, providers must be creative and resourceful, working with patients toward higher levels of self-efficacy within the resource bounds imposed on the situation by society at large. 2. Community-based care: No single provider or ancillary service organization (ASO) can provide all of the care needed for people experiencing homelessness. In order to maximize care, providers should make an effort to identify and be in communication with their local ASOs before a crisis, so that resources can be coordinated and maximized when acute issues arise. 3. Identifying and assisting the patient with current health needs is imperative. In addition to addressing homelessness, the patient may have 40 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
other acute and chronic health conditions that should be addressed and treated as appropriate. B. Patient teaching 1. Lifestyle modifications, focusing on diet, exercise, and smoking cessation, form the cornerstone of advanced practice nurse (APN) patient teaching for chronic disease management. The following principles should be used to guide the teaching of these principles in this population: a. People experiencing homelessness rarely have access to exercise facilities. In addition, they often lack a safe place to store their belongings while they exercise. b. People experiencing homelessness have little to no control over their food selection. Dependence on volunteer-driven, charity-led food banks and meal programs is a significant impediment to healthy eating, as many of these programs assume that a high-carbohydrate, calorie-dense meal, such as spaghetti and bread, is what people experiencing homelessness like and want to eat. c. The prevalence of poor dentition among the homeless greatly exceeds that of the stably housed, employed population. Accordingly, people experiencing homelessness may not be able to eat fresh fruits and vegetables. d. The rates of substance abuse among the chronically homeless exceed those in the general population. Some people may be successfully clean and sober from alcohol, some yet continue to smoke tobacco. Although this is not ideal, focus on patient strengths, praise sobriety, and acknowledge that smoking cessation is perceived as being more difficult than sobriety from alcohol and may need to have a lower priority in a patient's overall plan of care. e. Blanket dietary and exercise recommendations developed around stably housed, fully employed people will likely not translate well to people experiencing homelessness. Failure to account for the unique challenges of people experiencing homelessness will exacerbate feelings of depression, low self-worth, and decreased self-efficacy. f. Caring for individuals experiencing homelessness requires a team approach. Successful teams include clinicians, social workers, behavioral health providers, psychiatric providers, and also nursing staff. No one provider or discipline can address all of the needs of 41 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
people experiencing homelessness. It is also critical that the care team work well together and prioritize the work of building rapport with the patient, whose life experiences have likely reinforced his/her distrust of the systems that we all depend on to deliver care. Follow-Up A. One of the primary challenges facing providers of those experiencing homelessness is the deep-seated lack of trust that these people have in the health care system within which most providers operate. In order to encourage people to return to the clinic for appropriate follow-up care, every effort must be made during the first visit to establish a true therapeutic relationship with the patient. Providers should attempt to work with patients to identify and address concerns that are important to the patient. Providers should remember that topics, such as smoking cessation and sobriety from alcohol may best be deferred during an initial visit. All clinic staff should be trained to treat all patients with a professional, welcoming, and empathetic manner. Consultation/Referral A. Referring patients to specialists is an everyday part of primary care, and advanced practice nurses serve important screening and gatekeeper functions in this role. However, the insurance-based system that we rely on for care is not available to most people experiencing homelessness, as they lack health insurance. Should insurance be available, then providers must still identify specialists willing to take specific insurances and work with people experiencing homelessness. Effective providers will identify specialists in their local communities and seek to build relationships that will facilitate referrals. Given the lack of access to transportation in this population, it is important to set an expectation that a missed appointment does not mean that the patient does not want or need care, and that specialists may need to be flexible regarding missed appointments with people in this population. Individual Considerations A. Pediatrics/minors: According to data published by the National Association for the Education of Homeless Children and Youth (NAEHCY, www. naehcy. org), there are between 1. 6 and 1. 7 million children 42 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
experiencing homelessness every year in the United States. The majority of these children have been physically and/or sexually abused. Providers are strongly encouraged to review related content on the NAEHCY website. Additionally, providers should make contact with their community YMCA/YWCA resources to develop a referral plan should a homeless minor present for care. Please remember that homeless youth are likely to be extremely mistrustful of medical, social work, and law enforcement professionals. B. Pregnancy: All pregnant women who are experiencing homeless and present for care should be seen by a social worker before leaving the site. In cases where abuse is suspected, law enforcement must be notified. Elderly: All people older than 60 years of age who are experiencing homeless and present for care should be seen by a social worker before leaving the site. In cases where abuse is suspected, law enforcement must be notified. Resources Federal HUD exchange: Homelessness assistance: www. hudexchange. info National Coalition to End Homelessness: www. nationalhomeless. org National Health Care for the Homeless Council: www. nhchc. org State Providers should use the Internet search engine of choice to locate emergency shelters and care for people experiencing homelessness in their locale. There is no centralized database of state/local shelters. Many larger shelters will have a list of local places for people to find food and community assistance, and this information can be invaluable for providers to keep on hand. Classic Texts King, T. E, Jr., & Wheeler, M. E. (Eds. ). (2007). Medical management of vulnerable and underserved populations. New York, NY: Mc Graw-Hill. O'Connell, J. J. (Ed. ). (2004). The health care of homeless persons. Boston, MA: Boston Healthcare for the Homeless Program. Obesity Angelito Tacderas and Bunny Pounds Definition 43 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Obesity is a multifactorial disease with physical, psychological, and social consequences. The body mass index (BMI) is a standard measuring tool. The BMI is calculated by using the formula: Weight in kilograms divided by height in meters squared (weight [kg]/height [m]2). In adults, obesity is defined as a BMI greater than 30 kg/m2. TABLE 2. 1 Childhood Obesity by Percentiles Childhood Obesity Category BMI Definitions by Percentiles Underweight Less than the fifth percentile Healthy weight Fifth to less than 85th percentile Overweight 85th to less than 95th percentile Obese Equal to or greater than 95th percentile BMI, body mass index. TABLE 2. 2 Adult Obesity by BMI Classification of Adult Obesity by BMI BMI (kg/m2) Underweight <18. 5 Normal 18. 5-24. 9 Overweight (preobese) 25. 0-29. 9 Obesity 30. 0-34. 9 Severely obese >40. 0 Morbidly obese 40. 0-49. 9 Super obese >50. 0 Super-super obese (SSO) ≥60. 0 BMI, body mass index. B. The BMI for children is calculated the same way as for adults, but is interpreted using age-and gender-specific percentages (BMI-for-age) clinical 44 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
charts (see Tables 2. 1 and 2. 2). The Centers for Disease Control and Prevention (CDC) defines childhood obesity by percentiles. Charts for children are available on the CDC website at www. cdc. gov/growthcharts Incidence A. More than two thirds of the U. S. population is overweight (BMI of 27) and of those, one third of the adults are obese, along with 17% of U. S. children (ages 2-19 years). Obesity rates cross all groups in society, regardless of age, sex, race, ethnicity, socioeconomic status, educational level, or geographic group. Pathogenesis Numerous factors contribute to the development of obesity, including: A. Imbalance between energy intake and energy output B. Genetics (40%-70% presumed explanation) C. Environmental factors D. Drug-induced obesity 1. Antidepressants (amitriptyline, doxepin, imipramine, mirtazapine, nortriptyline, paroxetine, phenelzine) 2. Antihistamines (cyproheptadine) 3. Antipsychotics (clozapine, haloperidol, olanzapine, quetiapine, risperidone, thioridazine) 4. Antidiabetics (insulin, sulfonylureas, thiazolidinediones) 5. Anticonvulsants (sodium valproate, carbamazepine, gabapentin) 6. Steroids (contraceptives, glucocorticoids, progestational steroids) 7. Beta-or alpha-adrenergic blockers (propranolol, doxazosin) E. Sleep disturbance-induced obesity Predisposing Factors A. Consuming too many calories/high-fat diet B. Poor dietary choices C. Readily available food sources, especially fast foods D. Lack of exercise/sedentary lifestyle E. Decreased/elimination of physical education requirements in public schools F. Television, computer, and hand-held game use more than 3 hours a day 45 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Increased leisure time H. Lack of funding and planning for community parks and recreation areas I. Ethnic background: African American, Hispanic J. Family history of obesity K. Poverty L. Insomnia, difficulty staying asleep and frequent wakefulness Common Complaints A. Difficulties with activities of daily living (ADLs) or functional impairment B. Lack of interest/inability to tolerate exercise C. Shortness of breath and/or asthma exacerbations D. Difficulty with personal hygiene E. Urinary incontinence F. Desire to lose weight Other Signs and Symptoms A. Obstructive sleep apnea (OSA) B. Increased asthma symptoms C. Infertility/Polycystic ovary syndrome (PCOS) D. Symptoms associated with cholelithiasis E. Hypertension F. Early sexual maturity in girls G. Joint pain (OA) Subjective Data A. Review the onset of weight gain and duration of obesity. Identify when the patient first noticed the weight gain. B. Ask the patient about other symptoms secondary to obesity. C. Review full medical history. D. Review medications, including over-the-counter (OTC) herbals and diet products. E. Review the patient's previous history of weight-loss attempts. F. Assess activities of daily living (ADLs) and functional limitations and the presence of exercise intolerance. G. Elicit history of sleep disorders (i. e., snoring and obstruction, sleep 46 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
apnea). H. Review 24-hour dietary recall. Review the patient's normal average meals per day, including snacks. I. Review consumption of high-calorie drinks and alcohol intake. J. Assess for history of binge eating, purging, night eating syndrome, lack of satiety, food-seeking behaviors, and other abnormal feeding habits. K. Assess for depression. L. Assess for readiness and commitment for weight loss. People who voluntarily enroll in a weight-loss program generally lose weight. M. Ask the patient to describe his or her activity level, exercise routine, and daily activity (work activity). N. Ask about screen time. O. Ask about family history of obesity. P. Ask about possible biopsychosocial and behavioral risk factors for weight gain such as starting a new medication, change in occupation or marital status, recent illness, pregnancy, menopause, stressful events, or smoking cessation. Physical Examination A. Check pulse, respirations, and blood pressure: Supine, sitting, and standing B. Measurements: 1. Determine height and weight to calculate BMI. 2. Measure waist and hip circumferences to calculate the waist-to-hip circumference ratio. The waist-to-hip ratio is the strongest anthropometric measure that is associated with myocardial infarction risk and is a better predictor than BMI. A waist-to-hip ratio that is greater than 0. 8% usually has some form of premetabolic syndrome or insulin resistance. C. Inspect 1. Observe the overall appearance and note body fat distribution. 2. Examine the skin. 3. Mouth and teeth: Assess dental enamel for signs of purging. D. Auscultate 1. Heart 2. Lungs 3. Carotid arteries 47 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
4. Abdomen E. Palpate 1. Neck and thyroid 2. Extremities—noting edema 3. Abdomen for masses, tenderness, rebound tenderness Diagnostic Tests A. Thyroid function B. Lipid panel C. Liver enzymes D. Complete blood count E. 25-hydroxy vitamin D test F. Pregnancy test G. Fasting blood sugar/3-hour glucose tolerance test (GTT) H. Consider fasting insulin level I. Sleep study (if indicated) J. Consider genetic testing K. Nocturnal hypoxemia study Differential Diagnoses A. Obesity B. Pseudo tumor cerebri C. Binge eating D. Genetic syndrome (e. g., Prader-Willi syndrome) E. Cushing's syndrome F. Diabetes mellitus G. Insulin resistance syndrome H. Primary pulmonary hypertension Plan Manage obesity as a chronic relapsing disease, including the comanagement of other diseases secondary to obesity (i. e., diabetes, hypertension). A. General interventions 1. Treat any underlying cause of obesity. 2. Reinforce the positive impact that weight loss measures (diet, exercise) can have and the overall health benefits of weight loss. Weight loss of 48 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
even 5% to 15% can provide a significant reduction in obesity-related complications. 3. Identify and monitor any cardiovascular complications. 4. Behavior modification: Intensive behavior therapy has been shown to lead to better success with weight loss and sustainable weight loss for longer periods of time. Behavior therapy includes weekly meetings with health care professionals for at least 6 to 8 weeks. a. Dietary plan i. Consume 500 to 1,000 fewer calories per day for 1-to 2-pound-per-week weight loss. ii. Most diets have good short-term efficacy but limited sustainability. iii. Diets shown to be effective include portion control, low-fat, Mediterranean, low-carbohydrate, low glycemic index, and commercial weight-loss diets. iv. Increase water intake, particularly drinking 500 m L of water before meals v. Protein-dense and high fiber foods increase satiety with less calories b. Exercise: Both children and adults i. Approximately 150 minutes of moderate intensity exercise is recommended per week for adults, 155 to 180 minutes per week for children. ii. Multiple short sessions (four 10-minute sessions per day, 5 days per week) may have the same benefit as fewer longer sessions (one 40-minute session, 5 days per week). iii. Walking 30 minutes per day has been shown to prevent weight gain; higher amounts of exercise promote weight loss. iv. The combination of exercise and diet is more effective than either alone. c. Wide range of benefits of exercise and weight loss i. Helps lower blood pressure ii. Improves cholesterol count iii. Helps lower hemoglobin A1c in diabetes iv. Helps strengthen bones v. Promotes weight loss 49 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
vi. Improves depression vii. Boosts immune system viii. Reduces stress ix. Improves sense of well-being x. Believed to be a major driving force in lifestyle change xi. Improves joint pain d. Obtain counseling on stimulus control, goal setting, self-monitoring, and contracts that reward behaviors. e. Contraindication to exercise: There are several contraindications for beginning exercise: i. Individuals with recent myocardial infarction (2 weeks) ii. Unstable angina iii. Severe aortic stenosis iv. Decompensated congestive heart failure (low ejection fraction) v. Left ventricular outflow obstruction vi. Uncontrolled dysrhythmias vii. Uncontrolled diabetes or diabetic complications viii. Uncontrolled hypertension ix. Uncontrolled respiratory conditions such as asthma and COPD B. Patient teaching on obesity treatment modalities 1. Advise the patient to keep a food diary to identify food triggers and for accountability. Patients who maintain a food diary have been shown to have as much as 90% more weight loss than those who do not keep a diary. 2. Counsel patients about pharmaceutical therapy drug side effects and the lack of long-term safety data. Stress to the patient the temporary nature of the weight-loss medication. Typical weight loss is modest, less than 5 kg (10-11 lb) at 1 year. 3. Teach patients how to read food labels. C. Pharmaceutical therapy 1. After an adequate trial (minimum of 6 months) of diet and exercise therapy, consider adding pharmaceutical therapy. Pharmacological intervention is not covered by some health plans. State statutes should be considered before prescribing weight-control products. 50 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Studies lack evidence to support whether one drug is more efficacious than another; the literature does not support the use of combination therapy for increased weight loss. 3. The choice of a pharmaceutical agent depends on the side-effect profile of the drug and tolerance of the side effects. 4. The Food and Drug Administration (FDA) has not approved any weight-loss medication for use beyond 2 years in adults. Appetite suppressants that are FDA approved: a. Qsymia, phentermine, diethylpropion, benz phetamine, and phendimetrazine are approved for short-term (12 weeks) use. b. Sibutramine (Meridia, Reductil) is FDA approved for 1-year use. c. Orlistat (Xenical) is FDA approved for 2-year use. 5. Appetite suppressants a. Qsymia (phentermine and topiramate extended release). Start with 3. 75/23 mg extended release per day for initial BMI greater than 30 kg/m2, or BMI greater than 27 kg/m2 in the presence of risk factors. May gradually increase dose to 15/92 mg. i. Avoid evening dose. ii. Not to be taken by adolescents younger than 16 years of age. iii. Avoid in pregnancy. iv. Monitor for hypersensitivity to phentermine and topamax. v. These drugs are not recommended in the presence of hypertension, hyperthyroidism, cardiovascular disease, and drug or alcohol abuse. vi. Do not use if a history of glaucoma or hyperthyroidism is present, or within 14 days of use of monoamine oxidase inhibitors (MAOIs). b. Phentermine (Adipex-P) 37. 5 mg orally once daily before or 1 to 2 hours after breakfast, or 18. 75 mg one to two times per day for initial BMI greater than 30 kg/m2, or BMI greater than 27 kg/m2 in the presence of risk factors such as controlled elevated blood pressure, diabetes, and high cholesterol. i. Avoid late-evening dosing. ii. Not recommended for children younger than 16 years. iii. Not recommended in the presence of hypertension, 51 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
hyperthyroidism, cardiovascular disease, and drug or alcohol abuse. iv. Do not prescribe during or within 14 days of MAOIs. c. Benzphetamine (Didrex) 25 to 50 mg orally initially in the midmorning or midafternoon. Increase if needed to 25 to 50 mg one to three times a day. i. Not recommended in children or adolescents. ii. Not recommended in the presence of hypertension, hyperthyroidism, cardiovascular disease, and drug or alcohol abuse. iii. Not to be prescribed during or within 14 days of MAOIs. iv. Pregnancy category X: Known to cause fetal abnormalities or toxicity in animal and human studies. d. Diethylpropion (Tenuate) 25 mg 1 tablet every 8 hours, 1 hour before meals. May add one additional dose for night hunger. Half-life of 4 to 6 hours. i. Avoid late-evening dosing. ii. Not recommended for children younger than 16 years. iii. Not recommended in the presence of hypertension, hyperthyroidism, cardiovascular disease, and drug or alcohol abuse. iv. Do not prescribe during or within 14 days of MAOIs. e. Phendimetrazine (Bontril PDM) 35 mg orally two or three times daily 1 hour before meals. May reduce to 17. 5 mg/dose. Maximum dose 210 mg/d in three evenly divided doses. Also available in slow-release 105 mg in the morning 30 to 60 minutes before breakfast. i. Not recommended in children or adolescents. ii. Not recommended in the presence of hypertension, hyperthyroidism, cardiovascular disease, and drug or alcohol abuse. iii. Not to be prescribed during or within 14 days of MAOIs. f. Sibutramine (Meridia) 10 mg orally once a day. After 4 weeks, may titrate to 15 mg once a day. i. Not recommended in children or adolescents younger than 16 years. ii. FDA approved for use up to 2 years. 52 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
iii. Not recommended for nursing mothers. iv. Blood pressure and pulse should be monitored regularly during therapy. Consider discontinuing sibutramine with sustained blood pressure and pulse increases. v. Not recommended with severe renal or hepatic dysfunction or with a history of narrow-angle glaucoma. 6. Lipase inhibitor a. Orlistat (Xenical) for use with a low-fat diet. Recommend 30% of calories spread over three main meals. i. Take one 120-mg capsule orally during or up to 1 hour after main meals up to three times per day. ii. If a meal is missed or had no fat, skip dosage. iii. May decrease absorption of fat-soluble vitamins and beta-carotene. iv. Orlistat carries an FDA warning regarding safety and efficacy for use in patients younger than 12 years and in pregnancy and lactation as it interferes with the absorption of fat-soluble vitamins. v. Supplement diet with a multivitamin. vi. FDA approved for up to 2 years' use in adults. vii. Gastrointestinal side effects include fatty/oily stools, oily spotting, flatus with discharge, fecal urgency, and fecal incontinence. viii. Contraindicated in chronic malabsorption syndrome and cholestasis. ix. May affect doses for antidiabetic medications. x. Monitor warfarin and cyclosporine levels. b. Alli, a lipase inhibitor, is the only FDA-approved OTC weight-loss product. 7. Glucagon-like peptide-1 (GLP-1) receptor agonist a. Saxenda subcutaneous was FDA approved for chronic weight management as an adjunct to a reduced-calorie diet and increased physical exercise in December of 2014 for use in adults with BMI of 30 kg/m2 or greater or 27 kg/m2 or greater with at least one weight-related comorbidity. i. Start with 0. 6 mg once daily for a week; may increase by 0. 6 53 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
mg daily at weekly intervals up to 3 mg once daily. ii. Delay dose increase if tolerance is an issue. iii. If 3 mg once daily is not tolerated, discontinue drug. Efficacy has not been established for lower doses. iv. Evaluate at 16 weeks of therapy; discontinue if at least 4% of baseline body weight loss has not been achieved. v. Pregnancy category X; contraindicated in patients with multiple endocrine neoplasia syndrome type 2 (MEN2). 8. Off-label medications used for obesity: These medications are not FDA approved for weight loss. The patient should be counseled regarding this and use at discretion. a. Metformin (Glucophage) is used to decrease central adiposity in weight loss, lower insulin levels, and slow down the process of gluconeogenesis. i. Start Metformin 500 mg at the evening meal. The dosage can be increased by 500 mg/wk in divided doses up to the maximum of 2,000 mg/d. ii. Titrate slowly because of the gastrointestinal side effects. iii. Check a metabolic panel before and every 3 to 6 months to evaluate for lactic acidosis. iv. Metformin is contraindicated in patients with renal impairment; assess renal function before instituting metformin and monitor regularly. v. Metformin must be stopped before any procedure with radiographic dye. vi. May be used in children with central adiposity, especially those with signs of premetabolic syndrome. vii. May be used on a patient with a waist-to-hip ratio greater than 0. 8%. b. Topiramate (Topamax) is used to treat seizures and several types of headache. In small doses, it can be used alone or as adjunct with phentermine to suppress appetite longer. Be familiar with the risks associated with the use of Topamax. i. If used alone, the drug may start at 25 mg every day in the morning. Increase up to two or three times a day. Topamax has a long half-life of 19 to 25 hours. 54 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
ii. May be used as adjunct with phentermine. Start patient at 18. 75 mg of phentermine and 12. 5 mg of Topamax. Then gradually increase the dose to 37. 5 mg of phentermine and 25 mg of Topamax. iii. Always give the phentermine in the morning, preferably 30 minutes before meals. Topamax should be dosed in the afternoon or evening. iv. Phentermine (Adipex-P) 37. 5 mg orally once daily before or 1 to 2 hours after breakfast, or 18. 75 mg one to two times per day for initial BMI greater than 30 kg/m2, or BMI greater than 27 kg/m2 in the presence of risk factors such as controlled elevated blood pressure, diabetes, or high cholesterol. v. Avoid late evening dosing. vi. Not recommended for children younger than 16 years. vii. Not recommended in the presence of hypertension, hyperthyroidism, cardiovascular disease, and drug or alcohol abuse. viii. Do not prescribe during or within 14 days of MAOIs. Follow-Up A. Reevaluate the patient every week for 6 to 8 weeks, then monthly if pharmaceutical therapy is used until goal is achieved. B. Maintain the recommended schedule for comorbid conditions. C. If the patient is a candidate for bariatric surgery, follow recommended pretreatment/reauthorization guidelines required by the payer and bariatric center. Consultation/Referral A. Refer to a nutritionist/registered dietitian for consultation. B. Consider a referral to a bariatric center/surgical consultation and evaluation of bariatric surgery. C. Consider a psychology consultation (may be required before bariatric surgery). D. If the family is eligible, refer to the Women, Infant, and Children (WIC) program. Referral to some commercial weight loss programs may be 55 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
beneficial. See www. fns. usda. gov/wic/women-infants-and-children-wic Individual Considerations A. Pregnancy 1. Benzphetamine (Didrex) is a category X drug. Avoid use during pregnancy. 2. Weight loss should never be a goal during pregnancy. 3. Counsel patients regarding appropriate weight gain and healthy eating habits during pregnancy. B. Pediatrics 1. The cornerstone for management of obesity in children is modification of dietary and exercise habits. 2. The first step for overweight children older than 2 years is maintenance of baseline weight if there is no secondary complication of obesity (i. e., diabetes and hypertension). Any dietary modification must ensure adequate nutrients for the growing child (see chapter on pediatrics). 3. The weight-loss goal should be approximately 1 pound per month for a BMI below the 85th percentile. 4. Decrease sedentary behaviors (i. e., watching TV, surfing the Internet, and playing video games). 5. Increase physical activity and incorporate exercise into family time. 6. Long-term safety and effectiveness of low-carbohydrate, high-protein diets, such as the Atkins diet, have not been adequately studied in children. 7. Use of pharmacotherapies in children and adolescents requires further research, unless previously noted under drug therapies. C. Geriatrics 1. All adults should avoid inactivity. Some exercise is better than none. Any dietary modification must ensure adequate nutrients for the aging adult (refer to geriatric chapter). Resources American Heart Association: www. heart. org/HEARTORG American Heart Association Go Red for Women: https://www. goredforwomen. org Centers for Disease Control and Prevention (CDC). Overweight and obesity: www. cdc. gov/obesity/index. html 56 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Exercise: A guide from the National Institute on Aging: www. nia. nih. gov/Health Information/Publications/Exercise Guide National Institutes of Health (NIH) Senior Health: Exercise and physical activity for older adults: nihseniorhealth. gov/exerciseforolderadults/healthbenefits/01. html President's Council on Fitness, Sports & Nutrition: www. fitness. gov The Obesity Society: www. obesity. org/home SHAPE America, Society for Health and Physical Educators: http://www. shapeamerica. org/ Post-Bariatric Surgery Long-Term Follow-Up Cheryl A. Glass and Bunny Pounds Definition A. The number of obese people in the United States has more than doubled in the past 50 years, with severe obesity increasing more rapidly than nonsevere obesity. The traditional management of obesity, a combination of diet, exercise, and behavioral modification, often results in moderate success with limited sustainability. Increasing prevalence of obesity combined with improvements in surgical weight-loss procedures and improved insurance coverage has resulted in exponential growth of the number of people opting for surgical management. Patients who undergo surgical weight-loss procedures have unique health care needs and require lifelong follow-up. Although the bariatric treatment team is the ideal source of follow-up and monitoring, primary care providers can play a critical role and need to be cognizant of the unique needs of this population. B. The primary mechanism of action for surgical weight-loss procedures is either restriction or a combination of restriction and malabsorption (see Table 2. 3). All procedures have some form of restriction that reduces the volume of food that can be ingested. Restriction can occur by means of a physical barrier such as a laparoscopic adjustable gastric band (LAGB; see Figure 2. 1) or by removing a portion of the digestive tract such as with the gastric sleeve (GS; see Figure 2. 2). Malabsorptive procedures cause weight loss by changing the way nutrients are absorbed, which is accomplished by removing portions of the stomach and/or small intestine and sometimes by rerouting the digestive tract (Roux-en-Y; see Figure 2. 3). The success of surgical weight loss is defined by initial weight loss, maintenance of weight loss, and prevention of complications. Success is directly related to the aftercare a 57 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
person receives. TABLE 2. 3 Surgical Weight Loss Procedures and Mechanism of Action Incidence A. According to the 2009 to 2010 National Health and Nutrition Examination Survey, more than one third (35. 7%) of the adults in the United States are obese. The American Society for Metabolic and Bariatric Surgery (ASMBS) reports an estimated 200,000 weight-loss operations were performed in 2009. About 90% of surgical weight-loss procedures are performed laparoscopically now. The most common procedures performed today include the gastric bypass, gastric sleeve, adjustable gastric band, and biliopancreatic diversion with duodenal switch. Pathogenesis 58 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. The pathogenesis of obesity is reviewed under “Obesity” in this chapter. Significant improvements in the safety of surgical weight-loss procedures in recent years result from improved surgical techniques, accreditation, and the use of laparoscopy. The overall mortality rate is about 0. 1% and the risk of major complications about 4. 3%. The incidences of complications vary by surgical procedure. Postoperative complications may occur immediately or may occur many years after surgery. Nutritional deficiencies are by far the most common long-term complication. Predisposing Factors A. Higher body mass index (BMI) B. Noncompliance with bariatric diet and exercise C. Lack of follow-up with health care professionals D. Obesity-related health problems: 1. Sleep apnea 2. Diabetes 3. Arthritis 4. Hypertension 5. GERD E. Complexity and type of surgery Common Complaints Functional and Nutritional A. Dumping syndrome usually occurs within 30 minutes of eating high fat/high sugar foods and involves flushing, sweating, lightheadedness, tachycardia, palpitations, nausea, diarrhea, cramping. B. Hypoglycemia occurs 1 to 3 hours after eating high-carb meals and involves shakiness, anxiety, sweating, chills, clamminess, confusion, rapid heart rate, dizziness, hunger, and nausea. C. New or exacerbated reflux is more common with a gastric sleeve. D. Vitamin deficiencies or toxicities. Refer to Table 2. 4. 1. Most common a. Iron deficiency—fatigue, lethargy, pica, food cravings b. Iron toxicity—gastrointestinal irritation, nausea, vomiting, indigestion, constipation, diarrhea 59 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
c. Protein deficiency—weakness, decreased muscle mass, brittle hair, generalized edema FIGURE 2. 1 Laparoscopic adjustable gastric band (LAGB). Source: Reprinted with permission from the American Society of Metabolic and Bariatric Surgery. Copyright 2013, all rights reserved. 60 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
FIGURE 2. 2 Sleeve bypass procedure with stomach resection. Source: Reprinted with permission from Smith, Schauer, and Nguyen (2008). 61 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
FIGURE 2. 3 (A, B) Roux-en-Y gastric bypass (RYGB). Source: Reprinted with permission from the American Society of Metabolic and Bariatric Surgery. Copyright 2013, all rights reserved. d. Folate deficiency—fatigue, palpitations, sore tongue, diarrhea, restless legs e. Calcium deficiency—usually silent, hyperpara thryoidism f. Calcium toxicity—constipation, nausea, vomiting, dry mouth, loss of appetite g. Vitamin D deficiency—spasms/twitching of eyes, burning in mouth, sweating, weakness h. Vitamin B12 deficiency—fatigue, burning lips/mouth, rapid heart rate, palpitations, sore tongue, weakness, mood changes, neurologic changes 2. Less common a. Thiamine (B1) deficiency—usually in first 3 months postop, often a result of vomiting, blurred or double vision, difficulty swallowing, rapid heart rate, fatigue, confusion, memory loss, burning feet, leg weakness, amnesia b. Zinc deficiency—loss of smell, diminished sense of taste, poor wound healing, skin rashes or roughness, hair loss, poor appetite, lethargy, grooved or deformed nails, canker sores 62 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
TABLE 2. 4 Most Common Nutrient Deficiencies c. Magnesium deficiency—hyperexcitability, cramps, tremors, fasciculation, spasms, fatigue, loss of appetite, apathy, confusion, insomnia, irritability, poor memory d. Selenium deficiency (very rare)—signs of hypothyroidism (selenium is necessary for conversion of thyroxine into its active form, triiodothyronine) e. Selenium toxicity (rare)—hair loss, abnormal nails, dermatitis, peripheral neuropathy, nausea, diarrhea, fatigue, irritability, garlic 63 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
odor of breath E. Surgical complications 1. Short term a. Anastomic leak—less than 4. 4% with Roux-en-Y gastric bypass (RYGB), but has a mortality of up to 30% when it does happen; presenting symptom is tachycardia b. Bleeding—less than 4% after RYGB, 0. 1% after LAGB c. Wound infection—2. 9% of laparoscopic cases, 6. 6% of open cases d. Thromboembolism—deep vein thrombosis up to 1. 3%, pulmonary embolism up to 1. 1% after RYGB, lower with LAGB e. Anastomotic strictures—2% to 16% after RYGB, typically within first 3 months, nausea and/or vomiting 2. Long term a. Band slippage—15% to 20% of LAGB patients—abdominal pain, acid reflux, regurgitation, or dysphagia b. Band erosion—up to 4% of LAGB patients—may be asymptomatic, abdominal pain, gastrointestinal bleeding, weight loss, abdominal sepsis c. Intestinal obstruction—4. 4% after RYGB, caused by internal hernias, adhesions, and anastomotic stenosis—colicky central abdominal pain, nausea, vomiting, abdominal distention, absolute constipation d. Hepatobiliary complications—rapid weight loss is associated with gallstone formation; 13% to 36% of patients develop this within 6 months of surgery e. Gastrointestinal bleeding—rare and usually caused by ulceration f. Marginal ulcers—0. 7% to 5. 1% after RYGB—abdominal pain, vomiting, bleeding, or anemia Other Signs and Symptoms A. Expected weight loss 1. LAGB—Initial loss of 40% to 50% of excess body weight in 3 to 5 years. Expected maintenance < 50%. 2. GS—Initial loss of >50% of excess body weight in 3 to 5 years. Expected maintenance > 50%. 3. RYGB—Initial loss of 60% to 80% of excess body weight in 1 year. 64 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Expected maintenance > 50%. 4. Biliopancreatic diversion with duodenal switch (BPD/DS)—Initial loss of 60% to 70% of excess body weight in 1 year. Expected maintenance of 60% to 70%. B. Weight regain of up to 20 pounds is common after 2 years. C. Constipation and/or diarrhea may occur, depending on the procedure. D. Weight loss of less than 25% of excess body weight is considered a surgical failure and may be revised. E. Even if weight loss is adequate, patients may express disappointment and/or depression related to rate or amount of weight lost. F. Nausea and vomiting after LAGB may indicate need for band adjustment. Subjective Data A. Review onset and duration of symptoms. B. Elicit the date of surgery, type of surgery, and any reoperations or complications. C. Review previous highest weight and amount of excess weight lost since surgery. D. Evaluate the location and level of pain/discomfort. E. Evaluate the overall psychosocial changes since surgery. F. Review a 24-hour food recall, choices of healthy foods, skipping meals, food aversion (e. g., red meat), and intolerance. G. Review medications and supplement use Physical Examination A. Check height, weight, waist and hip circumference. Calculate body mass index (BMI), waist/hip ratio, pulse, respirations, and blood pressure. Check temperature if infection is suspected. B. Inspect 1. Examine the skin, evaluate surgical site(s), evaluate redness and tenderness. 2. Oral/dental examination. 3. Evaluate for dehydration. 4. Eye examination: Evaluate eye movement (thiamine deficiency). 5. Evaluate gait. 6. General overview of personal presence and affect. 65 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |