Family Practice Nursing Commons^™

Dental Caries Screening For Food Insecure Children, John Joseph Kane

Doctor of Nursing Practice

Background. Dental caries is the most common childhood disease, disproportionally impacting minorities, and socio-economically disadvantaged children. Food insecurity impacts 23.6% of children in Texas; the majority being African American and Hispanic. Food insecurity screening rates are abysmal. Dental caries and food insecurity are significantly correlated and likely syndemic. Purpose. Implement oral examination and the “Hunger Vital Sign” screening tool in detecting dental caries and food insecurity at an urban pediatric urgent care center. Evidence. Food insecure children experience adverse health outcomes, impaired long-term health outcomes, developmental and cognitive delays, psychosocial delays, and oral health deficiencies including caries and malabsorption of …

Program Development And Expansion Of A Clinician-Driven Wound Care Program At An Outpatient Wound Care Center, Zhenhai Niu

Doctor of Nursing Practice

Problem. Patients with chronic wounds often present with additional physical and emotional problems because healing of chronic wounds may require months to resolve. Practitioners develop treatment plans based on their own training and clinical expertise, but unfortunately, there are no universal guidelines to inform the management of chronic wounds. Expanding multi-factorial assessments and interventions could improve patient outcomes. The purpose of this project was to implement a wound care protocol for outpatient wound care clients based on a nutritional and psychological self-assessment. Methods. A patient-completed checklist, done on arrival to the clinic, triggered clinician-driven protocol interventions addressing mental health and …

Preserving The Force: A Quality Improvement Project To Reduce The Risk Of Opioid Use Disorder In The Military, Lecreshia S. Shields

Doctor of Nursing Practice

Military service members incur combat and noncombat related injuries which may lead to acute or chronic pain. Treatment of these conditions with opioids may place them at risk for opioid use disorder (OUD). Opioid related overdoses among the military community increased by 50% from 2010 to 2019. The Sole Provider Program (SPP) is recommended to address the risks of OUD among Veterans receiving care at military installations. The goal of this evidence-based project was to ensure that all persons who receive opioid prescriptions at a military facility were evaluated for inclusion into a SPP and prescribed naloxone. Objectives included: 1) …

An Interprofessional Prediabetes And Diabetes Self--Management Education Quality Improvement Project Among Vulnerable Populations At A Tuberculosis Hospital, Robert Saul Castro Natal

Doctor of Nursing Practice

Background. Patients greatly benefit from diabetes self-management education (DSME) as it boosts knowledge and self-efficacy, decreases body weight, fasting blood sugar, and hemoglobin A₁C levels, and improves overall health outcomes in a cost-effective manner. Unfortunately, many individuals with prediabetes and diabetes who qualify for DSMEs do not attend these classes nor receive sufficient prediabetes and diabetes support elsewhere to attain guideline recommended metrics. However, individuals from vulnerable populations and without DSME education experience disproportionate diabetes-related complications worsening health outcomes. Aims: Increase general prediabetes and diabetes knowledge, facilitate behavior change, improve glycemic, metabolic, and lipid values, and increase …

Addressing Obstacles In Following Prescribed Medication Regimens In Patients With Type 2 Diabetes Mellitus, Cristina Sarro

Doctor of Nursing Practice

Background. Type 2 diabetes is the ninth leading cause of death in the United States. Micro/macro vascular complications are common in diabetes. Purpose. To implement an evidence-based protocol addressing obstacles for patients with type 2 diabetes in following their prescribed medication regimens to reduce glycosylated hemoglobin levels. Evidence. Failure to follow treatment plans increases diabetes complications. Perceptions and complexities of treatment plans, side effects of therapies, and cost contribute to patients not taking their medications as prescribed. Goals. To increase the number of patients with type 2 diabetes who follow their prescribed medication regimen and reach their targeted glycosylated hemoglobin. …

Optimizing Diabetes Self-Management Using Continuous Glucose Monitoring And Improving The Transition Of Care For Adult Patients Discharged From The Hospital, Nikki Rose Angeles

Doctor of Nursing Practice

Background: Diabetes mellitus is a chronic medical condition that affects more than 34 million Americans (Centers for Disease Control and Prevention, 2020). The financial impact of diabetes is significant. Americans spend $327 billion on direct medical costs to treat the disease and its associated complications (American Diabetes Association, 2018). The management of diabetes requires a multidisciplinary approach that involves healthcare providers, diabetes self-management support resources, and a high level of commitment from the patient. Patients with diabetes discharged from the hospital often receive fragmented and inconsistent information about managing their health issues. As they transition from hospital to home, their …

Patient Care Management Of Hypertension Through Improving Follow-Up And Reducing Missed Appointments In A Primary Care Clinic: A Qi Project, Victoria Idubor

Doctor of Nursing Practice

Background. Missed follow-up appointments constitute significant problems clinics and health centers face nationwide. A significant portion of primary care providers’ patients will require follow-up appointments to manage their chronic illnesses. About 20 to 40% of patients seen at this clinic have a history of hypertension. Uncontrolled hypertension has been shown to increase the risk of certain cardiovascular disease events and mortality. Follow-up appointments are crucial for patients with hypertension to monitor for more life-threatening signs and manage their overall care. Purpose. The purpose of this project is to improve the timely management of care for patients with hypertension …

Implementation Of Comprehensive Footcare Program Within Primary Care, Moses Ademola-Ojo

Doctor of Nursing Practice

The incidence of diabetes and its complications is escalating, with over 34.2 million adults in the US having diabetes (CDC, 2020). Despite a decade-long decline in lower-extremity amputations, the incidence is growing (Nichols, 2019), with little emphasis on preventive foot evaluations within primary care. The purpose of this project was the implementation of a multi-faceted program aimed at early identification of lower extremity complications with focused patient education, improved assessment, and documentation, and referral for specialty care. The intervention process included staff training, patient education, foot examination, monofilament testing, pinprick tests, ankle reflex, and tuning fork test. Foot abnormality, loss …

Formalizing An Obstetrical Program For High-Risk Patients: Focus—Diabetes During Pregnancy, Valeria Jimenez

Doctor of Nursing Practice

Within the last 10 years, the number of pregnant women with gestational diabetes increased 56%, and the number of women with Type 1 or Type 2 diabetes before pregnancy increased 37% (CDC, 2018). The management of a pregnancy complicated by diabetes involves a multidisciplinary approach, medical nutrition therapy, glycemic control, and occasionally, pharmacological therapies (Nurain et al., 2019). In 2017, the total cost of diabetes in the United States was $237 billion (Riddle & Herman, 2018). The purpose of this DNP project was to standardize a Federally Qualified Health Care’s (FQHC) High-Risk Obstetrical (OB) Initiative, which attempted to provide in-person …

Formalizing A High-Risk Obstetrical Initiative: Focus—Hypertensive Disorders, Elena Vulgamott Rodrigue

Doctor of Nursing Practice

Background: Hypertensive disorders during pregnancy have a detrimental effect on maternal and fetal outcomes, causing low birth weights, preterm births, and stillbirths. During pregnancy, hypertensive disorders affect up to 13% of all pregnancies and make up 10% of all maternal mortality in the United States (Centers for Disease Control and Prevention [CDC], 2019). Purpose: The purpose of this DNP project was to implement and standardize a high-risk obstetrical initiative for hypertensive mothers. Summary of Evidence: Data suggest that increased education and increased surveillance for high-risk obstetric patients decreases the need for obstetric services and decreases the evolution of hypertensive …

Expansion Of A Comprehensive And Standardized Well-Woman Exam Program In A University-Based Clinic, Gabriela Trevino

Doctor of Nursing Practice

Background. Well-woman exams are an opportunity for women to receive focused screening, counseling, education, and care from a healthcare provider. Studies have found that 68% of women received well-woman exams between 2010 and 2016. During COVID-19 well-woman exams decreased by 80% in the United States. Standardized, comprehensive exams facilitate identification of the need for lifesaving care. Objective(s). The purpose of this quality improvement project was to expand a comprehensive and standardized well-woman exam program in a university-based clinic. Methods. Processes were implemented to promote well-woman exams, patient comfort measures, and completion of an evidence-based standardized comprehensive exam …

Improving The Early Detection And Management Of Peripheral Artery Disease In Patients With Diabetes Within The Primary Care Setting, Julyssa Amanda Rodriguez

Doctor of Nursing Practice

Background. Diabetes is a significant risk factor for peripheral artery disease. Individuals with diabetes, greater than 50 years of age, having at least one other risk factor should be screened for peripheral artery disease with an ankle brachial index. Purpose. Improve detection and management of peripheral artery disease in persons with diabetes within primary care. Evidence. Individuals with diabetes and peripheral artery disease have an increased risk of adverse cardiac and limb events, impairing the patient’s quality of life and causing long-term disability (Berger & Newman, 2020). Methods. During a 10-week period, these processes were implemented: (a) screening all patients …

A System Intervention Of Tetanus, Diphtheria, And Pertussis Vaccination For Pregnant Women In Primary Care, Tarshera Reyna

Doctor of Nursing Practice

The health care system in the United States has been described as having a deficit in care for women during pregnancy (IOM, 2019), and as a result there has been a resurgence over the last decade in diseases like pertussis, which is a severe respiratory infection that is particularly dangerous for infants less than 3 months of age (Tan & Gerbie, 2013). The primary objective of this project was to implement a Tdap vaccination program and increase the rates of Tdap vaccinations of obstetrical patients at a San Antonio clinic. The intervention included: 1) establishing standing orders for the Tdap …

Hpv Vaccination In Adults 18 Through 45: Reducing Missed Vaccination Opportunities In The Primary Care Setting, Ashley Hernandez

Doctor of Nursing Practice

HPV is the most prevalent sexually transmitted infection in the United States and is linked to six different types of cancer cell development. Prevention of infection from this virus could save hundreds of thousands of lives worldwide. An evidence-based quality improvement project was designed to increase the identification of HPV vaccination opportunities in the adult primary care setting to improve HPV vaccination rates. A protocol and patient eligibility algorithm were developed to align primary care practice with recently updated CDC guidelines. Interventions included clinic staff and provider education, designation of a vaccination champion, a flag within the patient chart to …

Is Anybody Listening?: Factors Affecting Pain Management In Veterans Within An Acute Care Rehab Setting, Laura Oseghae

Doctor of Nursing Practice

Background: In the United States, pain is a widely discussed issue due to the opioid epidemic stemming from a history of pain mismanagement. Clinical guidelines for successful pain management techniques are readily available for providers to incorporate into the individualized patient care plan.

Purpose: The purpose of this project is to improve pain management through implementation of the VA pain management guidelines and improved interdisciplinary team communication.

Objectives: This project aims to decrease the number of patients reporting moderate to severe pain, enhance staff/provider communication, and improve the provider’s overall process for managing pain with an individualized treatment plan.

Interventions: …

Establishing A Structured Mentorship Program For Novice Advanced Practice Registered Nurses In The Veterans Health Care System, Rodney Duckett

Doctor of Nursing Practice

Background. Mentorship is an age-old strategy still widely sought after to increase integration into the workforce. Employers of new APRNs must be aware that newly graduated APRNs are inexperienced. To maximize the employers’ investment, training on proper integration should be a high priority. This Doctor of Nursing Practice (DNP) project addressed this quality improvement issue through the implementation of a structured mentorship program to improve the overall transitioning of newly hired APRNs in the Veterans Health Care System (VHCS). Problem. The VHCS lacks a formalized, structured mentorship program for newly graduated APRNs entering the VA System. Intervention. Seven APRN mentors …

Optimizing Peripheral Neuropathy Management Through Vitamin B12 Screening In Adults With Type Two Diabetes Mellitus Taking Metformin, Jonathan Sidle

Doctor of Nursing Practice

Peripheral neuropathy is a significant co-morbidity for patients with diabetes and as early as 1969, metformin was linked to reductions in vitamin B12, leading to deficiency. Vitamin B12 deficiency causes increased levels of homocysteine and methylmalonyl-CoA which are toxic to the nervous system and therefore can contribute to demyelination. This quality improvement study aimed to optimize the management of peripheral neuropathy symptoms by implementing a process to identify patients with clinical or subclinical vitamin B12 deficiency and initiating replacement therapy. Adult patients presenting for a scheduled office visit with a diagnosis of type two diabetes and are taking metformin or …

Implementation Of Comprehensive Foot Exams In Primary Care: A Quality Improvement Project, Dora Elia Trevino

Doctor of Nursing Practice

The purpose of this quality improvement project was to increase performance and documentation of provider comprehensive foot exams (CFEs) by 50% among patients with Type 2 diabetes (T2DM) in a small clinic in the southwestern United States.

The project leader assessed clinic systems including the electronic health record (EHR) to identify means to increase CFE completion and documentation rate for patients with T2DM being seen for a chronic disease management (CDM) appointment. A process was created to incorporate a hardcopy CFE documentation form into the EHR and create a pop-up care reminder notification system. Staff and the provider were educated …

Patient-Centered Implementation Of Statin Therapy In Patients With Type 2 Diabetes, Giovanna P. Favarato

Doctor of Nursing Practice

Heart disease is the leading cause of morbidity and mortality in Americans with type 2 diabetes mellitus. The American Diabetes Association recommends statins and lifestyle modifications for all patients with type 2 diabetes mellitus for the prevention of atherosclerotic cardiovascular events. A patient-centered approach to primary prevention is encouraged, yet there are no specific instructions regarding implementation. The Statin Choice Decision Aid is a tool designed to facilitate shared decision-making between the patient and the provider in the clinical setting. The 2018 American College of Cardiology/American Heart Association guidelines for the primary prevention of atherosclerotic cardiovascular disease for patients with …

Improving Colorectal Cancer Screening And Testing In A Primary Care Clinic, Leslie Michelle Dubois

Doctor of Nursing Practice

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer-related deaths worldwide (World Health Organization, 2019a). In the United States, CRC was the fourth most common cancer in 2016 (Centers for Disease Control and Prevention, 2019a). The American Cancer Society (2020a) estimated that there will be 147,950 estimated new cases and 53,200 estimated deaths of CRC in the U.S. in 2020. The purpose of the project was to improve CRC screening completion rates and follow up referrals from 27.5% to 35% for adult patients, 50-75 years of age, within a family medicine clinic …

Increasing Adherence To Measurement-Based Depression Management In Primary Care, Renad Saadat

Doctor of Nursing Practice

Background and Review of Literature. Approximately 11 million Americans 18 years or older experienced a severe symptom of depression leading to impairment in 2017. The severity of depressive symptoms is often miscalculated in primary care as measurement-based tools for the diagnosis and ongoing reassessment varies. Purpose. The purpose of the project was to increase provider adherence in using the patient health questionnaire-9 (PHQ-9) for ongoing evaluation of the severity of depressive symptoms in patients with depression at a primary care clinic in San Antonio, Texas. Objectives. The main objective of this Doctor of Nursing Practice project is …

Implementing A Result Notification And Referral System In A Nurse-Led Wellness Center, Christine Bollom

Doctor of Nursing Practice

Cervical and breast cancer screenings reduce the risk of morbidity and mortality for American women. In 2017, about 70% of U.S. women over the age of 21 obtained a Papanicolaou (Pap) test, which screens for cervical cancer. African American women have a cervical cancer screening rate of 74.6% and Hispanic women have a rate of 68.6%. The cervical cancer screening rates decrease to 51% for women who are uninsured (Centers for Disease Control and Prevention, 2017). In the United States, 50% of women older than 40 are current on their screening mammogram. African American women have a screening mammogram rate …

Managing Childhood Obesity In A Primary Care Clinic, Linda Nnajiofor

Doctor of Nursing Practice

Background: Childhood obesity and overweight have increased health burdens on health care systems, and contribute to chronic diseases such as diabetes, heart disease, asthma, and cancer. Childhood obesity is very complex for healthcare providers to manage in primary care settings.

Purpose: To improve childhood overweight and obesity approach and management in a selected primary care practice (Clinic A) in a large east Texas urban community.

Objectives: 1. Increase the percentage of children and adolescents ages 2 to 19 years seen in Clinic A, who received adequate weight management and obesity counseling, to 75%. 2. Increase the number of referrals to …

Genetic Screening For Breast Cancer In The Primary Care Setting, Michael Nick Gomez

Doctor of Nursing Practice

The purpose of this project was to increase adherence to the U.S. Preventive Services Task Force and National Comprehensive Cancer Network guidelines for breast cancer screening and genetic testing.Screening for breast cancer risk factors including genetic testing helps reduce the incidence of breast cancer. A protocol was developed based on national clinical guidelines to increase screening and genetic testing for breast cancer. Provider responsibilities included screening all patients 18 years of age and older for risks factors of breast cancer, referring patients with a significant risk based on the screening for genetic testing and providing referrals for genetic counseling …

Increasing Adult Annual Wellness Visits, Martha Caceres

Doctor of Nursing Practice

The purpose of this quality improvement project was to increase adult annual wellness visits in a high-volume family practice clinic. The significance of an adult annual wellness exam is health maintenance, disease prevention, early disease detection, and management of chronic diseases. Approximately 133 million Americans are diagnosed with at least 1 chronic disease, including cancer, diabetes, and heart disease, and 1 in 4 adults are diagnosed with multiple chronic diseases (Raghupathi & Raghupathi, 2018). In 2011, the Affordable Care Act mandated insurance companies to remove deductibles for preventative health services, relieving the financial burden of out-of-pocket expenses (Borsky et al., …

Using The Adam Questionnaire In Primary Care To Identify Hypoandrogenism In Males Aged 40 Years Or Older, Jeremy Burns

Doctor of Nursing Practice

Testosterone replacement therapy (TRT) has been shown to improve the symptoms of metabolic syndrome by reducing Hemoglobin A1C, belly fat, cholesterol, and blood pressure (Cunningham, 2015). The ultimate goal for testosterone-deficient patients is to have an improved quality of life by starting TRT. This quality improvement project was conducted at a small primary care clinic in South Texas. The project was started by screening 84 male patients ≥ 40 years of age using the Androgen Deficiency in Aging Males (ADAM) questionnaire. The ADAM questionnaire was considered positive for anyone who answered “yes” to 3 or more questions or “yes” to …

Implementation Of A Program To Identify And Assess At-Risk Patients For Peripheral Arterial Disease, Brenna Brothers

Doctor of Nursing Practice

Lower extremity peripheral arterial disease is a condition that affects approximately 200 million people worldwide and 8 million women and men in the United States (McDermott, 2015). Although there are modifiable risk factors associated with peripheral arterial disease, it is believed to be under-diagnosed and under-treated in the general population (McDermott, 2015). The progression of asymptomatic peripheral arterial disease to symptomatic peripheral arterial disease can be reduced with the introduction of medications and therapeutic lifestyle modifications (Itoga et al., 2018). The purpose of the project was to identify and assess at-risk clinic patients with typical and atypical symptoms for lower …

Improving Provider Adherence To Guidelines And Screening For Adult Depression In Primary Care, Amber Crenshaw

Doctor of Nursing Practice

The purpose of this QI project was to improve provider adherence to the Institute for Clinical Systems Improvement (ICSI) Guidelines for Adult Depression in Primary Care to enhance the screening, diagnosis, treatment, and management of adult major depressive disorder (MDD). MDD is a widespread, disabling, and treatable psychiatric disorder that is primarily treated and managed by primary care providers (PCPs). Untreated depression is prone to become chronic and can lead to pain, suffering, disability, increased morbidity and mortality, and premature death, with serious repercussions for the individual and society. Universal and routine screening in primary care for depression in adults, …

Evidence-Based Foot Care For Persons With Type 2 Diabetes, Nicole Gutierrez

Doctor of Nursing Practice

Unmanaged Type 2 diabetes leads to macrovascular changes that affect the lower extremities, thereby damaging the sensory nerve fibers and leading to diabetic peripheral neuropathy. These patients may not be able to feel pain, heat, or cold in their lower extremities and often describe feelings of numbness and tingling. This sensory deficit may lead to the development of diabetic foot ulcers which often result in amputation. These preventable foot complications may be identified promptly with adequate diabetic foot exams. Comprehensive diabetic foot examinations reduce the occurrences of foot complications associated with uncontrolled glucose management and improves health outcomes for patients …

Improving Diabetic Foot Screening In A Primary Care Clinic For Homeless Adults: A Quality Improvement Project, Theresa Causa

Doctor of Nursing Practice

The purpose of this project was to increase the adherence of clinic providers at the homeless primary care clinic by implementing the American Diabetes Association Clinical Guidelines for the evaluation and management of Type 2 diabetes with foot care. Type 2 diabetes is a chronic condition that affects 13% of the Texas adult population (Centers for Disease Control and Prevention, 2014). The homeless person's main method of transportation is walking. The complications of undiagnosed foot problems include reduced mobility, pain, lower limb amputations, and difficulty controlling chronic diseases including diabetes and depression. Provider responsibilities include screening for diabetes in all …