Independent Nurse Practioneer27

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INDEPENDENT NURSE PRACTIONEER ISSUES IN NURSE MIDWIFE

PRACTIONEER PRACTICE:

INTRODUCTION:

Good morning Madam ,and my dear colleagues .How many of you havewatched a cocoon of a butterfly ?. one of the significant point to note is inthis cocoon where dynamic changes have taken place and now the butterfly

breaks through the cocoon to force its body through the cocoon opening till it progresses to enlarge and expand to form a full fledged butterfly .

This context can be applied to our nursing profession where from the birthof our profession to the current stage of becoming an autonomous profession.

Nursing has taken the full fledged wings of a vibrant butterfly that is ready tofly independently . so from this you can all guess my topic ? yes ! itsIndependent Nurse Practineer .

INDEPENDENT NURSE PRACTIONEER

DEFINITION

A Nurse practioneer is a registered nurse who has acquired the expertknowledge base , complex decision - making skills & clinical competencies

for expanded practice.An Advanced practice registered nurse ( APRN) is a nurse

who has completed an accredited graduate level education program preparing her for one of the APRN roles .

who has passed the national certification exam & who maintainscontinues competence as evidenced by recertification in role .

who has acquired advanced clinical knowledge & skills preparing her to

provide direct care to patients.

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whose practice builds on the competencies of registered nurses by

demonstrating a greater depth and breath of knowledge , increased

complexity of skills and greater role autonomy.

who is educationally prepared to assume responsibility and accountability

for health promotion and maintenance as well as assessment , diagnosis ,

management of patient problems that includes prescription of

pharmacologic and non-pharmacologic interventions.

CHARACTERISTICS OF ADVANCED NURSE PRACTIONEER

EDUCATIONAL PROGRAM

EDUCATION.

The entry level education for all APRNs is a graduate degree or postgraduate

certificate (postmasters or doctorate) awarded by an accredited APRN

program.

APRNs are educated in one of the four roles (CNP, CNM, CNS, CRNA) and

in one of six population foci: adult/geriatric, pediatrics, neonatal, psych/mental health, gender-specific (e.g. womens health) or family (across

the lifespan).

CERTIFICATIONIndividuals who have the appropriate education will be required to take a

national certification examination to assess competencies of the APRN core,

role and at least one population focus of practice. All graduates of an APRN

program must successfully pass the appropriate certification examination

prior to licensure.

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LICENSURE

Each state will issue an APRN license in addition to the registered nurse

(RN) license. Both licenses will be regulated by the state board of nursing.

APRNs will be licensed as independent practitioners for practice at the levelof one of the four APRN roles. Independent practice includes independent

prescriptive authority.

NATURE OF PRACTICE

integrates research , education, practice & management.

high degree of professional autonomy & independent practice.

case management.

advanced health assessment skills. Decision reasoning skills and

diagnostic reasoning skills.

recognized advanced clinical competencies.

provision of consultant services to health providers.

plans , implements & evaluates programs. recognized first point of contact for clients.

REGULATORY MECHANISM:

R ight to Diagnose.

Authority to Prescribe medication.

Authority to prescribe treatment. Authority to r efer clients to other professionals .

Authority to admit patients to hospitals.

Legislation to confer and protect the title.

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ADVANCED NURSE PRACTIONEER

Nurse practioneer care includes health promotion, disease prevention, health

education & families.EXTENDED AND EXPANDED NURSING ROLES:

DEFINITION:

E xtended role implies the performance of any activities by the nurse thatwere previously undertaken by medical doctors or other health carte

professionals. (Davis)

E xpanded role implies any enlargement of the nursing role within the boundaries of nursing education theory and practice.

(Mitchinson and Goodland ,1996)

Extended roles of nursing

The extended nursing roles involve the following .1. Ambulatory care Nurse2. Cardiac catheterization lab nurse3. Critical care nurse

4. Flight / transport nurse5. Forensic nurse6. Genetics nurse7. Geriatric nurse8. Legal nurse consultant9. Nursing informatics10. Occupational health nurse

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11. Parish health nurse12. Public health nurse13. Rehabilitation nurse14. Travel nurse15. Wound , Ostomy, Continence nurse16. Addiction nurse17..Holistic nurse18. Home health care nurse19. Hospice & Palliative care nurse20. Intellectual and deveplopmental disabilities nurse21. Emergency /Trauma nurse22. Military nurse23. Block nursing.

Expanded nursing roles

1.NURSE ANESTHETIST

A Nurse Anesthetist provides full spectrum of patients anesthesia care andanesthesia related care for individuals across the lifespan , whose healthstatus may range from healthy through all levels of acquity , including

persons with immediate , severe , life threatening illness or injury.

Settings

Hospital surgical suites Obstetrical delivery rooms Critical access hospitals Acute care Pain management centers Ambulatory surgical centres Offices of dentists , plastic surgeons , opthalmologists.

2.CERTIFIED NURSE MIDWIFE

The Certified nurse midwife provides a full range of primary health careservices to women throughout the lifespan , including gynecologic care,family planning services , preconception care, prenatal , postpartum care,

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childbirth and care of newborn , treating male and female clients for sexuallytransmitted diseases and reproductive health.

Settings A mbulatory care settings includes private offices ,community & Publichealth clinics.

3.CLINICAL NURSE SPECIALIST

The Clinical nurse specialist integrates care across the continum and throughthree spheres of influences : patient, nurse, system , practice in a specializedarea of practice(eg : pedatrics, oncology)

4.NURSE RESEARCHER

A N urse researcher is responsible for continued development and refinementof nursing knowledge , practice through investigation of nursing problems .nurse researchers are advanced educators with a doctoral level. They work inlarge teaching hospitals, research centres and academic settings.

5, NURSE ADMINISTRATOR

A Nurse administrator manages and controls client care. Educational

preparation for nurse administrators requires at least masters or advanceddoctoral degree . nurse administrators are responsible for specific nursing

units , academic settings.

6.NURSE EDUCATOR

A nurse educator role involves advanced education in nursing at a masters

degree. Nurse educators develop expert knowledge of theory in-depthknowledge of curriculum development and higher education.

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7. NURSE CONSULTANT

Nurse consultants function autonomously as clinician , treat clients with

various problems and refer them with complications to agencies connected

with her consultancy .

Specialties

ACHPN -(Advanced Certified Hospice & Palliative Nurse)

ACNP -( Acute Care Nurse Practioner)

ACPNP- (Acute Care Pediatric Nurse Practioner)

ANP- (Adult Nurse Practioneer)

(Specialty Programs: Adult Cardiovascular Care NP, Adult Primary

Care NP, Adult Critical Care NP, Adult Acute Care NP )

AOCNP or AOCNS -(Advanced Oncology Certified Nurse

Practitioner or Clinical Nurse Specialistby ONCC)

APMHNP -(Adult Psychiatric/ Mental Health Nurse P ractioner)

BC-ADM- (Board Certified - Advanced Diabetes Management)

ENP -(Emergency Nurse practioner)

FNP- (Family Nurse Practioner)

FPMHNP -(Family Psychiatric/ Mental Health Nurse practioner)

GNP -( Geriatric Nurse Practioner)

HNP- (Holistic Nurse Practioner; APN program )

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NNP -( Neonatal Nurse Practioner)

OHNP -(Occupational Health Nurse Practioner)

ONP- (Oncology Nurse Practioner)

PA/CCNP -(Pediatric Acute/Chronic Care Nurse Practioner ]

)PCCNP -(Pediatric Critical Care Nurse Practioner)

PCNP -(Palliative Care Nurse practioner; APN program)

PMHNP -(Psychiatric/ Mental Health Nurse P ractioner)

PNP -( Pediatric Nurse Practioner)

PONP -(Pediatric Oncology Nurse Practioner)

WHNP -(Women's Health Nurse Practioner).

PURPOSES OF INDEPENDENT NURSE PRACTIONER

1. Due to lack of physicians to promote health services

2. To meet the needs of the client without any issues

3. To reach out to clients to promote health care services and thereby promote health care for all

4. To ensure quality care services.

STANDARDS OF PRACTICE FOR NURSE PRACTIONERS

The Nurse practioners utilizes scientific process & national standards

of care as a framework for managing patient care

ASSESSMENT OF HEALTH STATUS

The nurse practioner assesses health status by obtaining relevant health& medical history

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Research as a basis for practice

STANDARDS OF PRACTICE FOR ACUTE CARE NURSEPRACTIONER

Assessment

The acute care nurse practitioner collects data for acute, critical andcomplex chronically ill patients.

1. Independently performs and documents a complete history and

physical examination for acute, critical, and complex chronically ill

patients.

2. Prioritizes data collection according to the patients immediate

condition,needs, and developmental level.

3. Collects data in a continuous process in recognition of the dynamic

nature of acute, critical, and complex chronic illness.

4. Collects data using appropriate assessment techniques, relevant

supporting diagnostic information and diagnostic procedures when

indicated.5. Utilizes physiologically and technologically derived data to

determine patients needs or conditions.

6. Distinguishes between normal and abnormal developmental and

age-related physiologic and behavioral changes in acute, critical, and

complex chronic illness.

7. Assesses for interactive and synergistic effects of multiple

pharmacological and nonpharmacologic interventions.

8. Promotes and protects health by assessing for risks associated with

care of acute, critical, and complex chronically ill patients, such as:

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a. Physiologic risk: medication side-effects, immobility, impaired

nutrition, immunocompetence, fluid and electrolyte imbalance,

invasive interventions, therapeutic modalities and diagnostic tests.

b. Psychological risks: impaired sleep and communication, crisisrelated to threat of life, self-image, finances, medication side-effects,

home and educational environment, and altered family dynamics.

c. Healthcare system risks associated with care of complex patients:

including but not limited to, multiple caregivers, and discoordination

of care continuity, care planning, or communication with family or

between multiple care providers.

9. Assesses the needs of families and caregivers of acute, critical and

complex chronically-ill patients.

10. Integrates data from all available resources to ensure that the

pertinent database is complete.

11. Synthesizes, prioritizes, and documents the database in a form that:

a. is confidential, understandable, and retrievable by all members

of the interdisciplinary healthcare team,

b. minimizes the potential for error, and

c. establishes accountability for the provision of professional services.

Diagnosis

The acute care nurse practitioner analyzes the assessment data in

determining diagnoses for the patient with acute, critical and complexchronic illness.

1. Formulates the differential and working diagnosis through the

analysis and

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synthesis of data from a variety of sources, using critical thinking and

diagnostic reasoning skills, previous experiences, and best practices.

2. Formulates diagnoses that encompass both nursing and medical

problems.3. Orders, performs, interprets, and supervises diagnostic tests and

procedures that contribute to the formulation of the differential

diagnoses, working diagnoses and subsequent plan of care.

4. Prioritizes diagnoses based on the interpretation of available

data and the complexity and severity of the patients condition.

5. Collaborates and consults with the interdisciplinary healthcare

team, the patient and family when developing differential

diagnoses, working diagnoses, and prioritizing problems.

6. Revises and reprioritizes diagnoses based on new and ongoing

patient data and the patients dynamic clinical status.

7. Diagnoses complications of acute, critical, and complex chronic

illness considering multisystem health problems.

8. Individualizes the diagnostic process based on the uniqueness of the

patient including the patients individuality, cultural differences,

spiritual beliefs, gender, race, ethnicity, disability, lifestyle,

socioeconomic status, age, use of alternative medicine, and family

configuration.

Outcome Identification

The acute care nurse practitioner identifies expected outcomesindividualized for the patient with acute, critical, and complex chronic

illness.

1. Derives expecterd outcomes from the diagnosis.

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2. Identifies expected outcomes that incorporate scientific evidence

and are achievable through implementation of evidence-based

practices.

3. Identifies expected outcomes that are consistent with the patients present and potential capabilities, as well as his or her values, culture

and environment.

4. Identifies expected outcomes mutually with the patient, family

and other healthcare providers.

5. Identifies expected outcomes taking into account the benefits and

costs for the patient, family, institution and society.

6. Establishes intermediate goals that reflect measurable incremental

indicators of progress in achieving expected outcomes.

7. Modifies expected outcomes based upon changes in the patients

condition

8. Promotes optimal outcomes by minimizing risk and promoting and

protecting the health of patients with acute, critical, and complex

chronic illness.

9. Collaborates with the patient family, and the interdisciplinary team

in establishing desired restorative, curative, rehabilitative maintenance,

palliative and end-of-life care outcomes.

Planning

The acute care nurse practitioner develops a plan of care that

prescribes interventions to attain expected outcomes for the patientwith acute, critical, and complex chronic illness.

formulates a plan of care that:

1. Is individualized, dynamic, and can be applied across the

continuum of acute care services.

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2. Integrates knowledge of rapidly changing pathophysiology of acute

and critical illness.

3. Incorporates input from the interdisciplinary team.

4. Prescribes the diagnostic strategies and therapeutic interventions(both pharmacologic and nonpharmacologic) needed to achieve

expected outcomes.

5. Utilizes evidence-based practice.

6. Incorporates health promotion, health protection, and injury

prevention measures that are specific to acute, critical, and complex

chronic illness.

7. Facilitates the patients transition between and within healthcare

settings (admitting, transferring, and discharging).

8. Incorporates mutually agreed upon plans for restorative, curative,

rehabilitative, and maintenance healthcare, as well as palliative and

end-of-life care

9. Develops the plan to reflect the actual and anticipated needs of the

patient and family, and includes their values and beliefs regarding

nursing and medical

therapies.

10. Incorporates considerations of cost and quality benefits in planning

care.

11. Provides patients with information about intended effects and

potential adverse effects of proposed prescriptive therapies.12. Documents the plan of care in a manner that is confidential,

understandable, and retrievable by all members of the

interdisciplinary healthcare team, to

minimize the potential for error.

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2. Incorporates the use of quality indicators, scientific evidence,

and the risk/benefit analysis of the treatment process when evaluating

the patients progress toward expected outcomes.

3. Utilizes interdisciplinary collaboration and multiple data resourcesas appropriate.

4. Modifies the plan of care based upon evaluation of outcomes.

5. Documents the evaluation process, and provides the results to

appropriate healthcare professionals.

6. Consults and makes appropriate referrals as needed, based on the

evaluation process.

STANDARDS FOR ANESTHESIA PRACTICE

1. Perform a through and complete preanesthesia assessment.

2. obtains informed consent for the planned anesthetic intervention

from the patient or legal guardian.

3. formulates a patient specific plan for anesthesia care.

4 implements and adjusts the anesthetic care plan based on patient,s

physiologic response.

5. monitor patients physiologic condition for the type of anesthesia

and specific patient needs

a) monitor ventilation ,oxygenation ,cardiovascular status, body

temperature ,neuromuscular function & status ,patient positioning.

6. there should be a complete, accurate , timely documentation of pertinent information on the patients medical record.

7. transfer responsibility for patient care to other qualified providers

which assures continuity of care and patient safety.

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8. adheres to safety precautions to minimize risk of fire explosion ,

electric shock, equipment malfunction., documents on patientss

medical record that the anesthesia machine & equipment are checked.

9. precautions shall be taken to minimize risk of infection to patientand health care providers

10 Anesthesia careshall be assessed to assure quality and contribution

to positive health outcomes.

11. the certified registered nurse anesthetist must respect and maintain

basic rights of patients.

STANDARDS OF PRACTICE FOR ADULT NURSE PRACTITIONER

The adult nurse practitioner is a provider of direct health care services.

Within this role, the adult nurse practitioner synthesizes theoretical,

scientific, and contemporary clinical knowledge for the assessment

and management of both health and illness states. These competencies

incorporate the health promotion, health protection, disease prevention, and treatment focus of adult nurse practitioner

practice

Assessment

1. Obtains and accurately documents a relevant health history for

adolescents and adults in their respective phases of the individual and

family life cycle.

2. Performs and accurately documents complete, system, or symptom-

specific physical examinations on adults (including developmental

evaluations, physical system evaluations, and behavioral evaluations

for each group).

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3. Assesses the impact of family, community, environment, home,

economic, work, and school environments on an individuals health

status.

4. Performs screening evaluations for mental health, substance abuse,and violence.

5. Distinguishes between normal and abnormal change with aging.

6. Assesses adolescents and adults throughout the stages of chronic

illness.

7. Assesses for common occupational, home, and recreational

exposures that affect health.

8. Assesses the effect of illness and/or injury on the individual:

a. Functional status.

b. Ability to work or return to work/school.

c. Physical and mental status.

d. Social relationships.

9. Assesses the changing impact and reciprocal effects of acute illness

and known chronic health problems in adolescents and adults.

10. Analyzes the multiple effects of pharmacologic agents, including

over-the-counter (OTC) preparations and folk remedies, in adolescents

and adults with multiple health problems.

11. Assesses the impact of family transitions, such as death, divorce,

marriage, employment and retirement, on the health issues of

adolescents and adults.12. Distinguishes ethnic and gender differences in presentation and

progression of common acute and chronic health problems in

adolescents and adults.

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13. Assesses and evaluates vague or ill-defined symptoms in

adolescents and adults.

14. Assesses for psychological manifestations of health problems in

adolescents and adults.Diagnosis

1. Discriminates among multiple potential mechanisms causing signs

and symptoms of health problems commonly diagnoses in adults and

adolescents.

2. Identifies both typical and atypical presentations of commonly

occurring health problems in adolescents and adults.

3. Differentiates between signs and symptoms indicating exacerbation

and/or remission of a chronic health problem and signs and symptoms

of a new problem in adults and adolescents with known

health problems.

4. Diagnoses commonly occurring complications of chronic health

problems, including psychological/mental health manifestations.

5. Diagnoses commonly occurring acute and chronic health problems

in adolescents and adults with an emphasis on multi-system health

problems.

6. Diagnoses common mental health and substance abuse problems

such as anxiety, depression, obesity, alcohol, and drug abuse.

7. Constructs appropriate differential diagnoses for further

investigation or referral in adolescents and adults who present with ill-defined health problems.

8. Recognizes the health impact of multiple demands on adults, such

as career, family, parenting, relationships, and finances.

Plan of Care and Implementation of Treatment

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13. Performs common primary care procedures, including, but not

limited to, suturing, microscopy, and pap tests.

14. Advocates for the patients/familys rights regarding decision

making as appropriate regarding durable power of attorney, advancedirectives, and other related issues.

15. Facilitates the patients transition between health care settings,

such as home to hospital or nursing home and provides for continuity

of care.

16. Applies research that contributes to positive change in the health of

or health care delivered to adolescents and adults.

Evaluation

These competencies describe the adult nurse practitioners role in

ensuring quality of care through consultation, collaboration,

continuing education, certification, and evaluation. The monitoring

function of the role is also addressed relative to monitoring ones own

practice as well as engaging in interdisciplinary peer and systems

review.

STANDARDS OF PRACTICE FOR FAMILY NURSE PRACTITIONER

. The family nurse practitioner employs evidence-based clinical

practice guidelines to guide screening activities, identifies health

promotion needs, and provides anticipatory guidance and

counseling addressing environmental, lifestyle, and developmental

issues.

1. Obtains and accurately documents a relevant health history for

patients of all ages and in all phases of the individual and family life

cycle.

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2. Assesses (a) the influence of the family or psychosocial factors on

patient illness, (b) conditions related to developmental delays and

learning disabilities in all ages, (c) womens and mens reproductive

health, including, but not limited to, sexual health, pregnancy, and postpartum care, and (d) problems of substance abuse and violence.

3. Performs and accurately documents appropriate comprehensive or

symptom-focused physical examinations on patients of all ages

(including developmental and behavioral screening and physical

system evaluations).

4. Performs screening evaluations for mental status and mental health.

5. Identifies health and psychosocial risk factors of patients of all ages

and families in all stages of the family life cycle.

6. Demonstrates proficiency in family assessment.

7. Demonstrates proficiency in functional assessment of family

members (e.g, elderly, disabled).

8. Assesses specific family health needs within the context of

community assessment.

9. Identifies and plans interventions to promote health with families at

risk.

10. Assesses the impact of an acute and/or chronic illness or common

injuries on the family as a whole.

11. Distinguishes between normal and abnormal change with aging.

Diagnosis of Health Status

The family nurse practitioner is engaged in the diagnosis of health

status. This diagnostic process includes critical thinking, differential

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diagnosis, and the integration and interpretation of various forms of

data.

1. Identifies signs and symptoms of acute physical and mental illnesses

across the life span.2. Identifies signs and symptoms of chronic physical and mental

illness across the life span.

3. Orders, performs, and interprets age-, gender-, and condition-

specific diagnostic tests and screening procedures.

4. Analyzes and synthesizes collected data for patients of all ages.

5. Formulates comprehensive differential diagnoses, considering

epidemiology, environmental and community characteristics, and life

stage development, including the presentation seen with increasing

age, family, and behavioral risk factors.

Plan of Care and Implementation of Treatment

The objectives of planning and implementing therapeutic interventions

are to return the patient to a stable state and to optimize the patients

health. These competencies describe the family nurse

practitioners role in stabilizing the patient, minimizing physical and

psychological complications, and maximizing the patients health

potential.

1. Provides health protection, health promotion, and disease prevention

interventions/treatment strategies to improve or maintain optimumhealth for all family members.

2. Treats common acute and chronic physical and mental illnesses and

common injuries in people of all ages to minimize the development of

complications, and promote function and quality of living.

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15. Facilitates transitions between health care settings to provide

continuity of care for individuals and family members.

16. Intervenes with multigenerational families who have members

with differing health concerns.17. Assists patient and family members to cope with end of life issues.

18. Applies research that is family-centered and contributes to positive

change in the health of and health care delivery to families.

Evaluation

These competencies describe the family nurse practitioners role in

ensuring quality of care through consultation, collaboration,

continuing education, certification, and evaluation. The monitoring

function of the role is also addressed relative to monitoring ones own

practice as well as engaging in interdisciplinary peer and systems

review.

STANDARDS OF PRACTICE OF GERONTOLOGICAL NURSE

PRACTITIONER

Assessment of Health Status1. Analyzes the relationship between normal physiology and specific

system alterations produced by aging and disease processes.

2. Assesses the developmental status regarding maintenance of self-

identity through later and final stages of life.

3. Assesses the dynamic interaction between acute illness and known

chronic health problems in older adults.

4. Assesses elders and caregivers for abuse and/or neglect.

5. Assesses for addictive behavior.

6. Assesses health/illness by conducting a complete health history in

light of physiologic and psychosocial changes of aging.

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7. Performs a comprehensive physical exam considering physiologic

changes of aging.

8. Performs a comprehensive functional assessment, including mental

status, social support, and nutrition.9. Assesses special risks of institutionalized older adults for common

patterns of illness and communicable disease.

10. Assesses sexual function and sexual well-being in older adults.

11. Assesses roles, tasks, and stressors of informal system/family

caregivers for older adults, especially the frail.

Diagnosis of Health Status

1. Recognizes the commonly occurring conditions associated with

aging, including differential diagnosis of delirium, dementia, and/or

depression.

2. Implements screening using appropriate, age-specific instruments

and guidelines and interprets results in light of expected changes

associated with aging.

3. Applies knowledge of atypical presentations of disease seen with

aging to the formulation of differential diagnoses.

4. Plans diagnostic strategies and orders, performs, and interprets

results of laboratory tests, clinical procedures, and other tests used in

diagnosis and management of older adults with specific organ

system alterations.

Plan of Care and Implementation of Treatment1. Treats acute and chronic illness and geriatric syndromes frequently

manifested in older adults such as Incontinence, falls, constipation,

loss of functional abilities, dehydration, dementia, depression,

delirium, and malnutrition.

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2. Adapts interventions to meet the complex needs of older adults and

frail elders arising from normal changes of aging, multiple system

problems, psychosocial, and financial issues.

3. Plans therapeutic interventions to restore or maintain optimal levelof functioning and when appropriate plans for palliative care.

4. Prescribes medications with knowledge of pharmacodynamics and

pharmacokinetic processes in older adults with high potential for

adverse drug outcomes

5. Works with an interdisciplinary health care team to plan and deliver

skilled gerontological care to older adults.

6. Assists older adults or designated care agent in formulating advance

directives, ethical decisions, and end-of-life care decisions.

7. Prescribes and monitors ancillary therapies for older adults in

various settings (e.g. physical therapy and nutritional therapy).

8. Formulates and implements a plan of care related to sexual health

and functioning in older men and women.

9. Coordinates care within a context of potentially limited endurance,

financial constraints, cultural considerations, family or caregiver

needs, and ethical principles.

10. Performs primary care procedures, including, but not limited to,

wound debridement, pap tests, and microscopy.

11. Applies research that is older adult-centered and contributes to

positive change in the health of or health care delivered to older adults.Evaluation

1. Assesses the impact of ageism on health care policies and systems.

2. Advocates for access to quality, cost-effective health care for older adults