Improving Blood Pressure and Weight in Patients with Diabetes.

The purpose of this study was to improve healthcare outcomes by reducing blood pressure and weight in adult patients with diabetes at afederally qualified health center. NextGen electronic health record was used to review aggregate data of blood pressures and weight pre-intervention and post-intervention for women and men (N = 304) between 20 and 87 years of age with type 2 diabetes and a BMI : 30. Findings from this study showed that blood pressure and weight did not improve as anticipated using a variety of educational approaches and strategies within the study population. An interdisciplinary team approach should be undertaken to fully examine the problem so that the intervention is specifically targeted to the community population. With diabetes affecting nearly 1.7 million Americans annually, advanced practice nurses are in an ideal position to educate patients on the importance of healthy habits in order to reduce morbidity and mortality from diabetes.

Implementing a Pediatric Fall Prevention Policy and Program.

Preventing patient falls begins with an accurate assessment of a patient's risk of falling followed by the initiation and continued evaluation of a fall prevention program based on patient-specific identified risks. Children have a normal tendency to fall based on developmental growth, and each child is different in physical and cognitive abilities. Falls may occur both in and out of the hospital setting. Prevention programs that have revealed the most favorable restuls include the use of a validated fall risk assessment tool. The Humpty Dumpty fall Scale is a screening tool specifically developed for pediatric patients to assess risk for fall. This project developed a pediatric fall prevention policy and implemented an inpatient pediatric fall prevention program. Pediatric staff contributed to the development of this policy and program by providing feedback, support, and cooperation, which was instrumental in the success of this program resulting in no falls after implementation.

Improving Follow-Up for Failed Newborn Hearing Screening in Emirati Infants.

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning and implementation of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

Preventing ventilator-associated events: complying with evidence-based practice.

The leading cause of death due to health care-associated infections is ventilator-associated pneumonia (VAP). The lack of clarity in the definition of VAP has made it difficult to execute and evaluate the effectiveness of prevention strategies. Beginning in 2013, hospitals were expected to implement a new surveillance definition algorithm to identify ventilator-associated events (VAEs). The Institute for Healthcare Improvement recommended the use of the Ventilator Care Bundle as part of an initiative to decrease the incidence of VAP. This article outlines the results of a quality improvement project that was conducted to address this recommendation, improve current staff knowledge, identify gaps in practice, and determine the rate of compliance with prevention strategies. The major findings of this project also exposed limitations of the electronic medical record system, and suggested enhancements, which would promote the VAP Bundle initiatives, facilitate documentation, and permit straightforward data collection.

Outcomes of a quality improvement project implementing stroke discharge advocacy to reduce 30-day readmission rates.

The purpose of this quality improvement project was to determine whether use of aspects of a transitional care model by nurse navigators would affect 30-day readmission rates in hospitalized ischemic stroke patients discharged home with self-care. Thirty-day readmission rates and emergency department (ED) visits were compared before, during, and after the implementation of the revised discharge process. Comparative analysis demonstrated reductions in readmissions and in ED visits. Thirty-day readmission rates to our hospital decreased from 9.39% to 3.24% when comparing pre- with postintervention data. Thirty-day ED visit rates to all state hospitals decreased from 16.36% to 12.08% when comparing pre- with postintervention data.

Exploring factors associated with nurses' adoption of an evidence-based practice to reduce duration of catheterization.

Hospitalized adult patients are at increased risk for adverse outcomes, particularly when undergoing invasive procedures that include indwelling urinary catheterization. This study identified factors associated with nurses' adoption of an evidence-based practice to reduce the duration of catheterization and potential for catheter-associated urinary tract infections in hospitalized adults.

An evidence-based parenting intervention with inner-city teen mothers.

The consequences of teen pregnancy have a substantial negative impact on both the teen mother and her child. Recent evidence clearly supports parenting education as the most effective means for improving adolescent parenting skills. This study evaluated the effectiveness of a school-based program using an evidence-based educational intervention to improve parenting style in high school teen mothers. Teen mothers, from 15 to 18 years of age, in a Title 1 high school were recruited from the Early Head Start program. Two groups of teens (N = 10) completed a pre-parenting style survey, enrolled in an 8- or 12-week group educational session, and completed a post-parenting style survey. While quantitative data did not yield a change in parenting style, qualitative findings highlighted a strong need for teens to "tell their story" and to share personal experiences related to parenting. These findings lend support for the role of parenting educational interventions in high schools with teens at high risk for pregnancy.

Statin drugs: reducing cardiovascular risk in older adults.

Dyslipidemia is one of the most modifiable risk factors in preventing heart disease. Evidence demonstrates that the process of atherosclerosis, a result of dyslipidemia, begins in young adults. Initiating statin therapy has been shown to reduce the risk of cardiovascular events and mortality. Determining the right statin medication and dose for an older adult based on national guidelines can be challenging, as multiple factors must be considered in this decision. When initiating statin therapy, clinicians should determine the appropriate percentage of reduction in low-density lipoprotein cholesterol needed to achieve the target goal. Additionally, when changing from one cholesterol-lowering medication to another, knowledge of equivalent dosing is important. Generally, statin drugs are well tolerated with a good safety profile in older adults but are underused in this patient population. Issues such as existing comorbid conditions, polypharmacy with the potential for drug-drug interactions, impaired drug metabolism, and decreased functional status can contribute to adverse events and increase the frequency of myalgias and less frequently, hepatotoxicity. Clinicians prescribing statin therapy for older adults need to remain current on advances in research regarding potential interactions and contraindications within this drug class.

Crushing or splitting medications: unrecognized hazards.

Given the high use and the cost of medications in the current economy, one way older adults may save money on prescription costs is to split some of their medications in half. However, not all oral medications can be split. Splitting inappropriate medications such as extended-release tablets can be harmful and in some instances very dangerous. In addition to splitting medications, older adults who have difficulty swallowing pills may resort to crushing the medication for ease of administration. This option is also problematic and potentially harmful if the medication is not intended to be crushed. Clinicians managing the care of older adults need to discuss medication administration, clarify the dosing schedule, and clearly indicate the route of administration. Patients should be cautioned not to split or crush a medication without checking with the health care provider or pharmacist.

Recommended routine vaccinations for older adults.

A goal of primary prevention is to avoid the development of disease. Immunizations are one of several strategies used by clinicians in primary prevention. Influenza and pneumococcal disease--both preventable--cause significant morbidity and mortality in older adults who have an altered immune system, often have several chronic health problems, and are at higher risk for complications. Tetanus, while not as common in older adults, carries a high mortality rate in those 65 and older. These infections are associated with significant disability that results from hospitalizations for congestive heart failure, hip fracture, stroke, and pneumonia. The goal of immunizing older adults is to decrease functional decline and disability, as well as potential hospital admissions linked to these preventable diseases, which often exacerbate underlying health problems. Age-defined recommendations are available to guide clinicians on the appropriate vaccinations and schedules for administration to older adults.

Pharmacological management of chronic constipation in older adults.

Chronic constipation in older adults has multiple etiologies, and many of these factors are interrelated. An initial medical history and physical examination can provide relevant clues to the causes of the problem. The Rome III classification system of functional constipation is useful in clinical practice to help clinicians identify symptoms and confirm a diagnosis. Additionally, the Bristol Stool Scale is a valuable medical aid designed to assist patients in describing bowel patterns in a way that is more useful for diagnosis and evaluation of treatment methods. Pharmacological management, along with dietary changes and patient education, is the initial approach to treat patients with idiopathic chronic constipation. Consensus statements support a five-step care approach for patients with constipation. Knowledge of this approach will help clinicians in prescribing the appropriate medications along with patient education.

Introducing insulin into diabetes management: transition strategies for older adults.

Many older adults with type 2 diabetes require insulin to supplement or replace oral hypoglycemic control. Overtime, the addition of this more intensive therapy is needed to preserve beta cell function or prevent macrovascular sequelae. This is the result of the natural progression of diabetes and not a failure on the part of the patient. Clinicians must evaluate many factors in an attempt to individualize a safe optimal glycemic level for older adults. Considerations should include when insulin should be initiated, the type of insulin and regimen, and a safe individualized target goal while preventing hypoglycemia. Important in this decision are the patients comorbid condition, functional and cognitive status, social environment, financial ability, and life expectancy. The risks and benefits of more stringent glycemic control must be considered in the context of treatment options, priorities, and quality-of-life issues for both the patient and family.

Anticoagulation therapy in older adults newly diagnosed with atrial fibrillation.

Atrial fibrillation (AF) is the most common chronic arrhythmia and the most serious heart rhythm irregularity in individuals older than 70. It is usually not life threatening in and of itself, but it can lead to serious medical problems, including stroke, additional heart rhythm problems, and heart failure. Symptoms of AF vary considerably. Some patients are asymptomatic and have a self-limiting arrhythmia of short duration that converts to normal sinus without any intervention. Symptomatic patients may experience minor palpitations, severe palpitations, or even more vague symptoms such as lightheadedness, shortness of breath, or fatigue. More serious symptoms, such as syncope, new or worsening heart failure, or a cerebral vascular accident, may occur. The initial goals of treatment include controlling ventricular rate and addressing anticoagulation status. New guidelines help clinicians effectively manage anticoagulant therapy for older adults newly diagnosed with AF.

Vitamin D.

There is growing awareness and evidence that vitamin D plays a pivotal role in maintaining health beyond its major biological function of enhancing calcium absorption and improving bone mineral density. Research findings suggest a strong relationship among a number of chronic diseases and vitamin D deficiency. Although vitamin D deficiency can occur across the age continuum, older adults with chronic diseases are particularly at risk. This article focuses on the role of vitamin D in maintaining health, current evidence linking vitamin D deficiency with chronic illness, and the importance of vitamin D supplementation.

Strategies for reducing polypharmacy in older adults.

Polypharmacy is a major concern in the care of older adults. Multiple factors contribute to this problem, and recognizing these factors is an initial step in addressing the problem. Further, identifying those individuals at risk for medication problems, as well as implementing specific strategies in practice to reduce the problem, will enable clinicians to develop safe and evidence-based medication regimens that minimize the risk of adverse drug reactions. The key to treating older adults is not necessarily to find a set number of medications and try to stay below it, but to find the right medication at the right dosage and for the shortest possible duration on a case-by-case basis. This individualized approach to treating patients will provide a much safer and effective means of practicing and will improve patients' quality of life.

Regulatory components for treating persistent pain in long-term care.

Persistent or chronic pain is frequently reported by older adults and has the potential to dramatically influence quality of life. Estimates indicate that 25% to 50% of community-dwelling older adults experience this kind of pain. This rate is even higher in long-term care facilities, where 50% to 75% of residents have chronic pain syndromes that are untreated or undertreated. To promote optimal pain management and enumerate the responsibilities of skilled nursing facilities to effectively treat and prevent pain, the Centers for Medicare & Medicaid Services released a new pain management surveyor guidance, F-Tag 309, which endorses the presence of an interdisciplinary team approach to pain management that involves the resident. The guidance delineates pain management principles, the need for ongoing professional education in all components of pain management, and emphasizes the important role of appropriate pharmacological treatment in conjunction with nonpharmacological interventions to aggressively manage pain. This directive will help skilled nursing facilities achieve optimal pain management for their residents.

Travel immunization update for older adults.

Older Americans are among the most widely traveled group in our society. Recent trends point to more international travel, more travel to Third World countries, and more travel by older adults with significant health problems. Regardless of the reason for travel, older adults need to plan for healthy travel. Primary care providers need to inquire at routine visits if patients have plans for international travel. If travel to other countries or regions is being considered, patients must be advised of the importance of early travel preparation. To begin with, older adults should be up to date on all routine immunizations. Those planning on international travel may need additional required and/or recommended immunizations, depending on the individual's health status, travel itinerary, length of stay, and health risks associated with destination sites. Primary care providers should be knowledgeable about travel medicine resources in the community to make referrals for travelers requiring additional immunizations and health information.