D118 Unit 2 Study Guide

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Western Governors University

D118 Adult Primary Care for the Advanced Practice Nurse

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Date

Unit 2: Determining Priorities in Wellness & Health Promotion

Module Vocabulary and Key Questions

These key questions are designed to guide your understanding upon completing this unit. Feel free to add your notes for deeper comprehension.

Evidenced-Based Approaches to Primary Care

What is evidence-based practice, and why is it important in healthcare?
Evidence-Based Practice (EBP) is a problem-solving approach to clinical decision-making that integrates the best current evidence with clinical expertise and patient values. It ensures healthcare providers make informed decisions that improve patient outcomes and safety within their communities (Melnyk & Fineout-Overholt, 2019).

What are key elements of quantitative research designs and their distinguishing characteristics?
Quantitative research includes various designs such as randomized controlled trials (RCTs), cohort studies, and case-control studies. These designs vary based on the level of evidence they provide, the study’s purpose, methods, data analysis, and how the findings apply to clinical practice. Grading evidence helps determine the reliability and applicability of the research findings.

How is evidence appraised using standard methods and grading scales?
Appraising evidence involves several steps:

Identifying the practice problem or change needed
Assessing the relevance and quality of research evidence
Determining the level of evidence based on research type and methodology
Applying grading scales to evaluate the strength and bias of the evidence

What are common models used in implementation science?
Implementation science focuses on translating research findings into practice through structured models:

Model Name	Description
Iowa Model of Evidence-Based Practice	A flowchart guiding problem-solving steps and feedback loops to facilitate change in clinical settings.
ACE Star Model of Knowledge Transformation	A five-stage model moving from discovery research to practice integration and evaluation.
Johns Hopkins Nursing EBP Model (JHNEBP)	PET model focusing on practice questions, evidence, and translation to rapidly incorporate research into care.
Stetler Model of EBP	Emphasizes critical thinking and uses both internal and external evidence for clinical decision-making.

Patient-Centered Care and Value-Based Purchasing

What is the Patient-Centered Medical Home (PCMH)?
PCMH is an integrated primary care approach focused on accessibility, accountability, and sustained patient partnerships within families and communities. It aims to provide care that is safe, effective, patient-centered, timely, efficient, equitable, and avoids harm (Agency for Healthcare Research and Quality, 2020).

What is Value-Based Purchasing (VBP), and what are its goals?
Value-Based Purchasing is a CMS payment reform linking hospital reimbursements to performance on quality measures grouped into four domains: safety, clinical care, efficiency and cost reduction, and patient-centered experience. The objective is to improve healthcare quality by incentivizing positive patient outcomes.

What are Accountable Care Organizations (ACOs)?
ACOs are voluntary groups of healthcare providers that coordinate care for Medicare patients to improve quality and reduce costs. ACOs operate in three tiers, each with specific organizational, performance, IT, and payment requirements.

Transitional and Chronic Care Coordination

What is transitional care, and why is it important?
Transitional care ensures coordinated, continuous patient care across different settings (e.g., hospital to home). Poorly managed transitions increase the risk of adverse events such as medication errors, infections, and rehospitalizations. Effective transitional care requires anticipating risks and clear communication among healthcare providers.

What is coordinated chronic care, and what models support it?
Care coordination involves organizing patient care activities among participants to deliver comprehensive services. The Chronic Care Model (CCM) includes six elements critical to managing chronic illness: community resources, health system support, self-management, delivery system support, decision support, and clinical information systems.

Lewin’s Change Theory and Its Application to Evidence-Based Practice

What are the stages of Lewin’s change theory?
Lewin’s model describes change in three steps:

Unfreezing – Preparing individuals to discard old behaviors
Movement – Transition to new behaviors and processes
Refreezing – Stabilizing the change into routine practice

This model is applied in EBP to facilitate adoption of new clinical guidelines or procedures.

Domains of Wellness

Domain	Description
Physical	Maintaining a healthy body through exercise, nutrition, sleep, and medical care
Emotional	Managing stress, expressing emotions appropriately, and seeking help when needed
Spiritual	Finding meaning and purpose in life, often connected to beliefs and values
Social	Building healthy interpersonal relationships and community connections
Occupational	Finding satisfaction and enrichment in work and professional life
Environmental	Ensuring safe, healthy surroundings and sustainable practices

Risks in Transitions of Care

Transitions between care settings often elevate the risk of adverse events due to communication breakdowns and care discontinuities. Common problems include:

Unnoticed lab abnormalities or missing test results
Adverse drug reactions or interactions
Post-discharge infections or falls
Conflicting medical instructions from various providers

Chronic Care Coordination Models

Model	Description
Patient-Centered Medical Homes (PCMHs)	Team-based primary care focusing on comprehensive, coordinated care for chronic conditions
Self-Management Programs	Empower patients to actively participate in managing their own chronic illnesses
Home-Based Primary Care	Providers deliver care via house calls and telecommunication, especially for homebound or elderly patients
Distance Chronic Disease Programs	Telehealth services that provide remote care to patients, often in rural or underserved areas

Telemedicine: Synchronous vs. Asynchronous

Type	Description	Technology Examples
Synchronous	Real-time interaction between patient and provider; both present simultaneously	Videoconferencing, remote examination tools
Asynchronous	Medical data is collected and sent for later review by a provider; no need for simultaneous presence	Store-and-forward images, biosignals, voice

Telemedicine improves access to care, especially in remote or underserved regions of the US.

Social Determinants of Health (SDOH)

Key components of SDOH include income, education, access to healthcare, and community resources. The Expanded Chronic Care Model (ECCM) integrates these social factors, recognizing their significant impact on the prevention and management of chronic diseases.

National Initiatives to Improve Healthcare Quality

Two major initiatives include:

The National Notifiable Diseases Surveillance System (NNDSS), which collects and monitors disease data nationwide to support public health.
The Healthy People 2030 program, setting objectives to enhance health outcomes and address social determinants on a national scale.

Pitfalls and Limitations of Laboratory Testing

Lab testing may be limited by lack of insurance coverage, leading to underutilization, or over-testing, which can result in unnecessary costs and patient burden.

Types of Quantitative Research

Quantitative research includes experimental designs such as randomized controlled trials (RCTs), observational cohort studies, and case-control studies. Each provides different levels of evidence for causation and prevention in healthcare.

Disease Prevention Framework

Level	Description
Primary Prevention	Preventing disease onset through risk reduction and health promotion (e.g., vaccination, lifestyle changes)
Secondary Prevention	Early detection through screening to halt disease progression (e.g., mammograms)
Tertiary Prevention	Managing existing disease to prevent complications and improve quality of life (e.g., rehabilitation)

Palliative Care

Palliative care focuses on relieving symptoms, managing pain, and providing emotional and spiritual support to patients with serious illnesses, regardless of prognosis.

Epidemiologic Triad for Infectious Disease Causation

The epidemiologic triad explains infectious disease through the interaction of three elements:

Component	Description
Agent	The infectious microorganism (virus, bacterium, parasite)
Host	The susceptible human population
Environment	External factors facilitating disease transmission (climate, sanitation, socioeconomic conditions)

Disease results from the dynamic interaction between these three factors.

Healthy People 2030 Objectives and Changes from 2020

Included Health Conditions:

Addiction
Chronic Diseases (heart disease, cancer, diabetes)
Infectious Diseases (vaccination, control)
Mental Health
Overweight and Obesity
Pregnancy and Childbirth
Social Determinants of Health (economic stability, education, healthcare access)
Other areas: oral health, osteoporosis, sensory disorders

Changes from 2020 to 2030:

Streamlined objectives with prioritization of critical health issues
Increased emphasis on social determinants of health
Adoption of rigorous data standards and adaptability to emerging health concerns

Current Screening Guidelines in Adults (USPSTF Recommendations)

Condition	Screening Recommendation	Notes
HIV infection	Screen all adolescents and adults 15-65 years; more frequent screening for high-risk individuals	Early ART reduces progression to AIDS
Colorectal cancer	Screen adults 50-75 (start at 45 if family history); stool tests and colonoscopy recommended	Higher risk for Black, American Indian, and Alaskan Native adults
Hypertension	Screen adults 18+; more frequent for adults 40+ or those at increased risk	Confirm with measurements outside clinical settings
Unhealthy drug use	Screen adults 18+ by asking about drug use
Hepatitis C	Screen adults 18-79; consider high-risk adolescents and older adults	Follow antibody testing with RNA confirmation; treat with direct-acting antivirals
Abdominal aortic aneurysm	One-time ultrasound screening for men 65-75 who have smoked; selective screening for non-smokers in this group	No routine screening for women without risk factors
Breast cancer	Biennial mammography for women 40-74 years	3D mammography is effective; separate recommendations for genetic risk assessment
Cervical cancer	Screen women 21-29 every 3 years with cytology; women 30-65 with cytology or HPV testing every 3-5 years	Early treatment of precancerous lesions reduces progression to cancer
Osteoporosis	Screen women 65+ and younger postmenopausal women at risk	DXA is the standard test; various pharmacotherapies available

20. What Are the Age-Specific Components Included in the Annual Wellness Exam?

The annual wellness exam is tailored to an individual’s age, incorporating various components pertinent to their stage of life. For younger adults, the exam focuses on preventive screenings, immunizations, lifestyle counseling, and assessment of risk factors for chronic diseases. Middle-aged adults receive evaluations targeting cardiovascular risk, diabetes screening, cancer screenings (such as colorectal and breast), and mental health. Older adults require assessments of cognitive function, fall risk, vision, hearing, immunizations (e.g., influenza, pneumococcal, zoster), and screening for geriatric syndromes such as osteoporosis and frailty. The exam also includes personalized counseling based on health history, family history, and current symptoms.

21. What Are the Screening Guidelines for Abnormal Blood Glucose and Type 2 Diabetes Mellitus in Adults Aged 40-70 Years Who Are Overweight or Obese?

The U.S. Preventive Services Task Force (USPSTF) recommends screening adults aged 35 to 70 years who are overweight (BMI ≥25) or obese (BMI ≥30) for prediabetes and type 2 diabetes mellitus (T2DM) (Grade B). Patients identified with prediabetes should be referred to effective preventive interventions.

Condition	Diagnostic Criteria	Laboratory Values
Prediabetes	Fasting plasma glucose	100–125 mg/dL
	Hemoglobin A1c (HbA1c)	5.7% – 6.4%
	2-hour post-load glucose	140–199 mg/dL
Type 2 Diabetes	Fasting plasma glucose	≥126 mg/dL
	Hemoglobin A1c (HbA1c)	≥6.5%
	2-hour post-load glucose	≥200 mg/dL

Early identification allows clinicians to initiate lifestyle changes or pharmacotherapy to prevent progression to diabetes and associated complications.

22. What Are the Screening Guidelines for Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer in Adults Aged 50-59 Years?

The USPSTF issues a Grade B recommendation for initiating low-dose aspirin in adults aged 50 to 59 years who meet the following criteria:

Have a 10% or greater 10-year cardiovascular disease (CVD) risk.
Are not at increased risk of bleeding.
Have a life expectancy of at least 10 years.
Are willing to take low-dose aspirin daily for at least 10 years.

Aspirin use in this population can reduce the risk of both CVD events and colorectal cancer. The decision should be individualized, weighing benefits against bleeding risks.

23. What Are the Screening Guidelines for Asymptomatic Bacteriuria in Pregnant Women?

Screening for asymptomatic bacteriuria is strongly recommended (Grade B) in pregnant persons aged 18 years and older, regardless of symptoms, through urine culture conducted between 12 to 16 weeks of gestation or during the first prenatal visit. Early detection and antibiotic treatment reduce the risk of pyelonephritis and adverse pregnancy outcomes.

24. What Are the USPSTF Recommendations for Breastfeeding Support?

The USPSTF gives a Grade B recommendation for providing interventions or referrals to support breastfeeding for all pregnant and postpartum women. Effective breastfeeding support includes:

Evidence-based, accessible interventions.
Behavioral counseling such as breastfeeding education and ongoing support.
Delivery of support by diverse healthcare professionals, including nurses, midwives, clinicians, lactation consultants, or trained peers.

Such measures improve breastfeeding rates and associated health outcomes for mothers and infants.

25. What Are the USPSTF Recommendations for Depression Screening in Adults?

Adults aged 19 years and older, including pregnant and postpartum persons and older adults (65+), should be screened for major depressive disorder (MDD) (Grade B). Screening targets individuals without diagnosed mental health disorders or recognizable signs of depression or suicide risk.

Common screening tools include:

Population	Screening Instruments
Adults	Patient Health Questionnaire (PHQ)
Older Adults	Geriatric Depression Scale (GDS)
Pregnant/Postpartum	Edinburgh Postnatal Depression Scale (EPDS)
Suicide Risk	Beck Hopelessness Scale, SAD PERSONS Scale, SAFE-T

Early identification and referral are key to improving mental health outcomes.

26. What Are the USPSTF Recommendations for Preventing Neural Tube Defects?

The USPSTF recommends that all individuals planning pregnancy or capable of becoming pregnant take a daily folic acid supplement of 400 to 800 micrograms (Grade A). This reduces the risk of neural tube defects such as spina bifida and anencephaly.

27. What Are the USPSTF Recommendations for Gestational Diabetes Screening?

Pregnant persons should be screened for gestational diabetes at 24 weeks gestation or later, regardless of symptoms (Grade B). Early detection allows for timely management to reduce maternal and fetal complications.

28. What Are the USPSTF Recommendations for Hepatitis B Screening in Adults and Pregnant Women?

Screening for hepatitis B virus (HBV) infection in pregnant women is strongly recommended at the first prenatal visit (Grade A). Testing includes hepatitis B surface antigen (HBsAg). Women with unknown or ongoing risk factors should be re-screened at delivery.

Intervention	Description
Infant vaccination	Vaccinate infants of HBV-negative mothers within 24 hours; complete series by 18 months.
Management of HBV-positive mothers	Includes viral load testing and referral for specialized care.

29. What Are the USPSTF Recommendations for Screening for Intimate Partner Violence (IPV)?

The USPSTF recommends screening women of reproductive age for IPV (Grade B) and providing or referring those who screen positive to support services.

Risk factors for elder abuse include isolation, poor health, and lack of social support. Common validated screening tools include:

HARK (Humiliation, Afraid, Rape, Kick)
HITS (Hurt, Insult, Threaten, Scream)
E-HITS (Extended HITS)
Partner Violence Screen (PVS)
Woman Abuse Screening Tool (WAST)

30. What Are the USPSTF Recommendations for Prevention in Women at High Risk for Preeclampsia?

Low-dose aspirin (81 mg/day) after 12 weeks of gestation is recommended (Grade B) for pregnant persons at high risk of preeclampsia. Risk factors include medical history, clinical findings, lab tests, and imaging results.

Prevention and Management	Details
Low-dose aspirin	Dose ranges from 60 to 150 mg daily.
Medical management	Includes antihypertensives, early delivery, magnesium sulfate.
Definitive treatment	Delivery of the placenta.

31. What Are the USPSTF Recommendations for Lung Cancer Screening?

Annual low-dose computed tomography (LDCT) screening is recommended for adults aged 50 to 80 years with a 20 pack-year smoking history who currently smoke or quit within the past 15 years (Grade B). Screening should be stopped if smoking cessation exceeds 15 years or life expectancy is limited.

Key clinical trials validating this include the National Lung Screening Trial (NLST) and the Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON).

32. What Are the USPSTF Recommendations for Syphilis Screening in Pregnant Women?

Early, universal screening for syphilis infection in pregnancy is strongly recommended (Grade A). If not done early, screening should occur at the first opportunity.

Screening uses a two-step testing process:

Test Type	Purpose
Nontreponemal Tests	Detect antibodies indicating tissue damage (e.g., VDRL, RPR)
Treponemal Tests	Confirm antibodies specific to Treponema pallidum (e.g., TP-PA)

33. What Are the USPSTF Recommendations for Rh(D) Incompatibility Screening in Pregnant Women?

Rh(D) blood typing and antibody testing are strongly recommended at the first prenatal visit (Grade A). Repeated antibody testing is advised at 24 to 28 weeks gestation for unsensitized Rh(D)-negative women (Grade B), unless the father is Rh(D)-negative.

Administration of Rh(D) immunoglobulin (300 µg) is recommended after repeated testing and postpartum if the newborn is Rh(D)-positive or weakly positive.

34. What Are the USPSTF Recommendations for Statin Use for Primary Prevention of Cardiovascular Disease (CVD)?

Statin therapy is recommended for adults aged 40 to 75 years with one or more CVD risk factors (dyslipidemia, diabetes, hypertension, smoking) and an estimated 10-year cardiovascular event risk of 10% or greater (Grade B). For those with risk between 7.5% and less than 10%, statins may be considered (Grade C).

35–44. What Are the Dietary and Physical Activity Guidelines for Adults?

The Dietary Guidelines for Americans recommend balanced consumption across food groups to maintain health and prevent chronic diseases.

Food Group	Recommended Daily Intake	Key Nutrients Provided
Protein	Men: 56g; Women: 46g	Essential amino acids
Dairy	3 cups	Calcium, phosphorus, vitamins A, D, B12, riboflavin, potassium, zinc, choline, magnesium, selenium
Grains	5–10 ounces (1 oz = 1 slice bread)	Fiber, B vitamins, iron, magnesium, selenium
Fruits	1.5–2 cups	Potassium, fiber, vitamin C, folate
Vegetables	2.5–3 cups	Vitamins A, C, fiber, potassium, folate

Physical activity guidelines recommend at least 150 minutes per week of moderate-intensity exercise to improve cardiovascular and metabolic health.

46. Why Is Knowledge of International Travel Important for Health and Wellness, and Where Can Practitioners Find Resources?

Travel exposes individuals to diseases uncommon in the U.S., such as yellow fever. Vaccinations protect travelers and prevent disease transmission upon return.

Practitioners can find comprehensive resources on the Centers for Disease Control and Prevention (CDC) vaccine websites, which detail required and recommended vaccines for specific destinations.

47. What Is the Role of Vaccines in Disease Prevention?

Immunity, either partial or full, enables resistance to infections. Vaccines stimulate immunity without causing disease, protecting individuals and creating herd immunity that limits disease spread within communities.

48–49. Which Vaccines Are Recommended for Adults and College Students?

Population	Recommended Vaccines
Adults (19+)	COVID-19, Hib, Hepatitis A & B, HPV, Influenza, MMR, Meningococcal, Pneumococcal, Polio, RSV, Tdap, Varicella, Zoster
College Students	MMR, HPV, Tdap

Vaccination ensures protection during critical periods of exposure, especially in communal settings like colleges.

50. How Does Health Literacy Influence Health Care Outcomes?

Low health literacy is linked to worse health outcomes and higher healthcare costs. Children of parents with limited health literacy are more likely to have emergency visits, severe conditions, and incomplete immunizations.

Improving health literacy involves simplifying communication, enhancing patient education, and ensuring comprehension.

51. How Do Health Care Disparities Impact Certain Populations?

Health disparities arise when groups experience barriers to care and worse outcomes. Healthcare providers should identify vulnerable populations and implement culturally appropriate interventions, such as traditional foods projects or community-based asthma prevention.

Addressing disparities starts with self-awareness of personal biases and active engagement in equitable care.

52. What Is Culturally Responsive Care?

Culturally responsive care respects an individual’s cultural context, influencing how care is sought and received. It encompasses understanding differing definitions of health, acceptable treatments, and illness behavior.

Providers must minimize bias and communicate effectively within patient-centered environments to deliver optimal care.

References

U.S. Preventive Services Task Force. (n.d.). USPSTF Recommendations. https://www.uspreventiveservicestaskforce.org/
Centers for Disease Control and Prevention (CDC). (n.d.). Vaccine Information. https://www.cdc.gov/vaccines/
U.S. Department of Health and Human Services. (2020). Dietary Guidelines for Americans, 2020-2025. https://www.dietaryguidelines.gov/
National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Diabetes Prevention. https://www.niddk.nih.gov/