APRN Observation Running Head: APRN Observation Paper

APRN Observation Paper: A Pediatric NP at a Childrens Hospital Fast Track Texas Tech Health Science Center The Advanced Practice Nurse Role NURS 5111 Dr. E. Merrill

By Sharon D. Scott, RN

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Introduction Methodist Childrens Hospital in San Antonio, TX, provides emergency medical care from approximately 175 to 325 children per day. A pivotal department within the childrens ER is the fast track area. This setting takes the pressure off of the main ER by seeing minor illnesses that could have been treated in the childs primary care providers office. Some examples are minor scalp lacerations, extremity injuries, and new onset fever, sore throats, and ear pain, constipation and urinary tract infections. In the fast track area, there are two providers caring for up to 10 patients between them. The providers are nurse practitioners (family or pediatric) and physician assistants. The role of these providers (referred to as physician extenders) is to provide primary care to all of the patients in the department, diagnose and treat with diagnostic testing, medications, the prescribing of medication for home use. NONPF Consensus Model and Competencies The National Organization of Nurse Practitioner Faculties (NONPF) consensus model, there are four roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). APRNs are educated in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, womens health/gender-related or psych/mental health. (NONPF, 2008).

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The population-focused competencies for a pediatric nurse practitioner, according to NONPF, include assessing health status, diagnosing health status, and implementing treatment (NONPF, 2008). The pediatric nurse practitioner also conducts health protection, disease prevention, and treatment. Scope of Practice According to the American Academy of Nurse Practitioners (AANP), scope of practice for the NP includes diagnosing, managing acute and chronic illness episodes, and support health promotion and disease prevention. In order to do this, NPs can provide services such as ordering and interpreting diagnostic and lab tests, prescribe pharmacologic agents, and teach and counsel patients. As licensed independent practitioners, they practice autonomously and in collaboration with health care professionals. They are interdisciplinary consultants and patient advocates. The entry level is at the masters, post-masters or doctorate level, having completed didactic and clinical courses preparing them with specialized knowledge to practice in their care setting. The Texas Board of Nursing (BON) is non-specific about scope of practice. Their position is that the NP starts at the basic level (what they learned in school), the regulations of the nurse practice act, and their competencies grow according to what their national professional specialty certifying body recommends, and that the nurse ask themselves a series of questions. The questions include but are not limited to: is the activity consistent with ones education in the role and specialty? Is the activity consistent with evidence-based care? Is it consistent with reasonable and prudent

APRN Observation practice? The board of nursing, in a way, puts the responsibility back on the nurse practitioner, to determine if they are practicing within their scope of practice. Observational Experience I followed Roberta Gonzales, PNP, C. She is a graduate of the University of Texas Health Science Center, one year ago. She falls under the APRN title with the role of CNP within the consensus model. She is a pediatric NP in the Methodist Childrens

Hospital Emergency Room Fast Track Clinic. This is a suburban hospital in San Antonio, TX. It is a for profit hospital, and serves all clients that come for care, to include Medicaid/CHIPS patients. During the evening that I followed Roberta, she saw patients with ear infections, diagnosed herpangina secondary to viral infection, hand-foot-mouth disease (there have been daycare breakouts of this illness), viral gastroenteritis, and minor closed head injuries. She saw children with minor wounds due to animal bites, minor scalp lacerations, viral and bacterial conjunctivitis, children with strep pharyngitis and viral pharyngitis, and children with extremity injuries. She ordered lab tests for children with fever according to differential diagnosis guidelines, diagnosed based on lab tests or physical exam findings, and prescribed medications when warranted. She also provided preventative care education and wellness/self care education to patients. The ER Physicians group, Greater San Antonio Physicians (GSEP), are responsible for supervising the nurse practitioners and PAs. Although the state only requires that ten percent of their charts be audited, the physicians audit 100 percent of their work. A document was created that describes nurse practitioner duties, scope of practice and protocols for how they should perform their duties, and is titled Physician

APRN Observation Extender Specific Duties Checklist. Roberta performed her duties utilizing the competencies set forth in the NONPF specialty competencies guidelines. She performed assessment of health status by obtaining a relevant history, performing a complete and accurate systematic pediatric

physical assessment, and performed age appropriate screenings. She diagnosed the health status by using situation appropriate screenings, labs such as strep swabs, complete blood count for children with fever, urinalysis for children with fever, diagnostic tests such as x-rays for extremity injuries and CT scan for minor closed head injuries, and identified the etiology of some disease processes. She developed a plan of care and treatment by prescribing pharmacological therapies, providing primary care procedures (i.e. wound care and staples for scalp laceration), and activating protection services (i.e.- animal bite report sent to health department for dog bite). She fostered the nurse practitioner-patient relationship by communicating effectively with the parents and the children, and provided guidance in preventative care and home care for issues that did not require a prescription or in clinic intervention (teaching how to rotate Tylenol and Motrin for fever care and how to keep a child hydrated that has herpangina until the mouth blisters dissipate). This description covers at least four of the competencies and sub-descriptions of the competencies published. Conclusion In following Roberta, I found that she was practicing within her scope of practice and within the competencies of the pediatric nurse practitioner, but feel that she is not practicing to her full extent. The term physician extender implies that the nurse

APRN Observation practitioner role in the fast track ER is to help the physician, rather than practice

independently. Reviewing 100% of the charts could be a liability protection issue because of the nature of the practice setting, but I also see it as a controlling factor as well. Her care was compassionate, thorough, and within her scope of practice and utilizing competencies published by specialty governing bodies.

APRN Observation References AANP (2006) Scope of Practice for Nurse Practitioners. Retrieved July 25, 2011 from http://www.aanp.org/Search/search.asp?zoom_query=scope%20of%20practice

NONPF (2008) Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Retrieved July 25, 2011 from http://www.nonpf.com/displaycommon.cfm?an=1&subarticlenbr=26 NONPF, (2002) Nurse Practitioner Primary Care Competencies n Specialty Areas: Family, Gerontological, Pediatric, and Womens Health. Retrieved July 20, 2011 from: http://www.nonpf.com/displaycommon.cfm?an=1&subarticlenbr=14