Front Matter| Volume 5, ISSUE 1, Pix-xxiv, May 2023

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        Editorial Board iii

        Contributors v

        Preface: Applying Words and Concepts to Transform Nursing Practice xxv

        Linda J. Keilman

        Introduction: A Celebration of Words xxix

        Linda J. Keilman


        Recognizing, Diagnosing, and Treating Posttraumatic Stress Disorder in Older Adults

        Deborah A. Kernohan, Linda J. Keilman, and Tamatha (Tammy) Arms
        Posttraumatic stress disorder (PTSD) is a mental health condition that is triggered by a disaster or traumatic event the individual has experienced or witnessed. Symptoms may include depression, anxiety, insomnia, nightmares, regularly reliving or thinking about the distressing memories or event, and severe emotional distress. These symptoms and others can affect daily life, work–life balance, relationships, and quality of life. Older adults are at higher risk for PTSD and have gone undiagnosed for months or years. Knowing how to recognize and screen for PTSD is important for primary care providers such as advanced practice registered nurses.
         A historical perspective 2
         Older adults and posttraumatic stress disorder 3
         Recognizing posttraumatic stress disorder 4
         Case study 6
         Resilience factors 8
         Impact of coronavirus disease 2019 on the development of posttraumatic stress disorder 8
         Comorbidity posttraumatic stress disorder and dementia 9
         Advanced practice registered nurse role 9
         Treatment 10
         Implications for practice 11
         Clinics care points 11
         Disclosure 12

        The Impact of Food Insecurity on Chronic Disease Management in Older Adults

        Vallon Williams, Pamela J. LaBorde, and Jyrissa Robinson
        Food insecurity among the older adult population not only centers on finances to purchase food. Food insecurity is impacted by the functional status of the individual to access food, to afford medical care in addition to food, and to have the needed social support to assist with access to food and decrease social isolation often caused by the lack of social support. Food insecurity in the aging population seriously impacts health conditions associated with increased disease burden.
         Case presentation 15
         Introduction 16
        Food security 16
        Food insecurity 16
         Associated factors 17
        Mobility-related conditions and disabilities 17
        Economic factors 17
         Food insecurity and chronic disease 18
        Food insecurities and cardiovascular disease 18
        Food insecurity and diabetes 19
        Food insecurities and depression 19
         Health care assessments 20
         Interventions 22
         Advanced practice registered nurse role 22
         Summary 23
         Clinics care points 23
         Disclosure 23

        Immunosenescence and Infectious Disease Risk Among Aging Adults: Management Strategies for FNPs to Identify Those at Greatest Risk

        Deanna Gray-Miceli, Kathy Gray, Matthew R. Sorenson, and Barbara J. Holtzclaw
        Age-related immune changes increase the risk for viral infections such as coronavirus disease-2019, its mutant variants, and common influenza outbreaks in long-term care settings. Utilization of evidenced-based nursing interventions such as cohorting practices and implications for testing and screening aims to reduce risk of infection and improve quality of life. Incorporating an infection control manager will add leadership in maintaining currency of information and case tracking.
         Introduction 28
         Pathophysiology 28
        Innate and adaptive immune systems 28
        Conceptual framework 30
         History 30
        Family and adult nurse practitioners 31
        Assessment: testing and screening 32
        Clinical management: maintaining a screening and testing plan: staffing 32
        Management: isolation and cohorting 35
         Summary 37
         Clinics care points: immunosenescence 38
         Clinics care points: implications for leadership 38
         Disclosure 39

        Mild Cognitive Impairment in Older Adults

        Melodee Harris, Janet Rooker, and Linda J. Keilman
        Mild cognitive impairment (MCI) is more prevalent than dementia. The global population of older adults is growing and therefore the prevalence of MCI will continue to grow. MCI is not dementia. Cognition in persons diagnosed with MCI may progress to dementia, stay the same, or revert to normal cognition. More research is needed to prevent the progression of MCI to dementia.
         Introduction 41
         Definition 42
         Risk factors 42
         Prevalence 44
         Pathophysiology 44
         Symptoms 44
         Screening 44
         Differential diagnoses 46
         Diagnosis 46
         Workup 47
         Treatment 47
         Supplements and medications 47
         Nonpharmacological interventions 50
         Coronavirus disease-2019 51
         Transition to dementia 51
         Summary 51
         Clinics care points 52
         Disclosure 52

        Heart Failure in Older Adults

        Margaret T. Bowers
        There is an increasing prevalence of heart failure in older adults. Early recognition and intervention are important to enhance the quality of life and moderate heart failure symptoms. Universal definitions of heart failure provide a framework to tailor therapies that include new medications. Addressing goals of care should guide therapeutic treatments that may include pharmacologic agents, devices, referral for advanced therapies as well as lifestyle changes.
         Introduction 55
        Pathophysiology 55
        Definitions and classifications 56
        History 57
        Assessment 58
        Diagnosis 59
        Management 59
        Medications 59
        Polypharmacy 60
        Devices 61
        Advanced therapies 61
        Goals of care 62
         Discussion 62
        Implication for advanced practice nurses 63
         Summary 63
         Clinics care points 64
        Disclosure 64

        A Life Course Approach to Understanding Urinary Incontinence in Later Life

        Thanchanok Wongvibul
        Urinary incontinence (UI) is a highly prevalent condition that affects individuals at any stage of life, especially in older adults. The presence of UI can seriously affect the overall quality of life, leading to feelings of shame, embarrassment, as well as stigmatization. To prevent or delay the progression of this condition, it is very important to understand the risk factors that contribute to the development of UI across the life span. A better understanding of UI will help indicate the development of interventions to reduce UI.
         Introduction 67
        Background and significance 67
        A life course approach to continence care 68
        Bladder health and urinary incontinence across the life span 68
        Associated factors of urinary incontinence across the life span 70
        Potentially modifiable factors 71
        Management principles of urinary incontinence 71
         Summary 72
         Clinics care points 72
         Implication for advanced practice registered nurses 73

        The Three-Generation Pedigree: Elucidating Family Disease Patterns to Guide Genetic Screening, Testing, and Referral

        Laura Hays
        A family history pedigree, a three-generation pedigree of a person’s biological relatives with attached pertinent health information, is a standard tool used to more readily recognize patients who may benefit from genetics services. The depiction of both relationships and disorder traits advantage the pedigree over a simple genealogy for identifying patterns of disease expression and risk of disease inheritance.
         Introduction 77
        Definition/Description 78
        Phenotype versus genotype 80
        Modes of inheritance 81
        Older adults: when is it “STnormal”? 81
        Population and extended pedigrees versus three-generation pedigrees 82
        Precision medicine 83
        History 84
        Issue management 85
        Enhanced data input 86
         Discussion 86
        Limitations 87
         Summary 88
         Clinics care points 89
        Disclosure 89

        Peripheral Arterial Disease in Primary Care

        Kara Elena Schrader, Kristin Castine, and Pallav Deka
        Peripheral artery disease is the stenosis of the peripheral arteries due to atherosclerosis that reduces perfusion to the extremities. The risk is increased in older adults aged 65 and older. Complications include claudication, nonhealing ulcers, gangrene, critical limb ischemia, and amputation. PAD is underrecognized, with diagnosis occurring late in the condition. Patients have an elevated risk for atherosclerotic cardiovascular disease and require evidence-based management strategies to reduce risk. Strategies include the management of associated conditions such as smoking, diabetes, hypertension, and hyperlipemia. It is essential for nurse practitioners to identify risk factors and symptoms to institute early guideline-directed medical treatment.
         Introduction 94
         Background and significance 94
         Racial disparities 94
         Quality of life 95
         Health care cost 95
         The American Heart Association pad national action plan 95
         Pathophysiology 95
         Risks factors 96
        Assessment 96
        Diagnosis 98
        Classification 100
        Management in primary care 100
        Lifestyle changes 101
        Nutrition 102
        Pharmacology 103
        Chronic disease management 103
        Referral 104
        Management summary 104
        Implications for nurse practitioner practice 104
         Summary 104
         Clinics care points 104
        Disclosure 104

        Women’s Health

        Assessment and Management of Pelvic Organ Prolapse for the Rural Primary Care Provider

        Lisa S. Pair and William E. Somerall
        Pelvic organ prolapse is a common condition occurring in more than 50% of female patients. Patients may be asymptomatic or have complaints of pelvic pressure, pelvic fullness, or bulging around the vaginal opening. They may also have urinary, bowel, or sexual function complaints including urinary incontinence or voiding or bowel dysfunction. Educating rural primary care providers in the assessment, diagnosis, and nonsurgical management of pelvic organ prolapse including lifestyle modifications, pelvic floor muscle training, and the use of a vaginal support device can provide access to care for rural patients and increase their quality of life.
         Introduction 107
        Pelvic organ prolapse 108
        Transgender surgery and pelvic organ prolapse 108
        Risk factors for pelvic floor prolapse 110
        History 111
        Physical examination 111
         Summary of initial management from primary care provider 117
         Clinics care points 117
        Disclosure 117

        Care for Women with Past Trauma Using Trauma-Informed Care

        Patricia M. Speck, LaQuadria S. Robinson, Karmie Johnson, and Lauren Mays
        Violence against women is prevalent in all societies. Healthcare providers have the opportunity to care compassionately by implementing person-centered trauma-informed care practices, furthering safety and trustworthiness by using methods that encourage transparency, mutuality, and collaboration during all aspects of healthcare. The article promotes interventions for recognition of the person with traumatic experiences, assisting healthcare providers in the delivery of trauma-informed care, suggesting interventions to address person-centered cultural, historical, and gender issues. Using trauma-informed person-centered approaches, authors propose intervention tools to assist the healthcare provider in recognition and intervention, promoting self-efficacy and confidence in persons overcoming their complex personal traumas.
         Introduction 119
        Introduction to trauma-informed care 119
        Vulnerable populations: women 125
        Vulnerable populations: healthcare providers 125
        Mental health and recovery 125
        Provider interventions 128
         Discussion 128
         Summary 133
         Clinics care points 133
        Disclosure 133

        Care for Women with past Trauma: The Physiology of Stress and Trauma

        Patricia M. Speck, LaQuadria S. Robinson, Karmie Johnson, and Lauren Mays
        When traumas are continuous or toxic, the body increases the hormonal response, and the sensory perception is that environments are unsafe and unpredictable. In these situations, increasing anxiety and fear are the overarching demonstrative emotions. The initial trauma responses release hormones to preserve life. The sensory memory is activated and the next time the senses detect a similar stimulus, the hormones release again. When the environment is toxic, there is continuous release of hormones that manifest in early organ system failure and muted memories. This article discusses the physiologic response to trauma, explaining formative causes of disease and inheritance.
         Introduction 137
         Trauma and stress 138
         Trauma and biology 140
         Discussion 145
         Summary 145
         Clinics care points 146
         Disclosure 147

        Cannabis Use in Pregnancy and Postpartum: Understanding the Complicated History and Current Recommendations to Facilitate Client-Centered Discussions

        Elizabeth Muñoz, Ellen Solis, and Stephanie Mitchell
        Cannabis use in pregnancy can lead to poor pregnancy outcomes and negatively affect the health of the pregnant person and fetus. Its use is also highly stigmatized and can even lead to legal ramifications for the pregnant person in some states. Health care professionals need to be ready to answer questions from clients regarding cannabis use in pregnancy and be able to do so in a bias-informed and evidence-based manner using client-centered language. This article examines the history of cannabis use and explores care considerations if a client is using the substance in pregnancy.
         History of cannabis 152
        Components of the plant 152
        Medicinal timeline 153
         Common medicinal uses of cannabis 153
         Legality of cannabis 154
         The dangers of unregulated cannabis 155
        Fentanyl 155
         Considerations from US history and policy 156
        Policies surrounding pregnancy 156
         Cannabis use in pregnancy and postpartum 157
        Nausea and vomiting 157
        Sleep 159
        Mood disorders 159
         Evidence review 160
        Limitations to the evidence 160
         Considerations for care 161
         Scripting for health care professionals to have bias-informed discussions 161
         Counseling on legal consequences 165
         Summary 165
         Clinics care points 166
         Disclosure 166

        Gaps in Social Determinants of Health History Taking, Clinical Documentation, and Billing/Coding Errors During Women’s Health Patient Encounters

        Melissa LeBrun, Kim Brannagan, and Antiqua N. Smart
        Defining social determinants of health (SDOH) and identifying key areas in which they influence health is pertinent in health care and health-care education. The objectives of this article are to define SDOH and identify key areas in which they affect health, discuss SDOH as they relate to issues faced primarily by women, common screening tools used to assess SDOH, clinical documentation pearls for health assessment, including areas specific to preventative care for women, and SDOH Z-codes used for billing purposes. Common SDOH documentation errors are also addressed along with solutions to reduce them.
         Introduction 169
         Social determinants of health defined 170
        Social determinants and health equity in Women'SGCIs health 172
         Screening tools for assessing social determinants of health 173
        Common documentation pearls for social determinants of health and coding in Women'SGCIs health 174
        Clinical documentation components for Women'SGCIs health and social determinants of health screening 175
         Insufficient documentation 177
         Preventative medicine service coding for Women’s health 178
         Billing and coding social determinants of health 178
         Common clinical documentation errors related to social determinants of health 179
         Solutions to reduce social determinants of health clinical documentation errors 180
         Summary 180
         Clinics care points 181
         Disclosure 181

        Sexual Dysfunction in Biologic Females for Family Practice Providers: Assessment, Diagnosis, and Treatment

        Christina M. Wilson
        Sexual health is an important part of many individuals’ lives, and when there are problems with sexual function, it can disrupt or have a significant impact in their life. Sexual dysfunction typically occurs in one of the areas of the sexual response cycle (desire, arousal, orgasm) or is related to a lack of lubrication and/or pain. Sexual dysfunction affects a substantial proportion of both premenopausal and postmenopausal women. Both nonpharmacologic and pharmacologic options are available to help treat sexual dysfunction but are commonly used in conjunction with one another depending on the diagnosis.
         Introduction 183
         Approach to care 184
        Assessment 184
        Diagnosis 187
        Treatment Options 188
         Summary 189
         Clinics care points 189
         Declaration of Interests 190


        The Importance of Sleep for Normal Growth and Development

        Ann Sheehan
        Sleep is a period of intense brain growth and restoration. Quality sleep is an important part of physiologic, emotional, and cognitive development. Individual variability in sleep need is influenced by behavioral, medical, environmental, and cultural factors. This article provided an overview of the development of the sleep-wake cycle, how achievement of developmental milestones can affect the sleep-wake cycle, and the elements for creating a bedtime routine that support quality and quantity of sleep throughout childhood and adolescence. The consequences of poor sleep results in chronic health conditions, mood dysregulation, school failure, obesity, and an increase in risk taking behaviors.
         Introduction 193
         Sleep basics 194
        Circadian rhythm process 194
        Homeostasis process 194
        Ultradian rhythm process 195
         Sleep and development 195
         Newborns (0 to 2 months) 196
         Infants (2 to 12 months) 196
         Toddlers (12 to 36 months) 197
         Preschool (3 to 5 years) 197
         School age (6 to 12 years) 198
        Adolescents (12 to 18 years) 199
         Healthy sleep promotion 199
        Cultural and family practices 200
        Sleep hygiene 201
         Consequences of poor sleep quality and quantity 202
         Advance practice registered nurse implications for advanced practice registered nurses 202
         Summary 204
         Clinics care points 204
        Disclosure 204

        Fever of Unknown Origin in Pediatrics

        Emily Davis and Teresa Whited
        Fever of unknown origin (FUO) is defined as fever lasting at least 3 weeks without an apparent source after 1 week of investigation. The cause of FUO includes infectious, autoimmune, malignancy, neurologic, genetic, pharmacologic, and iatrogenic. Workup for FUO includes a comprehensive history from the patient, a thorough physical examination, and discontinuance of any nonessential medications. Initial laboratory and radiology workup include a complete blood count with differential, blood culture, C-reactive protein, erythrosedimentation rate, procalcitonin, liver enzymes, renal function tests, lactate dehydrogenase, urinalysis, urine culture, and chest radiograph.
         Pathophysiology 207
         Evaluation 208
        Neonates (8–21 Days) 210
        Infants 1 to 3 Months old 211
        Infants and toddlers 3 Months to 3 Years of age 212
        Children aged older than 3 Years 212
        Implications for advanced practice registered nurses 214
         Clinics care points 214
         Disclosures 214

        Pediatric Asthma for the Primary Care Provider

        Sarah Ann Keil Heinonen, Amanda C. Filippelli, and Nancy Banasiak
        Asthma, one of the most common pediatric chronic diseases, disproportionately affects children living in low-income households. Characterized by airway hyperresponsiveness, inflammation, and obstruction, asthma causes symptoms including wheezing, coughing, chest tightness, and shortness of breath. Asthma control remains a primary goal through guidelines, education, appropriate medication, specialist referrals, asthma action plans, and access to health care providers. Poorly controlled asthma remains the leading cause of absenteeism from school and work and an economic burden despite medical advances. This review article provides an overview of pediatric asthma, diagnosis, and the most current guideline-based management for the primary care provider.
         Introduction 217
         Pathophysiology 218
         Diagnosis 218
         Differential diagnoses 220
         Asthma classifications 220
         Asthma management 220
         Single maintenance and reliever therapy 224
        Exacerbations 224
        Severe cases 224
         When to refer 225
         Summary 225
         Implications for advanced practice providers 226
         Clinics care points 226
         Disclosure 226

        The Weight of Body Image

        Elizabeth R. Silvers and Kimberly J. Erlich
        Prevalence of eating disorders (EDs) in the adolescent and young adult (AYA) population has increased since the start of the COVID-19 pandemic, which correlates with increased engagement with social media and negative body image in AYAs. In addition, increased severity of EDs at presentation is evidenced by higher rates of hospitalization since the start of the pandemic, underscoring the need for health-care providers to obtain further training in managing EDs and appropriately referring to higher levels of care when indicated.
         Introduction and relevance to primary care 229
         Impact of the COVID-19 pandemic on eating disorders in adolescents and young adults 230
         Pathophysiology: relationship of body image to eating disorders 230
         History 232
         Screening 233
         Assessment 233
         Diagnosis 233
         Management 234
         Discussion 236
         Implication for advanced practice nurses 237
         Clinics care points 237
         Disclosure 237

        Emerging Mental Health Issues in Children and Adolescents Secondary to the Coronavirus Disease-2019 Pandemic

        Kellie Bishop and Teresa Whited
        This article examines and compares the incidence and prevalence of mental health issues, including depression, anxiety, and suicide, among adolescents before and during the coronavirus disease-2019 pandemic. It discusses contributing factors, clinical presentation, screening tools, treatment options, and implications for advance practice nurses. This article prepares the advance practice nurse to promote mental wellness and identify, screen for, and appropriately manage emerging mental health issues in this vulnerable population.
         Background 242
         Significance 242
         Discussion 242
        Coronavirus disease-2019 242
        Depression 243
        Anxiety 243
        Suicide 245
         Summary 251
         Clinics care points 252
         Disclosure 252

        Attention-Deficit/Hyperactivity Disorder Update 2022: New Medications Are Here!

        Erin O’Connor Prange
        Over the last 5 years, there has been an explosion of new attention-deficit/hyperactivity disorder (ADHD) medications US Food and Drug Administration approved and available for clinical use on the market. Trying to discern what is the same, different, and best for a specific patient can prove challenging. To ease this burden, this article will review the pharmacokinetics of stimulants and non-stimulants and highlight the benefits of these newly available medications. In addition, the article will discuss the most common side effects and describe options to manage these potential concerns. It is not the intention of this article to review the diagnostic criteria for an ADHD diagnosis.
         Medication overview 256
        Choosing stimulant versus non-stimulant medication 257
        Choosing methylphenidate versus amphetamines in a stimulant nave patients 258
        Changing stimulant medication 260
        Managing side effects 260
         Summary 264
         Clinics care points 265
         Disclosures 265

        Primary Care Management of Autonomic Dysfunction

        June Bryant
        Autonomic dysfunction (AD) in the primary care setting can often be masked by other conditions or met with provider bias due to subjectivity of symptoms. Without specific diagnostic test markers, underdiagnosis or misdiagnosis is common in those conditions that fall under the umbrella of dysautonomia. This article gives a broad overview of the common types of AD presenting in the primary care setting, how advanced practice nurses should recognize, diagnose, and manage these types of AD, as well as when and what patients should be referred to a specialist.
         Introduction 267
         Pathophysiology 269
         History 269
         Assessment 271
        Important elements of history taking 271
        History of present illness 272
        Past medical history 272
        Trigger identification 272
         Diagnosis 273
        Valsalva maneuver 273
        Tilt table testing 273
        Orthostatic intolerance testing 274
         Management 274
        Nonpharmacological 274
        Pharmacologic 277
         Referral 279
         Special population considerations 279
        Long-COVID 279
        Pediatrics 279
         Summary 279
         Clinics care points 280
         Disclosure 280

        When It Is Not Just Attention-Deficit Hyperactivity Disorder: Coexisting Depression and Anxiety in Pediatric Primary Care

        Valerie C. Martinez
        Attention-deficit hyperactivity disorder (ADHD) often exists along with other psychiatric disorders, such as depression and anxiety, but these conditions may be misdiagnosed or undertreated due to often overlapping symptomatology. Because of significant systemic and structural barriers to accessing specialized mental health care, pediatric primary care providers (PCPs) must possess a comprehensive understanding of ADHD and coexisting depression and/or anxiety to effectively diagnose and treat their patient’s symptoms. The purpose of this article is to review the prevalence of ADHD with coexisting depression and anxiety and outline assessment, diagnostic, and management considerations for PCPs when it is not just ADHD that requires clinical decision-making.
         Introduction 283
         Prevalence 284
         Clinical practice guidelines 284
         Assessment 285
        History 285
        Screening and diagnostic assessment tools 285
        Physical examination 287
         Diagnosis 288
         Management 288
        Psychoeducation 288
        Nonpharmacologic treatment approaches 290
        Pharmacologic treatment approaches 293
        Suicide risk 294
        Referral to mental health specialists 294
        Follow-up monitoring 294
         Implications for clinical practice 295
         Summary 295
         Clinics care points 295
         Disclosure 296