Journal of the American Academy of Nurse Practitioners最新文献

Purpose: To discuss the causative factors, clinical course, and current treatment modalities for Ludwig's angina, a submandibular cellulitis, and to raise nurse practitioners' (NPs') awareness of this condition.

Data sources: Recent clinical articles, research, case studies, and medical texts.

Conclusions: Ludwig's angina may be fatal. Early diagnosis, aggressive antibiotic therapy, and management involving a multidisciplinary team approach are imperative for the patient to progress without complications.

Implications for practice: Education and awareness are crucial for successful diagnosis of and management of treatment for Ludwig's angina. Although NPs have a limited role in the treatment of Ludwig's angina, their ability to recognize the signs and symptoms will prompt emergency care and treatment and facilitate better outcomes for their clients.

Purpose: To provide nurse practitioners with a conceptual framework from which to diagnose and manage chronic neuropathic pain, specifically postherpetic neuralgia (PHN). A current review of the available treatment options for the management of neuropathic pain and PHN is provided.

Data sources: A comprehensive literature review was conducted. Clinical articles, meta-analyses, and reviews were selected for their relevance to the diagnosis and management of chronic neuropathic pain and PHN.

Conclusions: Managing patients with chronic neuropathic pain is a common clinical challenge due to variability in individual symptoms, mechanisms, and treatment responses. In patients with PHN, a balanced treatment approach focusing on efficacy, safety, and tolerability is recommended. With appropriate treatment, most patients are able to achieve clinically significant relief from neuropathic pain.

Implications for practice: Diagnosis and management of neuropathic pain syndromes is challenging. Because of the complexity of chronic pain, successful long-term treatment can be especially difficult (Nicholson, 2003b). While most acute pain is nociceptive (i.e., a response to noxious stimuli), chronic pain can be nociceptive, neuropathic, or of mixed origin. PHN is a chronic pain syndrome that can last for years, causing physical and social disability and psychological distress (Kanazi, 2000). Despite major recent advances in the treatment of PHN, many patients remain refractory to current therapy (Dworkin, 2003). For practicing clinicians, including nurse practitioners, viewing pain as a disease rather than a symptom is the first step towards its successful management. Understanding the pathophysiology of chronic pain and emerging treatment paradigms for the management of neuropathic pain and PHN is critical to optimal care.

Purpose: To determine if there would be a difference in students' performance and level of satisfaction when taught pharmacology in a problem-based learning format as compared to traditional lecture format.

Data sources: Control (n = 12) and experimental (n = 10) group means for middle-of-term examinations, final examinations, end-of-course numerical averages, and numerical scores of satisfaction were analyzed with a t test for statistically significant differences.

Conclusions: There was no significant difference between groups for any of the items measured, suggesting that problem-based learning and traditional lecture format may be equally effective course delivery methods. Replication with a larger sample is recommended.

Implications: The small sample size precludes generalizing results to the entire population, but outcomes of this pilot study suggest that problem-based learning may be at least as effective as traditional lecture and should be explored in larger studies.

Data sources: Case example and review of clinical trials, meta-analyses, and reviews provide relevant data regarding the management of herpes zoster.

Conclusions: Herpes zoster is a relatively common disease in elderly patients. It results from reactivation of varicella zoster virus (chickenpox). Characteristic vesicular lesions are often accompanied by significant acute pain. The risk of complications, such as postherpetic neuralgia (PHN), increases when patients age or are inadequately treated.

Implications for practice: Appropriate diagnosis and management of herpes zoster may shorten the overall disease course, accelerate cutaneous healing, and reduce the risk of PHN, a chronically painful complication. Greater understanding of the epidemiology, clinical manifestations, diagnosis, and available treatment options is essential for nurse practitioners and other primary care providers to initiate early treatment in patients with suspected herpes zoster infection.

Purpose: To discuss the impact of pain and its associated comorbidities in elderly patients with postherpetic neuralgia (PHN). To review the pharmacologic treatments available for patients with chronic pain and concurrent sleep disturbance, depression, and/or anxiety.

Data sources: Relevant clinical literature pertaining to the management of common comorbid conditions in patients with PHN and chronic pain syndromes.

Conclusions: Chronic pain strongly influences physical and psychological function in elderly patients. Comorbid illnesses, such as insomnia, depression, or anxiety, often develop in patients with chronic pain and complicate overall pain management and worsen prognosis. Pharmacologic treatment strategies that reduce pain frequently result in concurrent improvements in common pain-associated comorbidities. Pharmacologic treatment should be selected based on the efficacy of the selected agent(s), potential for adverse effects, and impact on pain-associated comorbidity. A multidisciplinary pain care management approach is essential to alleviate pain, manage pain-associated comorbidities, and improve function and quality of life.

Implications for practice: Elderly patients who often deny their chronic pain are at increased risk for such conditions as sleep disturbance, depression, and/or anxiety. Nurses and nurse practitioners are in a unique position to improve pain care management by recognizing pain and its associated comorbidities early, educating patients regarding their perception of pain, and facilitating rational pharmacotherapy with the goal to improve function and quality of life.

Migraine headaches are the source of significant disability for many individuals and their management can present a considerable clinical challenge. The American Academy of Family Physicians (AAFP) and American College of Physicians--American Society of Internal Medicine (ACP-ASIM) "Pharmacologic Management of Acute Attacks of Migraine and Prevention of Migraine Headaches," provides a succinct, evidence-based resource for primary care nurse practitioners. In addition to reviewing this clinical practice guideline, this column describes related supporting documents.

Purpose: To review and discuss the clinical evaluation and therapeutic options for a postmenopausal woman with osteoporosis.

Data sources: Review of scientific literature, practice guidelines, and a case study.

Conclusions: To prevent and treat postmenopausal osteoporosis, women should be encouraged to perform weight-bearing exercise, to not smoke, and to optimize calcium and vitamin D intake through diet and supplements. Drug regimens are effective and well tolerated in postmenopausal women with osteoporosis.

Implications for practice: Drugs currently approved by the U.S. Food and Drug Administration for the treatment of postmenopausal osteoporosis include the bisphosphonates risedronate and alendronate; the selective estrogen receptor modulator, raloxifene; and intranasal calcitonin-salmon spray. Bisphosphonates have demonstrated the most impressive fracture risk reduction in prospective clinical trials of women with postmenopausal osteoporosis. Risedronate has consistently demonstrated significant reductions in vertebral fracture risk at 1 year and in vertebral and nonvertebral fracture risk at 3 years. Alendronate has demonstrated significant reductions in vertebral and nonvertebral fracture risk after 3 years.

Purpose: To determine whether patients with hypercholesterolemia were being treated according to the updated 2001 National Cholesterol Education Program (NCEP) clinical guidelines and whether a difference existed between internists and cardiologists in the implementation of these guidelines.

Data sources: This retrospective study used data obtained from a review of 200 patient charts that were compared with the NCEP guidelines.

Conclusions: Results indicated that 67% of internal medicine patients and 71% of cardiology patients who qualified for pharmaceutical treatment received prescriptions for cholesterol-lowering medications. The difference between internal medicine and cardiology physicians was not statistically significant.

Implications for practice: Like physicians, nurse practitioners should become familiar with and utilize the updated guidelines as standards of practice to promote and improve patient outcomes over the life span.

Purpose: To provide clinicians in primary care settings information on the effects of sleep-disordered breathing in patients with heart failure (HF). Assessment and screening tools, as well as management considerations, are presented.

Data sources: Review of the scientific literature of the past 10 years, along with classic studies and Internet sources.

Conclusions: HF is an increasingly prevalent problem with a high degree of associated sleep-disordered breathing. There are two broad categories of sleep-disordered breathing: obstructive sleep apnea and central sleep apnea/Cheyne-Stokes breathing. Both of these occur on a continuum of mild hypopnea to severe apnea with hypoxia. Sleep apneas are particularly harmful to patients with HF and, if left untreated, may adversely affect their prognosis. Yet sleep apnea is not routinely screened for in this population.

Implications for practice: Given the serious consequences of untreated sleep-disordered breathing, there is sound justification to screen for sleep apnea in all patients with HF. Subsequent treatment of those patients with sleep apnea can significantly improve their quality of life and can decrease their mortality.