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Graduate Scholarly Synthesis Abstracts

Graduate Nursing Scholarly Synthesis Evidence Based Capstone Abstracts 2012

Harding, C. M. (May 4, 2012). Use it or lose it: Exercise management of knee osteoarthritis.
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Osteoarthritis of the knee is one of the five leading causes of disability in the U.S. Evidence has suggested that patients with knee OA may use targeted conditioning exercises without increasing joint pain, or the requirement for analgesics or NSAIDs. A systematic search of data-based literature from 2005 to 2011was performed to address the PICO question: In adult patients with osteoarthritis of the knee, will a Nurse Practitioner prescribed quadriceps strengthening program decrease pain? Evidence from one level 1 guideline, one level 1 review, and one level 2 RCT was utilized to design a research-based exercise protocol, guided by King’s mid-range Theory of Goal Attainment. A decrease in pain from pre-intervention levels was noted in 2 of 3 patients enrolled; one patient achieved a = 25% pain reduction. Future use of this protocol may provide an alternative strategy to manage knee OA pain in primary care.

Frank, J. (May 4, 2012). “Good Night Honey – Pediatric Nocturnal Cough Relief”
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Families present at the medical provider’s office looking for relief from their child’s bothersome nocturnal cough because it interferes with their activities of daily life and can even have a negative effect on their quality of life. This evidence-based proposal examines the question, “In children ages 2 years to18 years, with an upper respiratory infection, will prescribing an age-adjusted dose of buckwheat honey provide relief of nocturnal cough symptoms?” Katharine Kolcaba’s Theory of Comfort is the framework and Kolcaba’s concept of relief is the outcome of the EBP. Seven children met the inclusion criteria for the evidence-based protocol. One mother was not willing to give her son honey and one mother did not follow through with the protocol. Five children participated and all five had a positive outcome of relief from their nocturnal cough symptoms. The buckwheat honey provided relief from nocturnal cough symptoms!

Cadman, J. (May 4, 2012). “Uncontrolled Hypertension: "Wee" Can Help!”
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Hypertension (HTN), affecting approximately 73 million Americans, is associated with significant vascular morbidity and mortality (Kountz, 2009). Research supports the beneficial effects of quality blood pressure (BP) management, and that the most patients will require combination pharmacotherapy (Fitzgerald, 2011). The focused question is, “In adult patients with uncontrolled Stage I HTN for greater than one month after the initiation of an angiotensin converting enzyme inhibitor, will the addition of 12.5mg of hydrochlorothiazide (HCTZ) be effective in lowering the BP?” Results of a rigorous literature search were used to formulate an evidence-based practice protocol for additive pharmacologic HTN therapy. Imogene King’s Goal Attainment Theory was employed in the implementation. Second-line HCTZ treatment-induced systolic BP (SBP) and diastolic BP (DBP) reduction was demonstrated in seven out of eight patients representing 87.5% achievement. The reductions averaged -20.8mmHg for SBP and -8mmHg for DBP. These results exceeded those reported in the appraised literature.

Simeone, K. L. (May 4, 2012). Hyperglycemia management in the hospitalized patient: How sweet it is.
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Tight glycemic control is a focus of care for critically ill hospitalized diabetics. Yet, glucose management in non-critical medical and surgical diabetic patients, using premeal sliding scale insulin dosing, has provided suboptimal results. A systematic search of data-based literature from 2002 to the present was conducted to address the following PICO question: In hospitalized, non-critical, patients with type 2 diabetes and a hospital admission glucose value > 140 mg/dl, would the utilization of a weight-based, basal-bolus insulin protocol provide premeal glucose values to < 140 mg/dl? Evidence from two level 2 RCTs and one level 1 guideline was used to design an evidence-based protocol, guided by the Transtheoretical Model. While a reduction in pre-meal glucose values was achieved in all enrolled patients (4 of 4), none was able to achieve the target value. Future use of this protocol may require adjustment of the target glucose values and/or timeframes for measurement.

Wagner, P. (May 4, 2012). “Break a Leg: Vitamin D Supplementation in Obesity”
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

The significance of vitamin D to bone health is recognized worldwide, research has linked vitamin D to other chronic diseases affecting our society. Additionally, when BMI is > than 30 the fat sequesters vitamin D, therefore obesity increases the risk for vitamin D deficiency (Wortsman, 2000). In this paper the PICO question: In obese adults with vitamin D levels, less than 30ng/ml, are larger doses of vitamin D required to achieve adequacy. A systematic search of data based literature from 2000 to present was completed. Major recommendations based on a clinical practice guideline were used to formulate an evidence-based protocol (EBP) for treating hypovitaminosis D in the presence of obesity. Imogene King’s mid-range theory of Goal Attainment was used to guide the development and implementation of the protocol. A vitamin D prescription for 50,000 units of vitamin D twice weekly for four weeks increased 25(OH)D levels an average of 10ng/ml.

Vnuk, A.F. (May 4, 2012). Breaking the habit: A tobacco cessation strategy for primary care.
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

The Healthy People 2020 national health objectives seek to reduce the prevalence of cigarette smoking in the U.S. The primary care office has been recognized as the best setting for treating tobacco use. A systematic search of the data-based literature from 1996 to 2011 was conducted to address the PICO question: In adult heavy smokers will an NP prescribed nicotine nasal spray (NNS) protocol result in a reduction of cigarettes smoked a day? Evidence from one level I guideline, one level I review, and one level II RCT was used to design an evidence-based protocol, targeting the reduction or abstinence of tobacco use by heavy smokers. The mid-range 5A’s Behavioral Change Model was used to implement the protocol. Two of four enrolled patients (50%) showed a 50% reduction in numbers of cigarettes smoked in a four-week timeframe. Future utility of this protocol should address an extended timeframe for tobacco cessation.

Medura, C. (May 4, 2012). “It Take Four To Score – Centor Scoring in the Diagnosis of GABHS”
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Sore throat represents a very common complaint in adults who are seeking medical attention. Finding a practical and cost effective way to identify patients with GABHS pharyngitis would be vital to the APN and their patients who present with a sore throat. The use of a Centor score improves diagnostic accuracy by excluding patients with low risk of streptococcal infection by estimating the probability of GABHS pharyngitis. The Centor score was used for 53 people within one month with the results revealing 41 negative RADT and 12 positive RADT. Among the negative RADT, the outcome indicated 66% accuracy with Centor Score. Among the positive RADT, the outcome indicated 92% accuracy. The use of the Centor score by the APN saves time, money, unnecessary testing and treatment. The ease and affordability makes the Centor score a practicable tool for use in practice and has shown to be a reliable and valid tool.

Pedro, C.N. (May 4, 2012). Cerumen impaction: Can you hear me now?
Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Cerumen impaction is a common childhood health problem. Removal of cerumen is one of the most common ENT procedures performed by clinicians in primary care. Yet, there is a lack of consensus on the method of removal. A systematic search of data-based literature from July 2011 to January 2012 was conducted to answer the following PICO question: In children with cerumen impaction, will the use of a water-based cerumenolytic agent 15 minutes prior to irrigation with 50 ml of saline allow for symptom relief? Evidence from Level I and Level II literature was used to support a protocol designed to provide relief of ear symptoms in children with cerumen impaction. The protocol was guided by Kolcaba's mid-range Comfort Theory. Symptom relief was achieved in 6 of 6 children enrolled. Future use of this protocol will provide a viable, evidence-based treatment option for cerumen removal in children seen in primary care.


 

2011

 

Evans, A. M. (May 6, 2011). Valerian: Nature’s way of saying goodnight. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Insomnia is an under-reported and under-treated health problem in the United States. Adults who suffer from primary insomnia may be jeopardizing their own health, as well as the health and welfare of others. A systematic search of data-based literature from 2002–2010 was conducted to address the following PICO question: In adults with primary insomnia will the use of valerian improve their quality of sleep? Evidence from one Level I meta-analysis and two Level II RCT’s was utilized to support a research-based guideline for improved sleep quality, guided by Orlando’s mid-range Theory of Deliberative Nursing Process. Improved sleep quality was reported in all three of the adults (100%) who followed the protocol. Future use of this guideline may result in routine insomnia screening, combined with a safe alternative sleep management option for adults in primary care.

Murphy, L. M. (May 6, 2011). Osteoporosis follow-up: No bones about it. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

A gap exists between accepted recommendations and current practice in osteoporosis care. Treatment-naïve fragility fracture patients are not receiving adequate post-discharge care to prevent future fracture, due to low adherence rates for follow-up appointments. A systematic search of data-based literature from 2005 to present was conducted to address the following PICO question: In post-discharge home-based adults with fragility fractures, will a CNS managed coaching/guidance intervention increase High Risk Osteoporosis Clinic (HiROC) follow-up appointment adherence? Evidence from three Level II RCTs was utilized to design a research-based protocol for improving osteoporosis follow-up adherence rates, guided by the mid-range 5 A’s Behavioral Change Theory. Follow-up appointment adherence was seen in 58% of the adults enrolled in the intervention, a nearly 2-fold increase in the rate of HiROC follow-up. Future use of this system-based CNS intervention may result in sustained improvement in follow-up adherence rates for osteoporosis treatment.

Rowlands, M. R., (May 6, 2011). Crunching ‘carbs’ for glycemic control. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas PA.

The cornerstone of diabetes management is glycemic control. Dietary intervention has been a recognized management strategy for type 2 diabetics; however, there is lack of consensus regarding which diet is most effective in promoting glycemic control. A systematic search of the current literature from 2006 through 2011 was conducted to address the following PICO question: In adult type 2 diabetic patients who have a hemoglobin A1C = 7.0 % and are taking oral hypoglycemics, will the addition of a low carbohydrate diet improve glycemic control? Evidence from one guideline, one RCT, and one quasi-experimental study was used to design a research-based protocol for glycemic control, guided by the mid-range 5 A’s Behavioral Change Model. Two patients were enrolled in the CNS intervention; one (50%) successfully reached the outcome of glycemic control. Future use of this protocol may result in improved glycemic control for patients who manage dietary carbohydrates.

Shuker, C. M. (May 6, 2011). Rhinosinusitis: It ‘SNOT’ about antibiotics. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Sinusitis is a prevalent cause of morbidity in adults, the majority of whom seek symptom resolution with a prescribed antibiotic. The indiscriminate use of antibiotics to treat uncomplicated acute rhinosinusitis has been shown to contribute to the problem of antimicrobial resistance. A systematic search of data-based literature from 2003-2010 was conducted to address the PICO question: In adult patients 18 years and older with uncomplicated acute viral rhinosinusitis, will the use of palliative measures result in symptom resolution? Evidence from a level I systematic review, a level I guideline, and a level II RCT supported a research-based protocol for palliative symptom resolution, guided by Kolcaba’s mid-range Comfort Theory. Symptom resolution, as measured by the SNOT-20 score, was seen in four of the five adults (80%) enrolled in this intervention. Future use of this protocol may offer a safe and effective treatment option for acute viral rhinosinusitis, without unnecessary antibiotic use.

Slucki, A.M. (May 6, 2011). Acute otitis media: Let's wait and see. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Acute otitis media is the most common childhood illness for which antibiotics are prescribed. As experts debate the most effective management of AOM symptoms, the over-use of antibiotics is contributing to increased antimicrobial resistance at a rate that outpaces the development of new drugs. A systematic search of data-based literature from 2005-2010 addressed the PICO query: In children 2 to 5 years old with non-severe acute otitis media, is watchful waiting effective in symptom resolution? Evidence from one Level I guideline and two Level II RCTs supported a research-based watchful waiting protocol, guided by Kolcaba’s mid-range Comfort Theory. All three children (100%), who met the diagnostic criteria for non-severe AOM and were recruited into the protocol, experienced otalgia and fever resolution in 72 hours. Future use of this ‘watchful waiting’ protocol may provide a safe option for symptom resolution without unnecessary antibiotic use.


 

2010

 

Campagna, B. A. (May 7, 2010). Diet modification in pre-hypertension management. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Pre-hypertension is a diagnostic category recently identified by the JNC-7. It is estimated that pre-hypertension may affect as many as 31% of Americans, many of whom are currently not being treated. Early recognition and treatment in the primary care setting can reduce disease progression and subsequent health problems. A systematic review of data-based literature was conducted to address the following PICO question: In pre-hypertensive adults, will FNP-monitored diet modification including DASH and sodium restriction alone reduce blood pressure? Level I and Level II evidence was used to design a treatment protocol, based on the Health Belief Model, a shared mid-range theory. Of five pre-hypertensive patients recruited into the protocol, 80% experienced a mean systolic reduction of 19.5mm/Hg and a mean diastolic reduction of 8.5mm/Hg. It is anticipated that this evidenced-based protocol will provide an effective non-pharmacologic treatment option for pre-hypertensive adults.

Costanzo, A. (May 7, 2010). Older men and depression: Two-question screening. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Detecting depression in older men in primary care is a challenge, not only because men under-report and experience depression atypically, but also because older men are at the greatest risk for completing suicide. A systematic search of data-based literature from 2000 to present is conducted to address the following PICO question: For men >50 years old will a routine two-question screening protocol in primary care effectively identify those men with MDD symptoms compared to those screened with the PHQ-9? Level I, II, and IV evidence support a case-finding protocol for depression in older men, guided by Roy’s mid-range Theory of Person as an Adaptive System. Fifty-five men were screened. The 2-question protocol yielded 2 positive screens and the PHQ-9 failed to detect any positive results for depression. Future use of the shorter, 2-question screen may prove to be an efficient method for case finding in primary care.

Davis, L. (May 7, 2010). Efficacy of fish oil in rheumatoid arthritis pain control. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Rheumatoid arthritis pain is one of the leading causes of disability in the United States. Complementary pain management may have the potential to reduce RA pain for patients in the primary care setting. A systematic search of data-based literature from 2000 to present is conducted to address the following PICO question: In rheumatoid arthritis patients 30 years or older, would non-pharmacological supplementation with 2.7 grams daily dosing of fish oil result in decreased joint pain? Level I and level II evidence is used to develop a primary care protocol for fish oil supplementation. The protocol was guided by Kolcaba’s mid-range Comfort Theory. Seven patients were recruited into the protocol and 2 were lost to follow-up. Of the five patients on the protocol, 60% achieved reduction in RA pain at 4 weeks. Use of this protocol can provide a complementary treatment option for reduction in joint pain for adult RA patients.

Grencavage, S. L., (May 7, 2010). Achieving smoking cessation with Chantix and the Get Quit Support Plan clinical intervention project. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Tobacco use is a public health problem in the United States. Despite evidence of the long-term health consequences of smoking, few clinicians regularly provide sustainable smoking cessation options for their patients who smoke. A systematic search of data-based literature from 2005 to the present was conducted to address the following PICO question: In adult smokers (>10 cigarettes/day), how effective is Chantix combined with the Get Quit Support Plan vs. Chantix alone in reducing tobacco use? The shared, mid-range Transtheoretical Theory provides the framework for a smoking cessation guideline supported by Level I and Level II evidence. Five patients were recruited into the evidence-based protocol and two patients were lost to follow-up. Of the 3 remaining patients, 66% achieved smoking cessation with Chantix combined with the Get Quit Support Plan. Future use of the protocol may result in a sustainable decrease in cigarette smoking by adults seen in primary care.

Tewksbury, A.S. (May 7, 2010). Screening for hyperlipidemia in young men. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Current evidence links elevated cholesterol in youth with later CHD, yet young men are not being adequately screened and the associated treatment options lack specificity. A systematic search of current data-based literature was performed to address the following PICO question: In men aged 20 to 35 with 2 or more risk factors for CHD, will routine LDL-C screening in primary care differentiate those men who will benefit from therapeutic lifestyle changes from those who require treatment with pharmacologic agents? An evidence-based screening protocol was developed, using Neuman’s mid-range Prevention as Intervention Theory, and supported by level I, II and IV evidence. The protocol effectively identified three at-risk young men out of 14 who met the screening criteria. Tiered decision-making was used to refer one patient with an LDL-C of 137mg/dl to therapeutic lifestyle changes, while the remaining two patients were referred to annual re-screening.

Vidumsky, K. M. (May 7, 2010). Sucrose: A sweet solution to infant immunizations. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Immunization is the most frequent painful procedure performed on healthy infants beyond the neonatal age. Despite an increased focus on pain assessment in recent years, immunization-related pain in infants remains largely untreated in primary care. A systematic search of data-based literature from 1995 to the present was performed to address the following PICO question: In infants 6-months-old and younger receiving routine immunization injections, will the use of an oral sucrose solution provide greater relief of procedural pain than standard comfort measures alone? Level II evidence was used to design a protocol for pain reduction in infants, guided by the mid-range Theory of Comfort. There was a significant mean reduction in pain for infants receiving sucrose versus those receiving only standard comfort measures respectively, both at 2 minutes post injection (mean = 2.0 vs. 6.33) and again at 3 minutes (mean = 0.67 vs. 5.00).

Zeshonski, S., (May 7, 2010). Reducing fracture risk in men: Routine Screening using FRAX scores without BMD. Presented at the Graduate Nursing Synthesis Seminar, Misericordia University, Dallas, PA.

Older men have a higher mortality from hip fractures and a lower frequency of screening and treatment for osteoporosis. A systematic data-based literature search from 2005 to the present is conducted to address the PICO question: In men ages 50-69 not on a pharmacologic agent for the prevention of osteoporosis, will an FNP routine screening intervention using FRAX (without BMD), be an effective case finding strategy for identifying men requiring pharmacologic management to reduce fracture risk? Neuman’s mid-range theory of Prevention as Intervention is used to guide a screening protocol supported by Level I and Level IV evidence. Eleven men in the primary care setting were screened with FRAX. Although none of the 11 men screened positive for a 10-year fracture risk, it is anticipated that screening of larger numbers of men on a routine basis will result in the early identification of osteoporotic fracture risk in this population.