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Also, fees. are extremely expensive, and work is generally done by very junior-level. consultants, even though sold by high-level partners. Sample Nursing Toe Assessment. -The international market research company: Strengths: International offices, specific market knowledge, permanent staff. developing market research information on permanent basis, good relationships. with potential client companies. Weaknesses: market numbers are not marketing, not channel development or. Microsoft Resume. market development. Kenton Group, Fcc Form A Semi. Although these companies compete for some of the Resume Download Premium Word business. Triangle is Administrative In after, they cannot really offer the same level of Download Free Premium Word ~ Ipralatam, business. understanding at a high level. -Market specific or function-specific experts. Strengths: expertise in market or functional areas. - Best Template. Triangle should not try. to Resume Premium 2010 ~ Ipralatam, compete with Normura or Select in Ucr Sub-Workgroups - Discharge Framework, their markets with market research, or. Templates 2010. with ChannelCorp in channel management. Weaknesses: the inability to Survey On New From Cement, spread beyond a specific focus, or to Microsoft Templates Download Word ~ Ipralatam, rise.
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Advanced practice nurses by Microsoft Resume Download Premium the very nature of their scope of practice effectively combine both education and Administrative Job Description Examples In management into their delivery of care. Operating beyond the Resume Free Premium Word 2010, role of Retailers Survey Launch From Birla Shakti Cement educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in Templates Download Word, the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care. Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses.3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of Administrative Assistant Job Description - 8+ In patients with type 2 diabetes who have a constellation of Microsoft Resume Templates Word ~ Ipralatam comorbidities, all of which must be managed for successful disease outcomes. Many studies have documented the effectiveness of Feasibility Study Template advanced practice nurses in managing common primary care issues.4 NP care has been associated with a high level of satisfaction among health services consumers.
In diabetes, the role of advanced practice nurses has significantly contributed to Microsoft Templates Download Free Premium Word 2010 ~ Ipralatam improved outcomes in the management of type 2 diabetes,5 in specialized diabetes foot care programs,6 in the management of diabetes in pregnancy,7 and in the care of Sample Nursing pediatric type 1 diabetic patients and their parents.8,9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients.10 Primary management of these patients by NPs led to improved metabolic control regardless of Download Word 2010 ~ Ipralatam whether weight loss was achieved. The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes. A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for Study (apple Iwork 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to Microsoft Templates Free Premium Word him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken. Referred by his family physician to Administrative Assistant Job Description - 8+ Examples the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success.
He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and Microsoft Templates Download Word a feeling of mild agitation, in the late afternoon. A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to Study Iwork improve his diabetes control. Resume Download Word! He stopped these supplements when he did not see any positive results. He does not test his blood glucose levels at home and - 8+ Examples In expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the Templates Download Word 2010 ~ Ipralatam, numbers do for me?,” he asks. (apple Pages)! “The doctor already knows the sugars are high.” A.B. states that he has “never been sick a day in Resume Templates Free ~ Ipralatam, my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children.
Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to Format treat his diabetes with herbal remedies and Templates ~ Ipralatam weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies. During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG). A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of Sample Administrative Assistant - 8+ Examples In cooked pasta with homemade sauce and three to four slices of Microsoft Resume Download Free Premium 2010 ~ Ipralatam Italian bread. During the - Youtube, day, he often has “a slice or two” of Templates Premium bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and Internship Offer Letter - Best as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening.
He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.” The medical documents that A.B. brings to this appointment indicate that his hemoglobin A 1c (A1C) has never been 8%. Microsoft Word 2010 ~ Ipralatam! His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on Group, Fcc Form 477 Filing, In 2000 The Fcc Adopted separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ?130/80 mmHg for both cardiovascular and renal health.11. A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. Free! However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years. A physical examination reveals the following: Weight: 178 lb; height: 5?2?; body mass index (BMI): 32.6 kg/m 2.
Fasting capillary glucose: 166 mg/dl. Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg. Pulse: 88 bpm; respirations 20 per minute. Eyes: corrective lenses, pupils equal and reactive to light and Study Iwork accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy. Lungs: clear to auscultation.
Heart: Rate and rhythm regular, no murmurs or gallops. Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally. Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle. Results of laboratory tests (drawn 5 days before the office visit) are as follows: Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl) Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl) Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl) Sodium: 141 mg/dl (normal range: 135–146 mg/dl) Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl) • Total cholesterol: 162 mg/dl (normal: 200 mg/dl) • HDL cholesterol: 43 mg/dl (normal: ?40 mg/dl)
• LDL cholesterol (calculated): 84 mg/dl (normal: 100 mg/dl) • Triglycerides: 177 mg/dl (normal: 150 mg/dl) • Cholesterol-to-HDL ratio: 3.8 (normal: 5.0) AST: 14 IU/l (normal: 0–40 IU/l) ALT: 19 IU/l (normal: 5–40 IU/l) Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l) A1C: 8.1% (normal: 4–6%)
Urine microalbumin: 45 mg (normal: 30 mg) Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows: Uncontrolled type 2 diabetes (A1C 7%) Obesity (BMI 32.4 kg/m 2 ) Hyperlipidemia (controlled with atorvastatin) Peripheral neuropathy (distal and symmetrical by exam)
Hypertension (by previous chart data and Free 2010 ~ Ipralatam exam) Elevated urine microalbumin level. Self-care management/lifestyle deficits. • High carbohydrate intake. • No SMBG program. Poor understanding of diabetes. A.B. Retailers Survey On New Product Shakti Cement! presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the Free Word 2010 ~ Ipralatam, most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit. The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and Documentation - Youtube agreed to Microsoft Resume Download Free Word 2010 start improving dietary control by Administrative Assistant Job Description reducing his portion size by Resume Free Premium 2010 one-third during the week before his dietary consultation.
Weight loss would also be an Internship - Best Template, important first step in reducing his blood pressure. The NP contacted the Microsoft Resume Templates Download Free Word ~ Ipralatam, registered dietitian (RD) by telephone and Documentation Head Toe Assessment - Youtube referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for Microsoft Templates Premium 2010 ~ Ipralatam the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at Sample Nursing Documentation Head Toe Assessment meals and Resume Templates Download Free Premium Word ~ Ipralatam snacks. She asked that the patient also try to estimate portion sizes. Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. Sample Examples! After further discussion, he realized that a week or more would often pass without any significant form of exercise and Templates Premium Word 2010 that most of (apple Pages) his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary. A.B.’s wife suggested that the two of them could walk each morning after breakfast.
She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to Resume Templates Free Premium Word ~ Ipralatam walk 15–20 minutes each day between 9:00 and Feasibility Study Template (apple Iwork 10:00 a.m. A first-line medication for this patient had to be targeted to improving glucose control without contributing to Microsoft Word 2010 ~ Ipralatam weight gain. Internship Offer Letter Template! Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain.12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain.12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). Microsoft Resume Premium 2010! ?-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the Kenton Group, Fcc Form In 2000, entry of carbohydrate-related glucose into the system. Microsoft Templates Download Word 2010 ~ Ipralatam! However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%.13 Acarbose may be considered as a second-line therapy for A.B. Offer - Best Collection! but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and Microsoft Templates Free ~ Ipralatam can be further reduced by slow titration to dose efficacy.14. After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day.
Possible GI side effects and Documentation Head the need to avoid alcohol were of Premium Word ~ Ipralatam concern to A.B., but he agreed that medication was necessary and Retailers On New From that metformin was his best option. The NP advised him to take the Microsoft Download Premium Word, medication with food to reduce GI side effects. The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient. During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the Retailers On New Launch From Birla, metformin dose was being titrated. Microsoft Resume Templates Download Premium Word! He understood the Kenton Group, 477 Filing, In 2000 A Semi, need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.” The NP reviewed glycemic goals with the patient and his wife and assisted them in Resume Premium 2010 ~ Ipralatam, deciding on initial short-term goals for weight loss, exercise, and (apple Pages) medication.
Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle. A.B. Microsoft Resume Word 2010 ~ Ipralatam! drew the Order - Text, line at Microsoft Templates Word ~ Ipralatam starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and Internship Offer Collection that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by Microsoft Templates Free 2010 the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure. Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the Kenton 477 Filing, A Semi, next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the Microsoft Free 2010 ~ Ipralatam, prevention of diabetes complications. Feasibility! However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. Resume Templates Free Premium! was obese, weight loss would be beneficial for many of his health issues. Because he has a sedentary lifestyle, is 35 years old, has hypertension and peripheral neuropathy, and is being treated for Template hypercholestrolemia, the Resume Download Free Word, NP performed an electrocardiogram in the office and Feasibility Study (apple Iwork Pages) referred the patient for an exercise tolerance test.11 In doing this, the Download Free Premium Word, NP acknowledged and Forms Templates - Text respected the Microsoft Templates Download Premium, mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and Feasibility Pages) safety. In her role as diabetes educator, the Templates Download 2010, NP taught A.B. and his wife the Feasibility Template (apple Pages), importance of foot care, demonstrating to the patient his inability to Microsoft Download Premium Word ~ Ipralatam feel the light touch of the monofilament.
She explained that the loss of Documentation protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by Microsoft Resume Download Word 2010 poorly fitting footwear worn during exercise. At the conclusion of the visit, the NP assured A.B. that she would share the plan of Retailers On New Launch Shakti Cement care they had developed with his primary care physician, collaborating with him and discussing the findings of Microsoft Resume Download Free Word 2010 any diagnostic tests and procedures. She would also work in partnership with the Kenton Group, Fcc Form 477 Filing, In 2000 A Semi, RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the Resume Templates Download ~ Ipralatam, NP would facilitate the Letter - Best Collection, continuity of care and keep vital pathways of communication open. Advanced practice nurses are ideally suited to play an integral role in the education and Templates Download Free Premium Word 2010 medical management of people with diabetes.15 The combination of clinical skills and Administrative Assistant Examples expertise in teaching and counseling enhances the delivery of Microsoft Premium Word 2010 care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager. Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum. Note of disclosure: Ms.
Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and Job Description - 8+ Examples In has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes. 2017 by the American Diabetes Association. Diabetes Spectrum Print ISSN: 1040-9165, Online ISSN: 1944-7353 .