Adult Primary Care for the Advanced Practice Nurse (D118)

NURS 6820 Adult Primary Care for the Advanced Practice Nurse (D118) Study Notes 

Table of Contents

1. Introduction to Adult Primary Care
2. Health Promotion and Disease Prevention
3. Common Adult Health Conditions
   • Hypertension
   • Diabetes Mellitus
   • Hyperlipidemia
4. Chronic Disease Management
   • Asthma
   • Chronic Obstructive Pulmonary Disease (COPD)
5. Mental Health in Primary Care
   • Depression
   • Anxiety
6. Women’s Health
   • Menopause
   • Contraception
7. Men’s Health
   • Benign Prostatic Hyperplasia (BPH)
   • Erectile Dysfunction
8. Geriatric Care
   • Polypharmacy
   • Fall Prevention
9. Acute Conditions in Primary Care
   • Upper Respiratory Infections (URI)
   • Urinary Tract Infections (UTI)
10. Evidence-Based Practice
11. Case Studies with Analysis
    • Case Study 1: Hypertension Management
    • Case Study 2: Diabetes Management
12. Conclusion and Study Pack Benefits

1. Introduction to Adult Primary Care

Adult primary care focuses on the prevention, diagnosis, and management of health conditions in adults. Advanced Practice Nurses (APNs) play a critical role in providing holistic, patient-centered care. Key responsibilities include health promotion, disease prevention, and patient education.

Key Skills for APNs:

• Clinical reasoning
• Evidence-based practice
• Effective communication

2. Health Promotion and Disease Prevention

Health promotion and disease prevention are foundational in adult primary care. APNs must be familiar with screening guidelines and lifestyle interventions.

Screening Guidelines:

• Cardiovascular Health: Screen for hypertension, hyperlipidemia, and diabetes.
• Cancer Screening: Recommend mammograms, colonoscopies, and Pap smears based on age and risk factors.
• Immunizations: Ensure patients are up-to-date on vaccines like influenza, pneumococcal, and HPV.

Lifestyle Modifications:

• Encourage smoking cessation, weight management, and regular physical activity.

Example: A 45-year-old male with a BMI of 32 should be counseled on weight loss strategies and screened for diabetes and hypertension.

3. Common Adult Health Conditions

Hypertension

• Diagnosis: BP ≥130/80 mmHg on two separate occasions.
• Management:
  • Lifestyle changes: DASH diet, sodium restriction, and exercise.
  • Medications: ACE inhibitors (e.g., lisinopril), beta-blockers, or diuretics.

Example: A 50-year-old male with a BP of 150/95 mmHg should be started on lisinopril and advised to follow a DASH diet.

Diabetes Mellitus

• Diagnosis: Fasting glucose ≥126 mg/dL or HbA1c ≥6.5%.
• Management:
  • Medications: Metformin, insulin therapy.
  • Patient education: Glucose monitoring, diet, and exercise.

Example: A 45-year-old female with a fasting glucose of 140 mg/dL should be started on metformin and referred to a dietitian.

Hyperlipidemia

• Diagnosis: LDL >160 mg/dL.
• Management:
  • Medications: Statins (e.g., atorvastatin).
  • Lifestyle changes: Low-fat diet and exercise.

Example: A 55-year-old male with an LDL of 170 mg/dL should be started on atorvastatin and advised to follow a low-fat diet.

4. Chronic Disease Management

Asthma

• Symptoms: Wheezing, shortness of breath, and cough.
• Management:
  • Medications: Inhaled corticosteroids (e.g., fluticasone) and bronchodilators (e.g., albuterol).
  • Patient education: Trigger avoidance and proper inhaler use.

Example: A 30-year-old female with asthma should be prescribed a maintenance inhaler and a rescue inhaler.

Chronic Obstructive Pulmonary Disease (COPD)

• Symptoms: Chronic cough, sputum production, and dyspnea.
• Management:
  • Medications: Long-acting bronchodilators (e.g., tiotropium).
  • Lifestyle changes: Smoking cessation and pulmonary rehabilitation.

Example: A 60-year-old smoker with COPD should be advised to quit smoking and prescribed tiotropium.

5. Mental Health in Primary Care

Depression

• Symptoms: Persistent sadness, loss of interest, and fatigue.
• Management:
  • Medications: SSRIs (e.g., sertraline).
  • Psychotherapy: Cognitive-behavioral therapy (CBT).

Example: A 35-year-old female with depression should be screened for suicidal ideation and started on sertraline.

Anxiety

• Symptoms: Excessive worry, restlessness, and palpitations.
• Management:
  • Medications: Benzodiazepines (short-term) and SSRIs.
  • Psychotherapy: CBT.

Example: A 25-year-old male with anxiety should be prescribed a short-term benzodiazepine and referred for CBT.

6. Women’s Health

Menopause

• Symptoms: Hot flashes, night sweats, and vaginal dryness.
• Management:
  • Hormone replacement therapy (HRT).
  • Lifestyle changes: Regular exercise and a healthy diet.

Example: A 50-year-old woman experiencing hot flashes may benefit from low-dose HRT.

Contraception

• Options: Oral contraceptives, IUDs, and condoms.
• Counseling: Discuss efficacy, side effects, and patient preferences.

Example: A 28-year-old female seeking contraception should be educated on the benefits and risks of IUDs.

7. Men’s Health

Benign Prostatic Hyperplasia (BPH)

• Symptoms: Urinary frequency, hesitancy, and weak stream.
• Management:
  • Medications: Alpha-blockers (e.g., tamsulosin).
  • Surgical options: Transurethral resection of the prostate (TURP).

Example: A 55-year-old male with BPH should be started on tamsulosin.

Erectile Dysfunction

• Symptoms: Inability to achieve or maintain an erection.
• Management:
  • Medications: PDE5 inhibitors (e.g., sildenafil).
  • Lifestyle changes: Weight loss and smoking cessation.

Example: A 60-year-old male with erectile dysfunction should be prescribed sildenafil and advised to quit smoking.

8. Geriatric Care

Polypharmacy

• Risks: Drug interactions and adverse effects.
• Management: Regular medication review and deprescribing.

Example: An 80-year-old patient on multiple medications should have a comprehensive medication review.

Fall Prevention

• Strategies: Home safety modifications and balance exercises.
• Example: A 75-year-old female with a history of falls should be referred to physical therapy.

9. Acute Conditions in Primary Care

Upper Respiratory Infections (URI)

• Symptoms: Cough, sore throat, and nasal congestion.
• Management: Symptomatic treatment (e.g., acetaminophen, hydration).

Example: A 25-year-old male with a URI should be advised to rest and stay hydrated.

Urinary Tract Infections (UTI)

• Symptoms: Dysuria, frequency, and urgency.
• Management: Antibiotics (e.g., nitrofurantoin) and increased fluid intake.

Example: A 30-year-old female with dysuria should be tested for UTI and treated with nitrofurantoin.

10. Evidence-Based Practice

• Importance: Integrating clinical expertise with the best available evidence.
• Example: Using the latest guidelines for hypertension management to optimize patient outcomes.

11. Case Studies with Analysis

Case Study 1: Hypertension Management

• Scenario: A 50-year-old male with a BP of 150/95 mmHg.
• Plan: Lifestyle changes and lisinopril.
• Analysis: Early intervention prevents complications.

Case Study 2: Diabetes Management

• Scenario: A 45-year-old female with a fasting glucose of 140 mg/dL.
• Plan: Metformin and lifestyle changes.
• Analysis: Comprehensive management prevents long-term complications.

12. Conclusion and Study Pack Benefits

• Key Takeaways: Adult primary care requires a holistic approach.
• Study Pack Benefits: 100 Q&A with rationales for $30/month.
• Why Choose ulosca.com?: Guaranteed 100% pass rate in proctored exams.

Sample Practice Questions and Answers

Question 1:

A 58-year-old male patient presents with fatigue, unintentional weight loss, and persistent epigastric discomfort. He reports occasional dark stools. His medical history includes hypertension and chronic NSAID use for osteoarthritis. What is the most likely diagnosis?

Explanation:

Peptic ulcer disease (PUD) is the most likely diagnosis given the patient’s history and symptoms. PUD results from mucosal erosion due to an imbalance between protective and aggressive gastric factors. Key risk factors include chronic NSAID use, Helicobacter pylori infection, smoking, and stress. The symptoms of epigastric discomfort, fatigue, weight loss, and melena (dark stools indicating GI bleeding) strongly suggest ulcer formation.

• NSAID use: NSAIDs inhibit prostaglandin synthesis, reducing gastric mucosal protection and increasing susceptibility to acid-induced injury.
• Melena: Indicates potential upper gastrointestinal bleeding, common in complicated ulcers.
• Epigastric discomfort: A hallmark of PUD, often relieved by antacids or worsened with food, depending on ulcer location (gastric vs. duodenal).
• Weight loss and fatigue: Suggest complications such as chronic bleeding and anemia.

• GERD is primarily caused by lower esophageal sphincter dysfunction, leading to reflux of acidic gastric contents into the esophagus.
• Why is it incorrect? GERD typically presents with heartburn, regurgitation, and dysphagia, not dark stools or weight loss. While GERD can cause epigastric discomfort, it does not explain the patient’s melena, which suggests an active upper GI bleed.

• Gastric cancer can present with weight loss, epigastric discomfort, and GI bleeding, making it a potential differential diagnosis.
• Why is it incorrect? While the symptoms overlap, PUD is far more common than gastric cancer. The absence of additional red flag symptoms such as a palpable abdominal mass, persistent vomiting, or severe anorexia makes PUD the more likely diagnosis. A biopsy would be required to confirm gastric malignancy.

• IBS is a functional gastrointestinal disorder characterized by chronic abdominal pain, bloating, and altered bowel habits (diarrhea, constipation, or both) without structural abnormalities.
• Why is it incorrect? IBS does not cause melena, weight loss, or fatigue, as it is not associated with gastrointestinal bleeding or systemic symptoms. The presence of black stools suggests a serious pathology like an ulcer rather than IBS.

Question 2:

A 65-year-old female patient with a history of type 2 diabetes and hypertension presents with progressive exertional dyspnea, orthopnea, and bilateral lower extremity edema. On examination, she has jugular venous distension (JVD), rales on lung auscultation, and an S3 heart sound. What is the most likely diagnosis?

CHF is the most likely diagnosis given the history of exertional dyspnea, orthopnea, lower extremity edema, JVD, rales, and an S3 heart sound. These findings are characteristic of left-sided and right-sided heart failure.

• Dyspnea and orthopnea: Result from pulmonary congestion due to increased left atrial and pulmonary venous pressure.
• Bilateral lower extremity edema and JVD: Indicate right-sided heart failure, where blood backs up into the systemic circulation.
• Rales (crackles) on lung auscultation: Suggest pulmonary congestion/edema due to left ventricular dysfunction.
• S3 heart sound ("ventricular gallop"): Signifies volume overload and poor ventricular compliance, common in CHF.

CHF can be caused by long-term hypertension, coronary artery disease, and diabetes, all of which are risk factors in this patient.

Why the Other Options Are Incorrect:

• COPD presents with chronic cough, wheezing, sputum production, and exertional dyspnea due to airflow obstruction.
• Why is it incorrect? This patient lacks a history of smoking or chronic bronchitis and does not have wheezing or prolonged expiratory phase, which are hallmarks of COPD. Also, COPD does not cause JVD, edema, or an S3 heart sound, which point to CHF.

• PE typically presents with sudden onset dyspnea, pleuritic chest pain, tachycardia, and possibly hemoptysis.
• Why is it incorrect? PE is acute in onset, whereas this patient has progressive symptoms over time. Additionally, PE does not typically cause bilateral edema or JVD.

• CKD often presents with edema, fatigue, anorexia, and metabolic abnormalities (e.g., hyperkalemia, acidosis).
• Why is it incorrect? While CKD can cause fluid retention and hypertension, it does not explain the pulmonary congestion (rales) and S3 heart sound, which strongly indicate cardiac dysfunction rather than renal failure.

Question 3:

A 72-year-old male patient with a history of atrial fibrillation (AF), hypertension, and type 2 diabetes presents with sudden-onset left-sided weakness, slurred speech, and facial drooping. His symptoms started 1.5 hours ago. On examination, he has left-sided hemiparesis, facial asymmetry, and difficulty speaking. What is the most appropriate next step in management?

A. Administer aspirin immediately

B. Obtain a non-contrast CT scan of the head

C. Start anticoagulation with heparin

D. Perform carotid ultrasound to assess stenosis

Correct Answer:

B. Obtain a Non-Contrast CT Scan of the Head

Explanation:

The patient’s acute-onset neurological deficits (hemiparesis, facial droop, and speech difficulty) suggest an acute ischemic stroke, likely embolic due to atrial fibrillation.

• The first and most critical step in stroke management is to obtain a non-contrast CT scan to rule out hemorrhagic stroke before considering thrombolytic therapy.
• Time-sensitive intervention: Since symptoms started 1.5 hours ago (within the 4.5-hour window for tissue plasminogen activator [tPA] administration), rapid imaging is crucial to determine eligibility.
• Why non-contrast CT? It quickly identifies intracranial hemorrhage (ICH), which is a contraindication to tPA.

Why the Other Options Are Incorrect:

A. Administer aspirin immediately

• Aspirin is used for secondary stroke prevention in ischemic stroke, but it should not be given before ruling out hemorrhagic stroke.
• Why is it incorrect? If the stroke is hemorrhagic, aspirin could worsen bleeding. Thrombolysis (tPA) is preferred for eligible ischemic stroke patients within the 4.5-hour window.

C. Start anticoagulation with heparin

• Anticoagulation (e.g., heparin, warfarin, or DOACs) is used long-term for atrial fibrillation to prevent strokes, but it is not used in the acute setting of an active stroke.
• Why is it incorrect? Immediate anticoagulation increases the risk of hemorrhagic transformation in acute ischemic stroke.

D. Perform carotid ultrasound to assess stenosis

• Carotid artery stenosis is a major risk factor for ischemic stroke, and carotid ultrasound is used for secondary prevention.
• Why is it incorrect? It does not guide acute stroke management. The priority is brain imaging to determine if thrombolysis is an option. Carotid ultrasound is more useful in transient ischemic attacks (TIAs) or non-urgent stroke workups.

Question 4:

A 55-year-old female with a history of rheumatoid arthritis (RA) and chronic steroid use presents with severe low back pain, worsened by movement and unrelieved by rest. She denies trauma but reports gradual height loss over the past year. On examination, she has point tenderness over the thoracic spine but no neurological deficits. What is the most likely diagnosis?

A. Lumbar disc herniation

B. Vertebral compression fracture

C. Ankylosing spondylitis

D. Degenerative disc disease

Correct Answer:

B. Vertebral Compression Fracture

Explanation:

The most likely diagnosis is a vertebral compression fracture (VCF) due to osteoporosis secondary to chronic steroid use (glucocorticoid-induced osteoporosis).

• Chronic steroid use is a major risk factor for osteoporosis, increasing the likelihood of compression fractures.
• Back pain that worsens with movement and improves with rest is classic for compression fractures.
• Gradual height loss suggests vertebral body collapse due to multiple fractures over time.
• Point tenderness over the thoracic spine is a key physical exam finding, as VCFs commonly affect the thoracic and lumbar vertebrae.

Why the Other Options Are Incorrect:

A. Lumbar Disc Herniation

• Usually presents with radicular pain (sciatica), numbness, and weakness due to nerve root compression.
• Why is it incorrect? This patient lacks neurological deficits (e.g., leg weakness, sensory loss, reflex changes), making disc herniation unlikely.

C. Ankylosing Spondylitis (AS)

• A chronic inflammatory condition that presents with insidious onset of low back pain, morning stiffness, and improvement with activity.
• Why is it incorrect? This patient’s pain is worsened by movement and unrelieved by rest, which is inconsistent with AS. Also, AS typically affects younger males (onset before 40).

D. Degenerative Disc Disease (DDD)

• Characterized by chronic back pain, stiffness, and gradual progression over years.
• Why is it incorrect? DDD does not cause acute vertebral tenderness or sudden height loss.

Key Takeaways:

• Vertebral compression fractures are common in osteoporosis, especially in postmenopausal women or patients on chronic steroids.
• Back pain + height loss + spinal tenderness = Strong suspicion for VCF.
• Diagnosis: Confirmed with spine X-ray or MRI (to rule out malignancy).
• Management: Pain control, bracing, physical therapy, and in severe cases, vertebroplasty or kyphoplasty.