Role of Advanced Practice Nurse in Evidence-Based Healthcare Services - Essay Example

? Obesity in Pediatric Individual: The Role of Advanced Practice Nurse in Providing Evidence Based Genetic Healthcare Services Affiliation Author Note Author note with more information about affiliation, research grants, conflict of interest and how to contact Obesity in Pediatric Individual: The Role of Advanced Practice Nurse in Providing Evidence Based Genetic Healthcare Services Part-I The Condition: The patient’s name is CD, a 12 year old female child of Hispanic ethnicity, who visited for a yearly Well-Child physical examination. Her mother has expressed concern over the fact that she is found to be gaining too much weight and has accounted for a weight gain of 10 lbs over the last six months. This teenager is 5 ft 2 inches tall and weighed 175 lbs as of last week. Though the girl has no other complaints, the mother is concerned about her weight gain. Family history indicates that her father is obese and has Type 2 diabetes. The girl is alert and oriented, pleasant and cooperative and her vital signs indicate BP at 108/58, Heart Rate 64, RR 16, Temperature 98.4 and Body Mass Index (BMI) 32. The skin tone is dark pigmented neck, hands and underarms. The other conditions of the individual include: HEENT: Normocephalic, PERRLA, Visible fundus, without evident Micro vascular Damage. Exam otherwise unremarkable musculoskeletal – neck flexed, head down, poor posture d/t cervical dorsal hump Psychosocial – Poor self esteem, based on posture, body image. Lungs: good air entry, no adventitious breath sound. Heart: S1 S2 present, no murmur, click, or rub. Obesity can be perceived as health hazard that primarily derives from the intake of more “calories than the body requires” and it can also occur due to the “interaction of genetic and environmental factors” (Thorleifsson et al, 2008, p.1). The individual in the instant case does not have any complaints but her mother remains concerned about her weight gain of 10 lbs over the last six months. One concern with the patient is her BMI, which is 32, because a body mass index of “greater than 30” indicates the risk of obesity (p.1). This study further refers to various other researches that have located “obesity loci to numerous parts of the genome” and suggests that the variants in their experiment have shown significant effects on the “two obesity-related traits” of BMI and weight (p.1, 5). In the absence of any other obvious reasons identified in her case, the reportedly unusual weight gain of the girl seems to suggest an association with genetic or genomic causes. This becomes a specific concern since the subject’s father has a history of obesity with Type 2 diabetes. Evidence Supporting Genetic/Genomic Risk: Childhood and adolescent obesity is one of the major problems being faced by nations across the world in the modern day and this is especially so in the case of developed countries such as the United States. Though environmental changes play a key role in the prevalence of obesity across the world, evidence also suggests that “genetic component” also contributes to the risk (Bradfield et al, 2012, p.3). Recent studies based on genome-wide associations also indicate that “many genetic loci” are responsible for BMI/obesity in adults and the largest meta-analysis has brought to the fore “eighteen loci associated with BMI” (p.4). This study further corroborates the existence of “two novel obesity loci” which are associated with “elevated adiposity in the first eighteen years of life” (p.6). Thus, it transpires that genetic and genomic elements are high risk factors for the prevalence of obesity in children and adolescents, apart from environmental causes. Since the subject’s father happens to be diabetic, the apprehension of possible risk of inherited obesity is quite high in the instant case. Wardle et al, while agreeing to the notion that the high prevalence of obesity in the recent past can be attributed to environmental factors, contends that “inherited genetic differences” also are responsible for this public health concern (Wardle et al, 2008, p.398). The results from their study suggest that the element of adiposity in preadolescent children who are born after “obesity endemic is highly heritable” (p.401). The researchers further claim that their study is the first of its kind to “assess the heritability” of waste circumference (WC) in children, and they attribute “60% of heritability of WC” as common to BMI while 40% to “different genetic factors” and, thus, it can be construed that genetic elements have a crucial role in childhood obesity (p.401). In their report on the genetics of childhood obesity, Lindsay C Burrage and Shawn E McCandless attribute the “increasingly common problem” of childhood obesity to “genetic and environmental factors” (Burrage & McCandless, 2007, p.60). The authors further contend that genetic as well as environmental factors determine the intake and utilization of energy and “60-80% variance in body weight and BMI” is attributable to genetic factors (p.60). Thus, there exists ample evidence to support genetic and genomic factors as high risk elements that cause obesity in children. This enhances the chances of obesity in the subject referred to above, as her father has a history of obesity with Type 2 diabetes. Variation and Prevalence in the Population: The data from the National Health and Nutrition Examination Survey 2009-2010 reports that “one-third” of the adult population and “17%” of youth have been found to be obese during the years 2009-10 (Ogden et al, 2012, p.1). The data further suggests that the prevalence of this problem among is higher among adolescents than preschool children and boys are at higher risk with “18.6%” while girls stood slightly lower at “15%” (p.2). In the context of the subject of this study the risk factor is quite high as compared to girls of the other age group as females from 12 to 19 years of age are placed at the highest risk with the prevalence of “17.1%” during the year 2009-2010 (p.2). Therefore, it transpires that the subject, who is at the threshold of the highest group, has a higher risk of obesity both in terms of the environmental factors that show the trend in her age group as well as her hereditary background. On a population based premise, “78 million adults” (37.5 million males and 40.6 million females and 12.5 million children in the age group of 02 – 19 years (7 million boys and 5.5 million girls are found to be obese during the year 2009-2010 (p.3). Another interesting factor is that during the period from 2000-2010, obesity in men has increased by 8% whereas in the case of females the increase has recorded only a slight margin of 2.4%. On the other hand, the obesity in boys has increased by 4.6% during the same period while in the case of girls it has shown an increase only by 1.2%. While the trend may be encouraging in the context of a general populace, this in no way undermines the risk element for the subject under consideration as she falls in the higher risk group bother in terms of her age and gender as well as chances of inheritance. Causes of Obesity Including the Role of Environment: The modern human’s environment has undergone dramatic changes in the recent past with the advent of technology, improvement in the standard of living, transformation in the work culture, competitiveness due to globalization etc, which have had many far reaching implications on their life style. Various innovations in technology has made life more sedentary for people and culminated in a lack of physical activity. Similarly, the improvements in quality of life has also made them less physically active as they prefer to use cars rather than walking or cycling. The work culture has evolved drastically as a result of globalization and telecommuting has become a norm, which also contributed in reduced physical activities as people preferred to work from their homes rather than going to offices. Similarly, competition in the job field has seen a dramatic increase, as a result of which high work pressure has fallen upon the workforce, and it has been specifically so in the case white collar jobs. This entailed major changes in food habits and people turned to junk food, ignoring the need for balanced diets. Thus, the overall changes in the environment have promoted the onslaught of the obesity epidemic. A study conducted on behalf of the Vermont University identifies genetic factors as one of the major causes of obesity and finds that if the parent of a child is has this problem, its chances of being obese “significantly increases” and evidence further points to a “75% chance” if both parents are obese and “25-50%” possibility if one of them is obese (Jeffords, 2010, p.3). Dietary habits are another critical factor that induces obesity in humans and evidence suggests that patrons in restaurants eat about “350 more calories than they did 15 years ago” and also, the consumption of “sugar-sweetened beverages” has doubled, which contributes to the rapid spread of obesity in the US (p.5). Similarly, food that is rich in fat and protein contents can also cause the accumulation of extra flab in human body, thereby inducing obesity. The “lack of physical activity,” and prolonged hours being spent on computer/mobile phone games, or in front of the TV, is a crucial causative element for obesity in children (Ebbeling, Pawlak & Ludwig, 2002, p.475). The types of “parent-children interactions” as well as family environments also are found to exercise an influence in obesity and so are modern trends such as eating out, preference for fast food, desserts also (476). In addition, children who overtly engage in TV and gaming remain exposed to various types of advertisements that promote food and beverages that have potential risk for causing obesity. The report of 2nd Scandinavian Pediatric Obesity Conference, identifies “two alternatives that explain recent obesity trends” such as the upward regulation of appetite in some children and hungry become fatter due to the obesogenic factors in the environment (Cole, 2006, p.6). Thus, it transpires that in the modern world a lot of factors contribute to the obesity in children, thus making it a major public health concern in the world in general but particularly in developed countries such as the US. The subject in question has been gaining weight within the past six months and she seems at risk, especially in terms of her genetic factors. Indications to Suggest the Condition during Healthcare Visits: The main causes of obesity include genetic factors, accumulation of fat in the body and other environmental factors of the child. Thus, healthcare visitors need to focus their attention in identifying the prevalence of any of these causative elements in the target population. When any child is found to be overweight during their visits, the healthcare visitors must discuss this aspect with the parents and take appropriate intervention methods to check the tendency of weight gain. Similarly, during their visits to families they should ascertain the physical activities and TV viewing habits etc of the children. In addition, they should also ascertain the eating habits of any children who reveal the signs of weight gaining. Creating awareness among parents about the need for physical activities, avoiding long hours of TV viewing, computer games etc will also enable parents to come forth with any problem behavior in children. Treatments: Healthcare visitors, when visiting families must look for the above red signals and take appropriate intervention measures to control the menace of obesity. When they notice a child who is gaining weight, they should ascertain the behavior pattern of the child such the physical activities, eating and TV viewing habits etc. They should then provide suitable counseling to the parents as well as the child. Public health visitors can also create awareness in families about the need for taking a balanced diet and including physical exercises as a mandatory part of their daily routine. They should also create the awareness in families about various programs that the government has implemented for checking obesity and encourage the families and community to actively participate in such initiatives. Nursing practitioners also need to educate people about the need for checking nutrient content of food before buying them. Similarly, children should be discouraged from taking food that contain added sugars and encouraged to replace them with fresh fruits and vegetables. Parents should be counseled to motivate their children to engage in active physical activities and reduce sedentary lifestyle. Similarly, when children manifest the tendency to gain weight, they should be asked avoid travel to school by bus or car and use bicycles instead. Evidence also suggests that the chances of obesity can be reduced by “22%” if mothers breastfeed their children and, therefore, during their visits, nursing practitioners must explain this to pregnant women and encourage them to breastfeed their children (Solving the Problem of Childhood Obesity, 2010, p.13). If visiting nurses and other public health officials adequately intervene and take initiatives with the community, the problem of obesity can be controlled to a great extent. The Role of the Advances in Human Genome in the Diagnosis, Management and Prognosis of Obesity: The etiological heterogeneity of a person plays a crucial role in obesity and genes affect “energy intake” and expenditure as well as the “partitioning of calories” including the “proclivity to store calories ingested in excess of expenditure” (Agurs Collins, 2008, p.85). Evidence shows that the Human Genome Project of 2003 has entailed “rapid advances” in the field of human genomics research and points to the possibility of facilitating “personalized risk profiles” for various diseases (p.86). Thus, genomics, combined with genomics can enable the prediction of an individual’s “response to pharmacologic intervention” based on the gene type (p.86). This, in turn, offers the opportunity utilize the potential of genomic applications for “clinical and public health practice” for the benefits of the population (p.87). Evidence also suggests that genomic evaluation will help identify the genetic makeup, which is “susceptible” to specific conditions that promote the consumption of energy over expenditure and thus can go a long way in treating the obesity epidemic (Kunej et al, 2012, p.45). Part-II Application of the Essential Nursing Competencies to Address Genetic Healthcare Issues of the Subject and Family: Assessment, Screening, Diagnosis, Counseling and Treatment throughout Lifespan: The subject’s mother has already expressed a concern about unusual weight gain and also the girl has the risk of inheriting the disease from her obese father. Thus, the assessment must be focused on determining the patient’s condition and risk elements. She needs to screen her weight, daily physical activities, intake of food and other environmental factors that may enhance the risk of gaining weight. Regular monitoring of weight, eating habits and physical activities with a special focus on avoiding any risk behavior may help containing the problem at this stage. She also needs counseling with an orientation on physical exercises, healthy dietary practices as well as regular monitoring of weight. At this stage, the treatment needs not include any medication but must focus on improving the environment and eliminating risk behaviors. She also must be encouraged to follow a systematic lifestyle to maintain her health throughout the lifespan. In order to address the genetic risk in patients, there is a need to “incorporate genetic and genomic technologies and information” into nursing practice (Essential Nursing Competencies, 2006, p.11). Therefore, all the measures relating to assessment, counseling and treatment must also be addressed, keeping in mind of the genetic element inherent in the case. Evidence Based Healthcare Delivery (Intervention): The healthcare delivery and intervention in the case of genetically risky individuals need to be focused on the understanding that in addition to other environmental risks such persons also run an additional risk. Nursing practice should envisage the knowledge that such individuals may tend to gather more residual fat than they exhaust and also they may exhibit a tendency to eat more than what their body requires. Therefore, the assessment must focus on evaluating these trends. Similarly, intervention needs to focus on supplementing their appetite for food with less fat and calorie oriented food. Contribution of Advance Practice Nurses towards Persons with Genetic Problems: While environmental risks can be controlled, there are no measures that can effectively manage the interplay of genetic factors in causing obesity. Advanced practice nurses, therefore, need to understand the genetic elements that prompt individuals to eat more than their energy requirements and address the issue. During counseling sessions, they must attempt to create an understanding on the people at risk and explain to them clearly of their tendencies. They must advise such individuals about the risk involved in satiating their needs with food that can cause obesity and encourage them to avoid it and include more fruits and vegetables in their food so that while satiating their appetite for food, risk can be avoided. Part-III Financial, Ethical, Legal, Social, Cultural and Religious Issues Related to Family/Individual: Lifestyles, customs and eating habits of people depend to a large extent on their social, cultural, religious background as well as the financial resources available with them. On the other hand, obesity also can have a bearing on the financial and social conditions of individuals with obesity and their families. On many occasions, financial constraints impede the execution of various plans implemented for countering pediatric obesity as can be evidenced from the fact that the authorities found the Healthy Choices program instituted by the Massachusetts Department of Public Health (MDPH) to be “not sustainable” because it accounted for an expense of about “$20,000 per school per year” (Childhood Obesity, 2007, p.4). The recent recession has had a lot of negative impacts on the economies of developed nations, especially the US, and the federal as well as state administrations have had to exercise drastic cuts on various social programs. As a result of this, the local authorities and school have not been able to meet their commitment to various programs that have been instituted to fight the public health issue of obesity. Under the circumstances, most of the initiatives to counter the problem will have to be taken by individuals who fall in the risk category of obesity and their families, without much social support. Thus, the disease entails heavy financial burden both in terms of medical expenses as well as dietary modifications and cost of other preventive interventions to the individuals and families. This puts severe constraints on them, especially in the case of people from the lower social strata and this may be reason for the prevalence of this problem among socially and economically backward people in the community. In a social context, people who are victims of this public health hazard suffers a lot of problems as they tend to suffer from “lower self esteem” and the chances of “social rejection” (p.2). Social isolation can be especially damaging to children as it adversely affects their social skills and development. Consequently, their academic performance and confidence of children with obesity may decrease considerably. On the other hand, families of obese children also may suffer from the consequences of social isolation as well as poor performance of their children as these factors may have severe negative impacts on their stress level. Legal intervention is another method to control the lifestyle of obese children but it entails a lot of complications for both the individuals and their families. Though legal provisions exist for restricting children at risk for their “physical, mental, or emotional health, or morals” courts usually justify any intervention for obesity only if it is of such a “severe nature” as to be “life threatening” (Mitgang, 2011, p.561). Thus, in a legal context, obesity may even cause the compromising of an individual’s freedom when it reaches a dangerous proportion. This will pose both moral and ethical problems for the individual as well as family as they will face a dilemma of leaving the care of the individual at risk to the legal system for saving life, in exchange of individual freedom. Such an eventuality may also have some implications on the religious and cultural life of the individual suffering from obesity as well as his or her family. Addressing these Issues to Support the Provision of Patient Centered Care: Practicing nurses must have a clear grasp of these aspects and their repercussions on the individuals as well as their families so as to devise effective strategies to address the issue at its root. The girl being a Hispanic is likely to be in the category that consumes large amounts of meat and desserts. Besides, their culinary habits include oil and fat in the food. However, the subject’s food habits can be more focused on green salads as it is also part of their culture. She comes from a relatively reasonable background in terms of financial resources and, therefore, including fruits and vegetables should not be a problem. Also, her food can contain less fatty fish varieties and these aspects need to be considered and monitored appropriately. In the case of the subject for this study, two factors can be identified as risk such as BMI at 32 and genetic element as her father has been obese. Thus, the patient centered care in this case needs to focus on these two factors. BMI is currently accepted as the “standard” measure of obesity in children but the practitioner needs to consider the fact that its “percentile distribution changes” with age (August et al, 2008, p.9). An increased BMI may not necessarily suggest the accumulation of body fat and in the instant case it is also relevant that “pubertal progression” in females may cause fat tissues and a resultant increase in BMI (p.9). However, combined with the risk of genetic element, the instant subject can be considered as an ideal candidate for preventive intervention. Therefore, the practitioner needs to consider her waist circumference of the girl and also ask the individual and family to monitor it regularly. Though the BMI in the case of the subject is not in itself a matter of grave concern, it is nevertheless advisable to refer her to a geneticist. However, the subject and her family must be counseled about “labeling and false-positive results of testing” as these elements may result in misplaced worries in them (p.11). The line of intervention suggested will primarily focus on the change in lifestyle, recommendations for balanced diet that is especially inclusive of fresh fruits and vegetables and increase in physical activities. The subject and her family will also be advised to avoid calorie-dense food such as soft drinks, junk food and fat containing food such as red meats. At this stage, the girl’s case does not seem to warrant any pharmacotherapy intervention and it appears that physical exercises, diet control and avoidance of sedentary life will suffice to contain her weight to a great extent. This will help them avoid any redundant medical expenses and by adopting changes in lifestyles and dietary habits, the individual may be saving costs being spent on unhealthy beverages and junk food. In addition, the psychosocial environment of the subject will also be considered and the family will be requested to avoid any overemphasize on diet or other interventions to cause stress on the individual. To avoid any effect on self esteem, the patient will be counseled that her problem will not aggravate to a stage as to cause worry, if she modifies her life style. This may boost the confidence of the subject and her family and they will be able to overcome any unnecessary worries. Proposed Changes in Practice to Support and Address Persons at Risk of Genetic Condition: The review of various literatures for the purpose of this research has enabled me to gain an in depth understanding of the risk of genetic factors. Evidence from the literature suggests that the “genetic analysis” of several common types of obesity has established “association with a range of individual genes” that can cause obesity through inheritance (Walley, Blakemore & Froguel, 2006, p.127). The evaluation of the existing literature, in addition has enabled me to gain the knowledge that though genetics can cause energy imbalances that can entail redundant fat accumulation in the human body, obesity does not mean “being ill” (p.128). Therefore, the focus needs to be maintaining health even when the body is obese. Thus, when practicing, I will identify the “genetic background associated with every stage of obesity and its consequences for health” (p.128). In addition, the focus during interventions will on maintaining the health of the subject rather than on reducing the obesity as such. In the context of the subject for this study, therefore, the focus of intervention will be to encourage her to maintain her health through life style changes, balanced diet and increased physical activities as mentioned earlier. Another main area where I will change my practice is to try to clearly understand the psychosocial needs of the girl and her family. Her parents may be naturally worrying about the hereditary factor but adequate counseling will create awareness in them and enable them to overcome any emotional problems and view the issue in a very positive light. The subject will also be provided suitable counseling and motivation to eliminate any self esteem concerns that she may acquire because of her problem. Reference List Agurs-Collins, T. et al. (2008). 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White House Task Force on Childhood Obesity: Report to the President. Retrieved from Thorleifsson, G. et al. (2008). Genome-wide Association Yields New Sequence Variants at Seven Loci that Associate with the Measure of Obesity. Nature Publishing Group. Retrieved from Walley, A. J., Blakemore, A. I. F., & Froguel, P. (2006). Genetics of Obesity and the Prediction of Risk for Health. Human Molecular Genetics, Vol.15 (2): pp.124-130. Retrieved from Wardle, J. et al. (2008). Evidence for a Strong Genetic Influence on Childhood Adiposity despite the Force of the Obesogenic Environment. The American Journal of Clinical Nutrition, Vol.87: pp.398-404. Retrieved from Read More