WEEK 1 LECTURES
Primary care is different than tertiary care. The types of problems that are solved in primary care are different than those seen in acute- or critical-care settings, which you may be used to as a bedsid
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WEEK 1 LECTURES
Primary care is different than tertiary care. The types of problems that are solved in primary care are different than those seen in acute- or critical-care settings, which you may be used to as a bedside nurse. Upper respiratory infections, abdominal complaints, skin rashes, and vague somatic complaints are problems that are not often encountered in the hospital setting. Even chronic conditions present differently in primary care. HTN, CHF, arthritis, and DM present with day-to-day management problems that are different from the crises that acute-care nurses must respond to in a tertiary-care setting. As you will soon find, primary care is a new world with a different set of problems to be solved, different kinds of constraints on choices, and a different culture of care.
Diagnosing and treating up to 30 different patients or families in a day is both challenging and mentally exhausting. Although an office visits allows for focused one-on-one care with an individual patient, the NP must still recognize that healthcare is a business. In order to meet office overhead costs, including provider and staff salaries, the business must be profitable or at least have equal income to operational cost margins. Because of this, a nurse practitioner needs to have a solid understanding of how to obtain and process information in an organized approach. Learning to practice primary care in an artful way requires a certain kind of thinking. The mental task of eliciting and sorting through large amounts of data, clustering data elements into meaningful patterns, connecting patterns to reasonable diagnostic statements, considering risk factors, and selecting appropriate interventions require a high level of diagnostic reasoning.
Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of questioning one’s thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others.
Developing expertise as a nurse practitioner takes time. Students who are experts in hospital or specialty care become novices in the advanced practice role. Clinical judgment and diagnostic reasoning is based on experience. As a student, you will hopefully gain skills to function at the advanced beginner level through didactic work and the added clinical practicum experience. It took years for you to become an expert nurse, so you can expect that it will take years to become an expert NP. On your journey towards graduation from the FNP program, you will be given the necessary tools to help you be successful on the board certification exam and become a competent advanced beginner.
The type of data that you collect depends on the type of visit. Most visits are episodic or problem-focused where 1 or 2 specific issues need to be addressed. One thing I want to point out is that the information in the H&P should only be relevant to the complaint or problems that you are addressing. So, a patient with only a skin complaint does not need a full H&P. Rather, a focused history and exam as it relates to the skin complaint or associated symptoms should be recorded.
First, I want to go over two important, distinct concepts that seem to be an area of confusion for many students: subjective and objective findings. We will discuss these in more detail when we introduce the SOAP note lecture.
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