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3

Here&Now August 

2012 • Volume 3, Issue 8 

25 Hyperglycemia in 

the Hospital Setting 

When it comes to inpatient 

management of insulin levels, 

appropriate protocol selection 

is often a key decision in the 

course of hospital care. Heidi 

Rymaszewski, ANP-BC, BC-ADM, 

CDE, uses a case presentation 

to illustrate this essential point. 

25 

Columns & Departments 

First & Foremost ..............................6 

Front & Center ................................8 

Role & Growth ...............................10 

Calendar ...................................29 

Ad Index ...................................33 

Career Opportunities ..........................38 

Comments & Feedback ........................50 

Articles 

12 Head Lice Update 

It’s back-to-school time and that often means head lice outbreaks. Kara 

L. Caruthers, MSPAS, PA-C, and Patricia Jennings, DrPH, PA-C, describe 

the life cycle of head lice and how these organisms can be removed. 

(cover image by John Ciuppa/Doris Mohr) 

15 

21 

15 Patient Care 

Issues in Mild TBI 

This month’s CME/CE article 

provides information on mild 

traumatic brain injury, which is 

diagnosed more often today 

thanks to better understanding 

and recognition. Karen Williams, 

MSN, CRNP, outlines diagnostic 

criteria and treatment strategies. 

21 Symptom Overlap 

in the Irritable Bowel 

Irritable bowel syndrome is a 

functional bowel disorder whose 

symptoms can be confused with 

those of gluten sensitivity and 

celiac disease. Susan Andersen, 

PhD, RN, FNP-BC, explains how 

to decipher symptom overlap 

through careful history taking. 

The new season of ADVANCE Job Fairs & 

Career Events is here! 

Register now for your chance to meet recruiters in your 

area, attend top-notch sessions and enter to win prizes like 

a $500 Visa gift card! Visit www.advanceweb.com/events 

to see our complete schedule of FREE in-person and online 

events. 

Copyright 2012 by Merion Matters. All rights reserved. Reproduction in any form is forbidden without written 

permission of publisher. ADVANCE for NPs & PAs (ISSN 1096-6293) is published monthly by Merion 

Publications, Inc., 2900 Horizon Drive, Box 61556, King of Prussia, PA 19406-0956. 

Periodicals Postage Paid at Norristown, PA and additional mailing offices. Postmaster: send address changes 

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websites for health information professionals, healthcare executives, hearing 

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professionals, respiratory care and sleep medicine professionals, and speechlanguage 

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Please Recycle This Magazine 

® 

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ADVANCE is free to certified nurse practitioners and physician assistants 

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ADVANCE for NPs & PAs is the official publication of the Association of Family 

Practice Physician Assistants. 

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Dermatology Nurse Practitioners. 

4 ADVANCE for NP & PAs

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advanceweb.com/NPPA 

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yearly 

subscription. 

PA Response Breakdown 

This month, get the complete breakdown of 

physician assistant responses to the 2011 

National Salary Survey of NPs & PAs. (The nurse 

practitioner breakdown went live in July.) Find the 

report in the Salary Information section of our 

homepage. Please complete the 2012 survey while 

you're there! 

FREE 

online resources. 

FREE 

access to so 

much more. 

Don’t miss these 

upcoming 

issue features: 

• Geriatrics: Dementia 

• Concussions in 

Soldiers 

• CME/CE on 

HIV/AIDS 

• Reproductive Health 

Issues in Women 

• Technology in 

Clinical Care 

Don’t miss these 

upcoming online 

features: 

• Coverage from Major 

Conferences 

• Current Issues in Asthma 

• Women’s Health 

• Diabetes 

• Back-to-School 

Health Issues 

• Professional Issues Webinar 

A Study of Acute Care NPs 

Visit our website starting Aug. 2 for an article about 

a study of acute care practice by NPs in Florida. The 

author sought to determine the procedure competencies 

and job functions unique to acute care NPs in Florida 

and to compare these findings to those obtained in a 

2001 national survey of the same skills. Find the article 

by entering the author’s name, “Jo Ann Kleier,” in the 

Search Articles box on our homepage. 

Don’t miss all that ADVANCE offers! 

Subscribe or renew today – it’s quick and easy. 

• Call 800-355-1088 (M-F, 8am-6pm ET) 

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5

First&Foremost 

is published by Merion Matters 

Publishers of leading healthcare magazines since 1985. 

Joining Forces 

Nurse practitioners and physician assistants are 

heavily involved in the Joining Forces initiative for military veterans 

and their families. This program (http://www.whitehouse.gov/joiningforces) 

reaches out to service members and their families with 

resources for employment, education and wellness. 

A new effort to “join forces” is taking shape in the nurse 

practitioner profession. The boards of the American Academy 

of Nurse Practitioners (AANP) and the American College of 

Nurse Practitioners (ACNP) recently voted to work toward 

consolidation as one national group representing NPs in all specialties. As someone 

who has observed and reported on these esteemed organizations for 19 years, 

I applaud this decision. 

And based on the feedback we received as soon as we posted this news on our website 

and social media, many NPs feel the same way: “This is a wonderful opportunity for 

there is strength in numbers” … “I am excited about the possibilities associated with 

this merger” … “This couldn’t come at a better time. We need one voice.” 

We at ADVANCE for NPs & PAs echo these reader comments and wish the two 

boards of directors well as they navigate this complex process. Read more about 

the planned consolodation in this month’s news section (Front & Center, page 8). 

Did you know ADVANCE has been supporting NPs and PAs by publishing free 

peer-reviewed content specifically for your professions since 1993 Other journals 

in this market are moving toward subscription fees, but ADVANCE will not do that. 

Please help us ensure that our publication remains available free of charge by renewing 

or subscribing today. The U.S. Postal Service requires that we receive your official 

request each year. We will no longer be able to extend your subscription beyond the 

expiration date, as we have in the past. 

Time is running out for you to renew or add your name to our mailing list or digital 

subscriber list. Please call our Subscriber Services department at 800-355-1088 

or choose the “Subscribe” button at the top right corner of our homepage, www. 

advanceweb.com/NPPA. ■ 

— Michelle Perron Pronsati 

Publisher 

Ann Wiest Kielinski 

General Manager 

W. M. “Woody” Kielinski 

Chief Information Officer 

Khader Mohammed 

Editorial Staff 

Editor: Michelle Perron Pronsati 

Senior Associate Editor: Jennifer Ford 

Editorial Assistant: Kelly Wolfgang 

Web Manager: Jennifer Montone 

Design 

Vice President, Director of Creative Services: 

Susan Basile 

Design Director: Walt Saylor 

Art Director: Doris Mohr 

Multimedia Director: Todd Gerber 

advertising 

Director of Marketing Services: Christina Allmer 

Art Director: Chris Wofford 

EVENTS 

Public Relations Director: Maria Senior 

Job Fair Manager: Laura Smith 

Events Product Manager: Mike Connor 

ADMINISTRATION 

Vice President, Director of Human Resources: 

Jaci Nicely 

Information & Business Systems Director: 

Ken Nicely 

Digital Media Sales Director: Kim Noble 

Circulation Manager: Maryann Kurkowski 

Billing Manager: Christine Marvel 

Subscriber Services Manager: Vikram Khambatta 

Media & Marketing Opportunities 

Display Advertising 

Sales Director: Amy Turnquist 

National Account Executive: Shannon Ferguson 

Sales Associate: Ashley Hackett 

Healthcare Facility Advertising 

Sales Director: Kim Noble 

Group Manager: Robert Murray 

Education Advertising 

Sales Manager: Ed Zeto 

Senior Account Executive: Brock Bamber 

Account Executive: Sarah Rucinski 

CUSTOM PROMOTIONs 

Sales Manager: Mike Kerr 

Senior Account Executives: Noel Lopez, 

Sue Borjeson-Romano 

Sales Associates: Kristen Erskine, Danielle LaSorda, 

Desirae Slaugh, Gina Willett 

How to Contact Us 

The Editor Recommends … 

➼ Data collection for the 2012 National Salary Survey is under way. Have you 

filled out the survey yet Make sure your specialty, practice setting and geographic 

area are accurately represented. Visit our website to access the survey link in the 

"Salary Information" box near the top of the homepage. 

• For a FREE subscription: Call (800) 355-1088 or 

sign up at www.advanceweb.com/NPPA 

• To reach the editor: 

Michelle Perron Pronsati, mpronsati@ 

advanceweb.com or (800) 355-5627, Ext. 1221 

• To reach the senior associate editor and 

website editor: 

Jennifer Ford, jford@advanceweb.com or 

(800) 355-5627, Ext. 1384 

• To reach the editorial assistant: Kelly Wolfgang, 

kwolfgang@advanceweb.com, Ext. 1158 

• To order article reprints: (800) 355-5627, Ext. 

1446 

• To place an advertisement (display, calendar or 

recruitment): (800) 355-5627, Ext. 0 

ADVANCE for NPs & PAs 

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King of Prussia PA 19406 


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7

Front&Center 

By Kelly Wolfgang 

News for NPs & PAs 

AANP and ACNP Plan to Consolidate 

The boards of directors for the American Academy 

of Nurse Practitioners (AANP) and the American College 

of Nurse Practitioners (ACNP) recently announced plans to 

consolidate the two organizations. In a press release issued 

in July, the boards stated that the merger would result in a 

national nurse practitioner organization with aligned goals 

for policy change, healthcare reform, professional growth, 

education and research. 

“AANP is excited at the prospect of combining forces with 

ACNP. Aligning our organizations gives us the ability to speak 

and advocate for nurse practitioners with one collective voice. 

There has never been a better time for the consolidation of our 

organizations,” AANP president Angie Golden, DNP, FNP-C, 

FAANP, told ADVANCE for NPs & PAs. 

At the time this issue went to press, no further details about 

the consolidation plan were available. ADVANCE will continue 

to report on the consolidation effort as it evolves. 

AANP Conference Attendance Tops 4,300 

ORLANDO, Fla. — The American Academy of Nurse 

Practitioners (AANP) conference in Orlando, Fla., in June drew 

more than 4,300 NPs and NP students. The annual event focused 

on healthcare policy and the support of military members. 

At the opening session, keynote speaker James O. Prochaska, 

PhD, spoke about the impact of behavioral health. AANP has 

encouraged NPs to provide mental and physical care to current 

service members, veterans and their families through 

the Joining Forces initiative spearheaded by the White House. 

The first-ever Loretta C. Ford Award for Advancement 

of the Nurse Practitioner Role in Healthcare was presented 

to Joanne Pohl, PhD, ANP-BC, FAAN, FAANP, professor 

emeritus at the University of Michigan School of Nursing. 

The award was created in honor of Ford, who co-founded 

the NP profession. 

AANP’s director of health policy, Jan Towers, PhD, NP-C, 

CRNP, FAANP, FAAN, spoke about the importance of healthcare 

policy and encouraged NPs to reach out to their representatives 

and foster change. “Any way you slice it, there are 

Nurse practitioners gathered on the steps of the Orange County 

Convention Center for a white coat photo at the 2012 AANP conference. 

32 to 35 million patients without insurance, and NPs need to 

help,” Towers said. “... you need to step in to leadership roles 

in relation to that.” 

Also at the conference, past president Penny Kaye Jensen, 

DNP, APRN, FNP-C, FAANP, passed the gavel to current president 

Angie Golden, DNP, FNP-C, FAANP. Golden welcomed 

attendees and kicked off the opening of the conference. 

Attendees enjoyed sessions on topics such as genetics, medical 

Spanish, social media, reimbursement, immunization, smoking 

cessation, precepting and more. Workshops and seminars 

included suturing, sonographic technique, breast cancer risk 

assessment and pediatric autism spectrum disorders. 

To view photos from the conference, visit http://bit.ly/ 

Nh4daq. The next AANP conference will be held June 19-23, 

2013, in Las Vegas. 

Delaney Takes Reins as 

AAPA President 

James Delaney, PA-C, recently began 

a 1-year term as president of the American 

Academy of Physician Assistants (AAPA). 

“I’m so pleased to take on this role because 

this is an exciting time for the PA profession. 

PAs are being recognized for their 

James Delaney, 

PA-C 

ability to increase access 

to quality, coordinated 

healthcare in virtually 

every medical setting 

and specialty,” Delaney 

said in a press release 

issued by the AAPA. 

“Now more than ever, 

increased awareness will be placed on the 

role and the value of the PA as an integral 

partner of the health care team,” Delaney 

said. “Our ongoing challenge is to keep the 

PA profession in the forefront of both state 

and federal legislators.” Delaney began 

his term as president-elect in June 2011. 

His term as president will expire in 2013. 


Front&Center 

AFPPA Backs Title Change 

The Association of Family Practice Physician Assistants 

(AFPPA) recently released a position statement in support of 

changing the word “assistant” in the PA name. In the statement, 

the AFPPA requests the establishment of a committee to determine 

a “reasonable and evolutionary way that would also allow 

members to realize that they have been heard and responded to 

regarding this long-standing problem.” 

“The AFPPA believes that the assistant 

part of the PA title presents the 

profession with a problem. On many 

levels the term assistant at best is confusing 

and tends to place the PA profession 

on a level that most consumers, 

legislators and executives associate 

with a trade school or community 

college degree,” the document states. 

“Especially in primary care, the word 

assistant connotes that the ‘assistant’ is 

the helper and you are helping/assisting 

someone else. More than any other 

specialty, our primary care membership 

sees patients autonomously, fully 

diagnosing and treating them. It may 

border on being untruthful to say that 

we assist someone when that person 

is not even present in the building.” 

Beth Smolko, PA-C, president of 

AFPPA, told ADVANCE that concerns 

about the cost of a name change 

are unfounded without backup. "We 

often hear the argument that the 

name change would cost too much 

and it might open holes in legislation 

to restrict our scope of practice. A 

research study has not been conducted 

to validate those arguments. Why 

would we not want to research a way 

to strengthen our profession" 

Members of the AAPA made a similar 

request at the organization’s 2012 

conference. After 2 days of debate, the 

House of Delegates voted it down. For 

more information on the AFPPA and 

its position statement, visit http:// 

www.afppa.org/. 

NCCPA Searches for 

New President 

Following the July departure 

of Janet Lathrop as president and 

CEO of the National Commission on 

Certification of Physician Assistants (NCCPA), the board of 

directors has begun a search for a new leader. Pamela M. Dean, 

NCCPA chief operating officer, is serving as acting CEO. “We 

continue to move forward with a commitment to providing 

excellent service to PAs seeking and maintaining certification 

while serving the public’s interest in all that we do,” said 

NCCPA chairperson Patricia Cook, MD, FACP. ■ 

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9

Role&Growth 

Accountable Care: Where 

Will NPs & PAs Fit In 

By Candace C. Harrington, DNP, ANP-BC, GNP-BC 

Accountable care organizations 

(ACOs) are more than a fad in the healthcare 

industry. In some form, ACOs are 

part of our future as we transition from 

a volume- and intensity-driven model of 

care toward a value- and outcome-based 

system. The ACO focus on patient-centered 

care, based on standards of preventive, 

evidence-based and collaborative 

care, does not require a culture shift for 

NPs and PAs who already embrace these 

practice philosophies. It is in our best 

interest to understand ACO concepts and 

their implications, regardless of setting. 

What is an ACO 

An initiative of the Patient Protection and 

Affordable Care Act, ACOs are groups 

of providers who form a healthcare network 

generally comprised of primary 

care physicians, NPs, PAs, specialists 

and hospitals. 1,2 An ACO must have a 

legal structure to distribute incentive 

payments to members within the ACO 

and a patient population of at least 5,000 

Medicare beneficiaries who are enrolled 

in Medicare Parts A and B. 1,2 

In an ACO, high-quality care delivered 

at low costs will result in high incentive 

payments, provided that the ACO also 

reins in growth in healthcare expenditures. 

3 A common thread in all ACO 

models is a primary care physician to 

oversee care coordination. 1,2 The extent of 

oversight may be variable based on design. 

Demonstration Projects 

Over the next 3 years, the Centers for 

Medicare and Medicaid Services will conduct 

demonstration projects to identify 

the best design for ACOs. The Medicare 

Shared Savings Program for Accountable 

Care Organizations is a shared savings 

program that rewards providers with 

incentive payments for quality, cost and 

outcomes. Each network is accountable 

for its patient population. Success will be 

gauged on cost of care and approximately 

33 quality measures in four domains. 3 

These domains include patient experience, 

care coordination and patient safety, preventive 

health and at-risk populations. 3,4 

The Federally Qualified Health Center 

(FQHC) Advanced Primary Care Practice 

Demonstration evaluates the impact 

of advanced primary care practice on 

improving care, prevention, and reducing 

healthcare costs among Medicare beneficiaries 

served by FQHCs. 3 It will assess 

the impact that additional support has on 

the ability of FQHCs to transform their 

practice and become formally recognized 

as patient-centered medical homes. 3 

The Advance Payment Accountable 

Care Organization Model will provide 

additional support to providers participating 

in the Medicare Shared Savings 

Program who also would benefit from 

additional start-up resources to build 

the necessary infrastructure, such as new 

staff or information technology systems. 3 

The Pioneer Accountable Care 

Organization Model is complementary 

to the Medicare Shared Savings Program, 

designed for organizations that provide 

integrated care across settings. 2 The initial 

Pioneer sites will be positioned to rapidly 

demonstrate what can be achieved when 

we provide highly coordinated care to 

Medicare fee-for-service beneficiaries. 3 

Candace Harrington is an adult and gerontologic nurse practitioner who is 

a clinical assistant professor at East Carolina University College of Nursing and 

a member of the adjunct faculty at Vanderbilt University School of Nursing. 

ACO Success Factors 

◗ All stakeholders 

must be included 

when establishing 

an ACO. (This 

is a cooperative 

effort.) 

◗ Abandon economic incentives 

incompatible with the intent of an 

ACO. (Productivity is defined by 

quality of service, not quantity of 

service.) 

◗ Make information technology a top 

priority. (Invest in computer training 

if you feel deficient.) 

◗ Assist in choosing an EHR with 

Health Information Exchange 

capabilities to communicate, track, 

analyze and improve patient care 

and outcomes. 

◗ Establish a meaningful set of quality 

measures to rate ACO metrics. 

◗ Realize that patients and their experiences 

are at the center of an ACO. 

Adapted from Spoerl S. 8 biggest mistakes 

an ACO can make. Becker’s Hospital Review. 

2012;2012(5):1,30-31. 

Ongoing Debate 

The decision to put ACO care coordination 

in the hands of physicians is controversial 

and the source of heated debate for NPs 

and PAs. The ACO design may change 

as the demonstration projects progress. 

ACOs cannot succeed without buy-in and 

full participation of all healthcare team 

members and their patients. ■ 

References 

1. Camper S. Accountable care organizations: 

Lights! cameras! but where is the action National 

Healthcare Reform Magazine. http://www.healthcarereformmagazine.com/article/accountable-careorganizations-lights-cameras.html 

2. Devers K, Berenson R. Timely analysis of immediate 

health policy issues: Can accountable care organizations 

improve the value of health care by solving the 

cost and quality quandaries Robert Wood Johnson 

Foundation Urban Institute. www.rwjf.org/files/ 

research/acobrieffinal.pdf 

3. The Affordable Care Act: Helping providers help 

patients. The Centers for Medicare and Medicaid 

Services ACO Menu of Options. https://www.cms.gov/ 

Medicare/Medicare-Fee-for-Service-Payment/ACO/ 

downloads/ACO-Menu-Of-Options.pdf 

4. Harrington C. Measuring success under a microscope. 

ADVANCE for NPs & PAs. 2011;2(10):16. 

illustration Dave perillo 


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11

Pediatrics 

Head Lice 

Getting down to the nit of things 

By Kara L. Caruthers, MSPAS, PA-C, and Patricia R. Jennings, DrPH, PA-C 


Pediatrics 

John Ciuppa 

➼ Between 6 million and 12 

million infestations of head lice occur 

every year in the United States. 1 Children 

between the ages of 3 and 11 are the most 

often affected, with occurrence more 

frequently in girls. 1 

Although head lice pose no public 

health threat or transmission of disease, 

they are an expensive nuisance. 

Treatments, lost wages and school 

expenses total an estimated $1 billion 

annually — an amount almost three 

times the estimated expenditure in the 

1990s. 2 The direct and indirect costs of 

treatment could be reduced by ending 

the “no-nit” policies enforced by most 

school systems and by delivering efficacious 

treatments. 

Current Issues 

Pediculus humanus capitus is a six-legged 

parasite that grows no larger than 2 mm 

or 3 mm. Each leg has claws that allow 

the organism to grasp a hair follicle. Head 

lice survive by feeding off human blood 

every 3 to 6 hours. In optimal conditions, 

adult lice can survive more than 3 

weeks. Pruritus of the scalp is the most 

common symptom of an infestation, a 

result of localized allergic reaction to 

the louse bites. An infestation may be 

present for 6 weeks before symptoms 

become evident. The female lice 

lay eggs, or nits, within ¼ inch 

of the scalp. These hatch in 5 

to 10 days. The adult stage 

is reached about 10 days 

after hatching. 1,3 

Head lice infestation 

has historically 

been associated 

with lack of personal 

hygiene, lack of cleanliness 

in the home environment 

and (erroneously) lower 

The direct and indirect 

costs of treatment could 

be reduced by ending the 

“no-nit” policies enforced 

by most school systems 

and by delivering 

efficacious treatments. 

socioeconomic status. The truth is that 

head lice infestations affect 5% to 10% 

of school-age children across all facets 

of life; rates of infestations among black 

children are lower. 1,2 

Head lice are most commonly transmitted 

through direct contact with the hair 

of an infected person. Environments in 

which direct contact often occurs include 

school, home, sporting practices/events, 

camps and slumber parties. Although 

parents and schools have long recommended 

that children avoid sharing hats, 

scarves, coats, combs, brushes and bed 

linens to prevent head lice spread, these 

are uncommon forms of transmission. 1,2 

In an attempt to curtail the transmission 

of head lice, the National Pediculosis 

Association advocates a “no nit” policy: 4 

screening children for head lice to identify 

any evidence of lice or nits and immediately 

removing students with nits or 

lice from class until a re-examination 

proves clearance. 

Given the $1 billion burden associated 

with treating head lice and missing school 

and work, is this the best policy The 

American Academy of Pediatrics, the 

National Association of School Nurses 

and the Centers for Disease Control and 

Prevention recommend that children 

return to class as soon as treatment has 

been provided. 1,2,4 The CDC goes a step 

Kara L. Caruthers is an assistant professor in the physician assistant program at the University 

of Alabama at Birmingham and works clinically in emergency medicine. Patricia R. Jennings 

is director of the physician assistant program at the University of Alabama at Birmingham and 

also serves as a professor. She works clinically in the Division of Infectious Diseases at the 

University of Alabama Medical Center and the Birmingham Veterans Affairs Medical Center. The 

authors have completed disclosure statements and report no relationships related to this article. 

further by stating that children should not 

be immediately dismissed from school after 

a positive lice finding; instead, they should 

be allowed to complete the school day. 1 

Head lice do not fly, hop or jump. They 

crawl through the head, staying close to 

the scalp for both warmth and access 

to their food source (blood). They usually 

do not survive longer than 48 hours 

when away from the host. 1,3 Nits cannot 

hatch and usually die within 7 days if 

the temperature is not comparable to 

that of the scalp. 1 These facts support 

recommendations for discontinuing nonit 

policies. The cost of unnecessary 

absenteeism exceeds the risks associated 

with head lice. 

Permethrin 

The longstanding pharmacologic treatment 

of choice for head lice infestation 

is permethrin 1% lotion. 5 Permethrin 

(Nix) is a pediculicide that has reported 

secondary ovicidal properties. It is indicated 

for patients older than 2 months. 

Permethrin lotion was introduced in 1986 

and has been available over the counter 

since 1990. 2 It is associated with low 

levels of toxicity. 2 

Before using permethrin, hair must be 

washed with a nonconditioning shampoo 

and towel dried. A sufficient amount of 

lotion must be applied to saturate the 

hair and scalp; it should be rinsed off 

after 10 minutes. Current labeling for the 

product recommends a routine second 

treatment 7 to 10 days later. 2 

In recent years, reports of treatment 

failure with this therapy have surfaced 

throughout the world. Experts initially 

believed that the treatment failures were 

due to user error (nonadherence or failure 

to properly comb out nits), but in the 

United States, treatment failure is mostly 

attributed to increased resistance as a 

result of overuse and formula changes. 4,6 

Malathion 

Malathion 0.5% (Ovide), an organophosphate, 

is a prescription pediculicide with 

ovicidal properties. It is available in a 

lotion or gel, and studies show it is more 


13

Pediatrics 

The most obvious drawback for the preferred utilization of malathion is cost, 

since it requires both an office visit and a prescription. 

efficacious that permethrin 1%. 4-7 No 

reports of resistance have been associated 

with the current U.S. formulation of 

this drug. 6 Malathion 0.5% lotion is safe 

to use on patients older than 6, and the 

gel formulation is safe to use on patients 

older than 2. 

To deliver this treatment, the lotion or 

gel is applied to dry hair and allowed to 

air dry. The lotion remains on the hair 

for 8 to 12 hours; the gel preparation 

remains on the hair for 30 minutes. The 

gel is associated with fewer odors, easier 

application and less likelihood of eye 

irritation because of diminished dripping. 

Studies show that the gel formulation is as 

effective as the lotion formulation, with 

similar rates of retreatment. 2,5,7 

The most obvious drawback for the 

preferred utilization of malathion is 

cost, since it requires both an office 

visit and a prescription. Potential side 

effects must also be considered. Because 

malathion is a cholinesterase inhibitor, 

the potential for respiratory depression 

with ingestion is concerning. The 

potential risk of inadvertent ingestion 

by young children in the home should 

be considered. 2 No such cases have been 

reported, however. 

Newer Agents 

Three other pharmacologic agents have 

been introduced over the last 3 years to 

address emerging resistance. Benzyl alcohol 

5% (Ulesfia) lotion was approved in 

2009 for use as a prescribed pediculicide 

for the treatment of head lice in patients 

older than 6 months and in pregnant 

women. The lotion is touted as nontoxic 

because it does not contain pesticides; 

malathion 0.5% and permethrin 1% 

do. Ulesfia has a unique mechanism 

of asphyxiating lice by “stunning” their 

external breathing component. 8 

Ulesfia lotion should be applied in 

sufficient quantity to cover all lice on 

the hair and scalp. The application is 

rinsed off after 10 minutes and must 

be repeated in 7 days. In clinical trials, 

head inspection 1 day after the second 

dose showed clearance rates of 92% or 

higher. 5,8 Development of resistance is 

thought to be unlikely with Ulesfia since 

the mechanism of action opens the external 

breathing pathway of the louse. 

Spinosad 0.9% (Natroba) is a cream rinse 

for patients older than 4; it was approved in 

2011. This product is a prescribed pediculicide 

that targets the nicotinic receptor 

of acetylcholine and the gamma aminobutyric 

(GABA) gated chloride channel 

of the louse, causing paralysis. 

The hair and scalp should be saturated 

with Natroba and left on for 10 

minutes. In clinical trials, most patients 

only needed one treatment. A second 

treatment can be given in 7 days if live 

lice are still present. Eighty-five percent 

of patients were lice-free 14 days after the 

final treatment. While spinosad 0.9% is 

neurotoxic to lice, it is thought to have 

fewer side effects than permethrin. 5 

Ivermectin lotion 0.5% (Sklice) is a lice 

treatment for patients older than 6 months; 

it was approved in February 2012. This 

lotion is a prescribed pediculicide that also 

works on the GABA chloride channels, 

causing paralysis and resulting in death 

of the louse. The lotion is applied to dry 

hair and to the scalp. The contents of the 

entire 4-gram tube should be applied. The 

product should remain on the hair and 

scalp for 10 minutes before being rinsed 

out. The current recommendation is for 

use as a one-time treatment. 

Two trials of ivermectin lotion demonstrated 

71% to 76% lice eradication 

14 days after a single treatment. 9 Oral 

ivermectin has been used off label for 

the treatment of head lice for some time. 

Safety concerns exist about crossing 

Head Lice Through the Years 

➼ find our archived coverage of head lice by entering the term in our Search 

box at www.advanceweb.com/NPPA. 

the blood–brain barrier and potential 

for neural transmission interruption in 

younger patients. 2 

Rethinking Policy 

Head lice infestations in school systems 

across the United States are a public health 

nuisance and an economic burden on 

families. Prolonged absenteeism from both 

school and work are unnecessary considering 

the lifespan and patterns of the human 

head louse. Several health organizations 

recommend an end to “no nit” policies in 

American school systems. Children should 

be allowed to return to the classroom once 

treatment has been initiated. 

Permethrin is still considered the 

treatment of choice for head lice, but 

increasing pesticide resistance warrants 

consideration of other treatment modalities. 

Malathion, benzyl alcohol, spinosad 

and ivermectin should be considered for 

head lice treatment since these therapies 

can be more efficacious than permethrin. 

While copayments and prescriptions are 

burdensome for some, these costs may 

be worth it when weighed against the 

potential for prolonged absence from 

school and work. 4 ■ 

References 

1. Centers for Disease Control and Prevention. 

Parasites-Lice-Headlice. www.cdc.gov/parasites/lice/ 

head/index.htm. 

2. Frankowski BL, Bocchini JA. Head Lice. Pediatrics. 

2010;126(2):392-403. 

3. Texas A&M University. Louse. http://insects. 

tamu.edu/fieldguide/aimg37.html. 

4. Gur I, Schneeweiss R. Head lice treatments 

and school policies in the US in an era of emerging 

resistance: a cost-effectiveness analysis. J 

Pharmacoeconomics. 2009;27(9):725-734. 

5. Keller E, Tomecki K. Cutaneous infections and 

infestations: new therapies. J Clin Aesthet Dermatol. 

2011;4(12):18-24. 

6. Meinking TL, et al. Comparative in vitro pediculicidal 

efficacy of treatments in a resistant head 

lice population in the United States. Arch Dermatol. 

2002;138:220-224. 

7. Meinking TL, et al. A randomized, investigatorblinded, 

time-ranging study of the comparative efficacy 

of 0.5% malathion gel versus Ovide Lotion (0.5% 

malathion) or Nix Crème Rinse (1% permethrin) 

used as labeled, for the treatment of head lice. Pediatr 

Dermatol. 2007;24(4):405-411. 

8. Meinking TL, et al. The clinical trials supporting 

benzyl alcohol lotion 5% (Ulesfia): a safe and effective 

topical treatment for head lice (pediculosis humanus 

capitis). Pediatr Dermatol. 2010;27(1);19-24. 

9. Sanofi. Sklice Lotion prescribing information. 

http://products.sanofi.us/Sklice/Sklice.pdf 


CME/CE: Neurology 

Concussion Care 

Considerations for primary care providers 

By Karen Williams MSN, CRNP 

Learning Objectives 

1. Identify the prevalence and mechanisms of injury involved in concussion. 

2. Summarize the importance of early detection, avoidance of additional concussions and 

early education. 

3. Describe how to screen for a concussion and the common presenting symptoms. 

4. Discuss the treatments for common symptoms of concussion. 

Eligibility: This article is eligible for 1 AMA PRA Category 1 Credit hour and 2 CE contact hours. After reading 

and completing the posttest and evaluation, eligibility for AMA PRA Category 1 Credit is available for 6 months 

past the publication date of this issue (Aug. 1, 2012). This article was last reviewed on July 20, 2012. The article 

is eligible for CE contact hours for 2 years after the publication date. The author has completed a disclosure 

statement and reports no relationships related to this article. The editor and reviewers have completed 

disclosure statements and report no relationships related to this article. 

This activity has been planned and implemented in accordance with the Essential Areas and policies of the 

Accreditation Council for Continuing Medical Education through the joint sponsorship of Wayne State University 

School of Medicine and ADVANCE for NPs & PAs. The Wayne State University School of Medicine is accredited 

by the ACCME to provide continuing medical education for physicians. The Wayne State University School of 

Medicine designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit(s). 

Physicians should only claim the credit commensurate with the extent of their participation in the activity. 

This activity also is approved for 2 CE contact hours. The issuer of CE contact hours is Merion Publications (a 

division of Merion Matters), which is approved as a provider of continuing education in nursing by three agencies. 

For details on CE provider numbers, visit the CE Test Center on our website, www.advanceweb.com/NPPA. 

➼ Traumatic brain injury (TBI) 

encompasses a broad spectrum of injury 

with symptoms and effects that range 

from mild to severe. 

This article focuses on mild TBI (mTBI) 

and reviews the symptoms and treatments 

for this injury, commonly known 

as a concussion. 

Prevalence 

Head injury is a leading cause of disability 

throughout the world. Each year 

in the United States, an estimated 1.7 

million people sustain a TBI. 1 Concussion 

accounts for about 75% of these brain 

injuries. 2 The leading cause of TBI is 

falls (35.2%), followed by motor vehicle 

crashes (17.3%), being struck by or falling 

against something (16.5%), and assaults 

(10%). 1 In the United States armed forces, 

233,425 TBIs were reported between 2000 

and 2011. 3 Of these, approximately 76% 

were mTBIs. 3 

➤ 

Karen Williams is a family nurse practitioner 

who practices in the neurology and 

traumatic brain injury unit at Landstuhl Regional 

Medical Center in Landstuhl, Germany. She is 

an employee of the United States Army. 

Tom Whalen 


15


Table 1 

Definition of Mild Traumatic Brain Injury 7 

A patient with mild traumatic brain injury has experienced a traumatically induced physiologic disruption of brain function, as 

manifested by at least one of the following: 

1. Any loss of consciousness 

2. Any loss of memory about events immediately before or after the accident 

3. Any alteration in mental state at the time of the accident (feeling dazed, confused, seeing stars) 

4. Focal neurologic deficits that may or may not be transient but in which the severity of the injury does not exceed the following: 

loss of consciousness for 30 minutes or less; after 30 minutes, an initial Glasgow Coma Scale score of 13 to 15; posttraumatic 

amnesia lasting not more than 24 hours 

This definition includes: 

1. The head being struck 

2. The head striking an object 

3. The brain undergoing an acceleration/deceleration movement (i.e., whiplash) without direct external trauma to the head 

Developed by the American Congress of Rehabilitation Medicine, http://www.acrm.org/pdf/TBIDef_English_Oct2010.pdf 

Blast-related events are the leading 

cause of head injury in the military, 

followed in order by the other events 

mentioned above. 4 As a result of several 

factors, the number of concussions 

reported is lower than the number of 

actual occurrences. 

Many patients who experience concussion 

and receive medical care do not 

have a TBI diagnosis recorded, especially 

when multiple injuries are present. 5 In 

addition, up to 25% of patients with a 

concussion do not seek medical care. 6 

Reasons include lack of outward physical 

injury, symptom resolution before 

they can seek medical care, and lack of 

awareness that they should seek care. 

In 2007, the Department of Defense 

(DoD) started TBI screening programs 

for service members who returned from 

war zones, in order to identify soldiers 

who may have sustained a concussive 

event while deployed. Today, screening 

is performed on all service members at 

the end of deployment or when evacuated 

from theater due to injury. Because 

so many service members and former 

service members are seen outside the 

military healthcare system, providers 

in civilian settings should be aware of 

the incidence and causes of concussion 

in this population. 

Mechanisms of Injury 

The mechanisms of injury in an mTBI 

encompass one or more of the following: 

• Direct contact, such as something 

hitting the head while the head is at rest, 

causing focal damage. 

• Acceleration in combination with 

deceleration, also known as coup–contrecoup, 

in which the brain moves within 

the skull. This can cause damage to multiple 

areas, depending on how the brain 

slides. This can occur in a car accident 

that produces a forward and backward 

motion of the head, causing the brain 

to slide. The frontal and occipital lobes 

absorb this impact. 

• Rotational forces that cause shearing 

of the cerebral white matter axons. 

• A blast overpressure wave, followed 

by possible further concussive forces, such 

as being hit by debris, being thrown or 

inhaling fumes. 

Diagnostic Criteria 

The American Congress of Rehabilitation 

Medicine established criteria for mTBI 7 

(Table 1) in 1993, defining it as a traumatically 

induced physiologic disruption of 

brain function. The diagnosis of mTBI 

does not mean the symptoms are mild; 

at times these symptoms can be disabling. 

In 1997, the American Academy of 

Neurology published a sports concussion 

grading system (Table 2). 8 

An essential common element in the 

two sets of criteria is a traumatic blow or 

jolt to the head that causes an inability 

for the brain to function normally, even 

if it is for seconds. 

In our current state of heightened 

awareness of TBI, especially among 

military personnel, it is not uncommon 

for providers and patients to diagnose a 

concussion based on symptoms alone. 

But if alteration of consciousness (AOC) 

or greater has not occurred, a concussion 

diagnosis is not appropriate. In addition 

to being inaccurate, a symptom-based 

diagnosis may delay treatment of the 

real diagnosis. 

The natural history of a concussion 

involves resolution within minutes to 

several months. 9-11 In patients older than 

40 and in patients with preexisting conditions, 

recovery may take longer. 10 When 

symptoms last more than 3 months, the 

diagnosis of post-concussion syndrome 

may apply. 

The percentage of patients who have 

unrelenting symptoms ranges from 5% 

to 15%. 12,13 Influencing factors include 

pre-existing conditions, psychiatric conditions, 

chronic pain, substance abuse, 

secondary gain, unemployment and lack 

of support systems. 14 

Repetitive Injury 

Education about the prevention of repeat 

brain injury is vital yet often overlooked. 

A patient with a concussion may not be 

thinking clearly and may put himself or 

herself at risk for additional head injuries. 

In addition, the patient’s reaction time 

may be slowed. 

Several studies have documented the 

consequences of repeat concussions. 

Repetitive brain injury can lead to longer 

lasting symptoms, chronic headaches, 

slower response time and decreased academic 

scores. 15 

Recent studies of football players who 

sustained multiple concussions identified 

changes to brain pathology, known 

as chronic traumatic encephalopathy, 16 



which may increase the risk of neurologic 

disorders such as Alzheimer and 

Parkinson diseases. 17 

Diagnosis of Concussion 

Until an objective measure is available, 

the only way to diagnose a concussion 

is through a history of the event. It is 

best to use an open-ended format to 

interview the patient and/or others who 

witnessed the injury. Let them tell their 

story and describe what they were doing 

just before, during and afterward. Ask 

the patient to include what he or she saw, 

heard, smelled, tasted and felt. In some 

cases, it may not be possible to establish 

whether loss of consciousness (LOC) or 

post-traumatic amnesia (PTA) occurred. 

Establish the timeline of the event 

as soon as possible, when memories 

are fresher. In addition to helping with 

questions about the case later on, recording 

early memories helps confirm the 

length and degree of cognitive impairment. 

Understanding the particulars of the 

injury is helpful: type of vehicle, belted or 

not, protective gear, position, speed, what 

body part hit what, and so on. Ask whether 

any damage to protective gear occurred 

(crack in helmet or safety glasses, etc). 

What symptoms did the patient experience 

right after the event, and what are the 

current symptoms Common symptoms 

immediately after a concussive event can 

include headache, tinnitus, dizziness, 

nausea, vomiting and increased irritability. 

The initial interview should also 

include a thorough patient history to 

evaluate concurrent conditions, current 

or prior use of alcohol or drugs, current 

medications, caffeine use, dietary 

habits and prior history of concussions. 

These answers are helpful in determining 

treatment options and in identifying 

issues that may exacerbate symptoms or 

complicate recovery. 11 

The physical examination portion of 

the visit should consist of three parts: 

• a focused neurologic exam including 

a mental status assessment, cranial 

nerve testing, extremity tone and deep 

tendon reflex testing, strength, sensation, 

gait and postural stability (Romberg test) 

• a focused vision exam including 

gross acuity, eye movement, binocular 

function and visual fields/attention 

Table 2 

Sports Concussion Grading System 8 

Grade 1: Transient confusion with resolution of symptoms in less than 15 minutes 

Grade 2: Transient confusion and symptoms lasting more than 15 minutes 

Grade 3: Any loss of consciousness 

Developed by the American Academy of Neurology, http://www.aan.com/professionals/practice/guidelines/ 

pda/Concussion_sports.pdf 

Table 3 

Indications for Computed Tomography After 

Minor Head Injury 18 

(The New Orleans Criteria) 

Consider computed tomography within 7 days of minor traumatic brain injury for 

patients who exhibit one or more of the following: 

◗ Physical evidence of trauma above the clavicles 

◗ Seizure 

◗ Vomiting 

◗ Headache 

◗ Short-term memory deficits (persistent antrograde amnesia) 

◗ Age older than 60 

◗ Drug or alcohol intoxication at the time of injury 

◗ Coagulopathy 

http://www.nejm.org/doi/pdf/10.1056/NEJM200007133430204 

• a focused musculoskeletal examination 

of the head and neck, to include 

range of motion of the neck and jaw, focal 

tenderness and referred pain. 

Normal neurologic exam findings suggest 

that no major structural injuries to 

the brain have occurred. Findings that 

require urgent consultation with the 

neurology or neurosurgery departments 

include altered consciousness, progressive 

decline in neurologic findings, pupillary 

asymmetry, seizures, repeated vomiting, 

double vision, worsening headache, 

inability to recognize people, disorientation 

to place, unusual behavior, confusion, 

slurred speech, unsteadiness, and 

weakness or numbness of arms or legs. 11 

Understanding the mechanism of injury 

helps determine whether radiologic 

studies are needed. The New Orleans 

criteria for computed tomography after 

minor head injury are shown in Table 3 

and are intended for use within the first 

7 days after injury. 18 If imaging is desired 

after the first 7 days, it may be more effective 

to use MRI or other imaging studies 

that can provide more detail about the 

brain anatomy. 

Often, an affected patient exhibits 

no outward signs of a concussion. The 

symptoms of concussion are wide ranging. 

Physical symptoms of concussion 

include headache, dizziness, balance 

problems, nausea or vomiting, fatigue, 

visual disturbances, light sensitivity, tinnitus, 

and sleep disturbances. Cognitive 

symptoms include slowed thinking, poor 

concentration, trouble with word choice, 

and short-term memory loss. Emotional 

issues include anxiety, depression, irritability 

and mood swings. 

The physical examination findings and 

the symptom complaints should direct 

care. Start with the symptom that is most 

disabling for the patient. An interplay may 

exist among some of the most common 

symptoms. When one of the symptoms 

is treated effectively, others may improve. 

For example, the symptoms of headache, 

sleep disturbance, memory loss and mood 

change tend to improve when one of them 

is improved. 19 

➤ 


17


The most effective treatment approach is thorough patient education about 

concussion, the patient's particular findings, possible treatments and the 

expectation for recovery. 

Tools are available to assess symptoms 

after a concussion. The Rivermead Post- 

Concussion Symptom Inventory is a validated 

tool that can be used to track the 

course of symptoms, including impact 

on the patient and his or her daily functioning 

(http://www.tbi-impact.org/cde/ 

mod_templates/12_F_06_Rivermead.pdf). 20 

Treatments 

The most effective treatment approach 

is thorough patient education about concussion, 

the patient’s particular findings, 

possible treatments and the expectation 

for recovery. 21 This education should be 

repeated at subsequent visits, due to the 

short-term memory issues and anxiety 

common in this population. 

Typical areas to cover in patient education 

include the natural history of mTBI 

and expected recovery, sleep hygiene techniques, 

the need for abstinence from drugs 

and alcohol (which can increase symptoms 

and decrease the brain’s ability to heal), 

proper nutrition, coping strategies and 

avoidance of repeat concussion. The dangers 

of self-medication should be addressed, 

since patients may try caffeinated beverages 

to treat cognitive issues, alcohol or drugs 

to help with sleep and anxiety, and OTC 

medications to treat headaches or other 

symptoms. Reinforce the need for rest and 

Table 4 

Additional Resources 

avoidance of caffeine and alcohol, as well 

as use of medications only as prescribed. 

Using a medication organizer is one way 

of ensuring the patient safely dispenses his 

or her own medication in the right dosing 

and time frame. 

Until the patient has recovered, he or 

she should not engage in activities that 

will increase symptoms, such as mental 

or physical exertion. Depending on home 

and work status, specific guidance about 

return to work or school may be necessary. 

Start with a gradual increase in activity 

and increase the amount of activity as 

symptoms improve. 11 Driving, climbing 

and operating heavy machinery are areas 

of concern when visual, balance, cognitive 

or coordination difficulties exist. 

Cognitive functioning should return 

to baseline about 7 days to 1 month after 

mTBI. 21 Instruct the patient to follow up 

in 1 week if symptoms are not improving. 

Make a specialist referral for evaluation 

of ongoing cognitive symptoms or other 

symptoms that are severe, such as depression, 

pain or post-traumatic stress. 22,23 

These specialists may use neuropsychologic 

testing to help determine when return 

to work, school or play is appropriate. 24 

The involvement of several medical and 

complementary specialties may be necessary 

to provide complete care. Depending 

The Centers for Disease Control and Prevention operates a concussion resource 

center at http://www.cdc.gov/Concussion/. 

The Defense and Veterans Brain Injury Center website, www.DVBIC.org, provides 

information for service members and their families, as well as for healthcare providers. 

At this site, you can request a copy of the “Mild Traumatic Brain Injury Pocket Guide” 

and other tools. These can also be downloaded to iPhones, iPads and devices that use 

the Android platform. 

The Veterans Administration and Department of Defense clinical practice guideline for 

the management of mild traumatic brain injury is geared toward healthcare providers 

within the VA/DoD healthcare setting, but it can be useful to providers in the civilian 

setting. http://www.dvbic.org/pdf/VADoD-CPG---Concussion-mTBI.pdf 

The American Association of Neuroscience Nurses and the Association of Rehabilitation Nurses developed 

“Care of the Patient with Mild Traumatic Brain Injury.” This document can be downloaded at http://www. 

rehabnurse.org/uploads/files/cpgmtbi.pdf 

on the provider’s level of comfort and the 

resources in the clinic, several symptoms 

may be appropriate for treatment in primary 

care. Adopt a “start low and go slow” 

approach to any prescription medications. 

After injury, the brain is more sensitive 

to medication and therefore the risk of 

side effects increases. 25 

Headaches are often managed by primary 

care providers, and in this patient 

population headache would be a typical 

symptom to treat. The cause of post-traumatic 

headache is not completely understood, 

but the treatments are aimed at the 

type of headache that occurs: migrainous, 

tension-type, cervicogenic, overuse/ 

rebound, chronic daily or combination. 

Treatments for these headaches include 

non-narcotic pain medications (avoiding 

tramadol because it can increase seizure 

risk), nonsteroidal anti-inflammatory 

drugs, triptans, tricyclic antidepressants, 

anti-epileptic drugs, beta-blockers, botulinum 

toxin and occipital blocks. Referral to 

a neurologist may be beneficial depending 

on the experience of the clinician, the type 

of headaches experienced and the response 

to attempted treatments. Refer to a dentist 

for evaluation of pain, popping or clicking 

at the temporomandibular joint. 

Sleep problems are common in patients 

who have experienced a concussion. They 

may report trouble getting to sleep, frequent 

awakenings, nightmares or weird 

dreams. Good sleep hygiene and the 

incorporation of relaxation techniques 

can be helpful. Trazodone is considered 

first-line treatment for sleep disturbances 

in patients recovering from concussion; 

this is an off-label use. 26 The short-term 

use of sleep aids such as zolpidem or 

eszopiclone can provide quick results 

for patients. Other possibilities are using 

medications that will work on multiple 

issues, such as a tricyclic antidepressant 

that helps prevent headaches, increases 

nighttime sleepiness and may improve 

mood. It is important to avoid the use 

of benzodiazepines because they may 

interfere with neuronal recovery. 27 Referral 



to a behavioral health provider may be 

helpful for cognitive behavioral therapy 

and to reinforce sleep hygiene techniques. 

Balance and vision are two areas that 

require additional questions in order to 

clarify the true problem. Three systems 

maintain balance: the functional nervous 

system, the visual system and the vestibular 

system. Concussion may cause issues 

with vision and/or the vestibular system. 

Balance issues may present in a variety 

of ways. Many patients complain of “dizziness,” 

and clinicians must differentiate what 

type of balance difficulties or sensations 

they are experiencing. Vertigo causes a 

spinning sensation, usually when changing 

head position quickly. Benign paroxysmal 

positional vertigo is common in association 

with concussion and can be treated 

by performing a procedure to reposition 

the crystals in the semicircular canals of 

the inner ear. This is often performed by a 

specialist with training in vestibular rehabilitation. 

These specialists may include 

physical therapists, audiologists or occupational 

therapists. Some patients describe 

a feeling of rocking on a boat, which can 

be indicative of visual disturbances and/or 

a milder vestibular issue. In this case, the 

patient may require the services of both 

vestibular and optometry specialists. Still 

others may have occasional lightheadedness 

when standing quickly. 

Visual problems that may occur after 

concussion include photosensitivity, 

difficulty maintaining reading focus 

(convergence), difficulty with distance 

perception (accommodation) and, on 

occasion, double vision in one or more 

areas of gaze. The patient may or may 

not mention these problems, so ask about 

vision changes. Regardless of findings, 

any patient who reports vision changes 

should receive a referral to optometry 

or ophthalmology for evaluation with 

binocular examination. This examination 

can identify difficulties with maintaining 

focus. Treatments include eye exercises to 

strengthen the ocular nerves and muscles 

and possibly a prescription for glasses. 

Additional specialties that may be 

of benefit, depending on the patient’s 

symptoms, are: 

• Neurology for management of headaches, 

sleep and pain 

• Behavioral health professionals for 

mood, sleep and pain management, cognitive 

testing and related treatment 

• Social work and nurse case management 

for biopsychosocial evaluation, 

education and support based upon this 

evaluation 

• Speech therapy for evaluation of 

speech and language skills, from a foundational 

framework 

• Occupational therapy for evaluation 

of cognitive assessment, from a functional 

standpoint 

• Audiology for evaluation of tinnitus, 

vestibular function and auditory processing 

• Physical therapy for evaluation and 

treatment of balance, gait and vestibular 

management 

• Optometry for evaluation of visual 

acuity and binocular testing. 

Get Connected 

Concussions are common and can be a 

challenge to treat. The best preparation 

is to become familiar with concussion 

resources in your area and to equip yourself 

with basic knowledge about how to 

assess, diagnose and treat mTBI. Table 

4 lists resources that can provide further 

guidance. ■ 

References 

1. Faul M, et al. Traumatic brain injury in the United 

States: emergency department visits, hospitalizations, 

and deaths: 2002-2006. http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf. 

2. Centers for Disease Control and Prevention, 

National Center for Injury Prevention and Control. 

Report to Congress on mild traumatic brain injury 

in the United States: steps to prevent a serious public 

health problem. http://www.cdc.gov/ncipc/pub-res/ 

mtbi/mtbireport.pdf. 

3. Armed Forces Health Surveillance Center, 

2012. TBI numbers by severity. www.dvbic.org/TBI- 

Numbers.aspx. 

4. Champion HR, et al. Injuries from explosions: 

physics, biophysics, pathology, and required researchfocus. 

J Trauma. 2009;66(5):1468-1477. 

5. Moss NE, et al. Admissions after head injury: 

how many occur and how many are recorded Injury. 

1996;27(3):159-161. 

6. Sosin DM, et al. The incidence of mild and moderate 

brain injury in the United States 1991. Brain Inj. 

1996;10(1)47-54. 

7. American Congress of Rehabilitation Medicine. 

Definition of mild traumatic brain injury. J Head 

Trauma Rehabil. 1993;8(3):86-87. http://www.acrm. 

org/pdf/TBIDef_English_Oct2010.pdf. 

8. Ruff RM, et al; NAN Policy and Planning 

Committee. Recommendations for diagnosing a 

mild traumatic brain injury: a National Academy 

of Neuropsychology education paper. Arch Clin 

Neuropsychol. 2009;24(1):3-10. 

9. Levin HS, et al. Neurobehavioral outcome following 

minor head injury: a three-center study. J 

Neurosurg. 1987;66(2):234-243. 

10. McCrea MA. Acute Symptoms and Symptom 

Recovery. In: Mild Traumatic Brain Injury and 

Postconcussion Syndrome: The New Evidence Base 

for Diagnosis and Treatment. New York: Oxford 

University Publishing Press; 2008: 86. 

11. Hoge CW, et al. Mild traumatic brain injury 

in U.S. soldiers returning from Iraq. N Engl J Med. 

2008;358(5):453-463. 

12. Alexander MP. Mild traumatic brain injury: 

pathophysiology, natural history, and clinical management. 

Neurology. 1995;45(7):1253-1260. 

13. Ruff RM, et al. Miserable minority: emotional risk 

factors that influence the outcome of a mild traumatic 

brain injury. Brain Inj. 1996;10(8):551-565. 

14. Department of Veterans Affairs & Department 

of Defense. Clinical Practice Guideline. Management 

of Concussion/Mild Traumatic Brain Injury. http:// 

www.healthquality.va.gov/mtbi/concussion_mtbi_ 

full_1_0.pdf. 

15. Guskiewicz KM, et al. Cumulative effects associated 

with recurrent concussion in collegiate football 

players: the NCAA concussion study. JAMA. 

2003;290(19):2549-2555. 

16. McKee AC, et al. Chronic traumatic encephalopathy 

in athletes: progressive tauopathy after 

repetitive head injury. J Neuropathol Exp Neurol. 

2009;68(7):709-735. 

17. National Institute of Neurological Disorders and 

Stroke. Traumatic brain injury: hope through research. 

Bethesda, MD: National Institutes of Health; 2002. 

NIH Publication No.: 02-158. http://www.ninds.nih. 

gov/disorders/tbi/detail_tbi.htm. 

18. Haydel MJ, et al. Indications for computed tomography 

in patients with a minor head injury. New Engl 

J Med. 2000;343(2):100-105. 

19. Oullet MC, Morin CM. Efficacy of cognitivebehavioral 

therapy for insomnia associated with 

traumatic brain injury: a single-case experimental 

design. Arch Phys Med Rehab. 2007;88(12):1581–1592. 

20. King NS, et al. The Rivermead Post Concussion 

Questionnaire: A measure of symptoms commonly 

experienced after head injury and its reliability. J 

Neurol. 1995;242(9):587-592. 

21. Ponsford J, et al. Impact of early intervention on 

outcome following mild head injury in adults. J Neurol 

Neurosurg Psychiatry. 2002;73(3):330-332. 

22. Frenchman KA, et al. Neuropsychological studies 

of mild traumatic brain injury: a meta-analytic 

review of research since 1995. J Clin Exp Neuropsychol. 

2005;27(3):334-351. 

23. Gioia G, et al. New approaches to assessment 

and monitoring of concussion in children. Topics in 

Language Disorders. 2009;29(3):266-281. 

24. Jagoda AS, et al. Clinical policy: neuroimaging and 

decision making in adult mild traumatic brain injury in 

the acute setting. Ann Emerg Med. 2008;52(6):714-748. 

25. Cifu D, et al. Repetitive head injury syndrome. 

http://emedicine.medscape.com/article/92189-overview. 

26. Arciniegas DB, et al. Mild traumatic brain injury: a 

neuropsychiatric approach to diagnosis, evaluation, and 

treatment. Neuropsychiatr Dis Treat. 2005;1(4):311-327. 

27. Zasler ND. Advances in neuropharmacological 

rehabilitation for brain dysfunction. Brain Inj. 

1992;6(1):1-14. 

Better Mental Healthcare for Veterans 

➼ Enter "healthcare for veterans" in the Search 

Articles box at www.advanceweb.com/NPPA to find "Improving 

Healthcare for Veterans and Military Families" and hear how 

healthcare organizations have partnered with a White House 

initiative called Joining Forces to increase access to mental 

healthcare for the military. 


19


Concussion • NPPA24 

Questions 

1. The leading cause of concussion 

in the U.S. civilian population is: 

a. Assaults 

b. Falls 

c. Motor vehicles accidents 

d. Being struck by something 

2. Reasons for not receiving care 

after a concussion include which of 

the following 

a. Multiple injuries have occurred 

b. Lack of outward physical signs 

c. Unaware of the need to seek care 

d. All the above 

3. Mechanism of injury in mild TBI 

includes: 

a. Cerebral vascular accident 

b. Acceleration/deceleration in a 

rapid and forceful way 

c. Blast overpressure wave 

d. Both B & C 

4. Which statement is most 

accurate in describing diagnostic 

criteria for a concussion 

a. You can diagnose a concussion 

based on the symptoms. 

b. A loss of consciousness must 

accompany a blow or jolt to the 

head. 

c. A blow or jolt to the head 

that causes any alteration of 

consciousness. 

d. None of the above 

5. Why is education to prevent a 

repeat head injury important 

a. The postconcussive patient may 

have slowed reaction time. 

b. Repetitive injury may lead to 

longer lasting symptoms. 

c. Multiple concussions may lead to 

changes in brain pathology. 

d. All of the above 

6. Diagnosis of concussion is made 

using which of the following 

a. History of the event 

b. Brain imaging 

c. Focused neurologic exam 

d. Evaluation by biomarkers 

7. Appropriate examination of the 

patient who has had a concussion 

includes: 

a. A focused neurologic exam 

b. Focused vision exam 

c. CT of the head 

d. Both A & B 

8. The most effective treatment for 

a concussion is: 

a. Patient education about expected 

recovery 

b. Management of headache 

c. Management of sleep disorders 

d. Management of memory issues 

9. When prescribing medication 

to a postconcussive patient, the 

following applies: 

a. It is important to start low and 

go slow. 

b. The patient will not require 

medication. 

c. Medications should be started at 

the highest possible dosing. 

d. Start with multiple medications 

at one time. 

10. The following specialists may 

be considered when caring for the 

postconcussive patient: 

a. Optometry 

b. Neurology 

c. Occupational therapy 

d. All the above 

Evaluation 

1. The educational objectives were 

achieved. 

a. strongly disagree 

b. disagree 

c. neutral 

d. agree 

e. strongly agree 

2. Based on what you learned in 

this article, will you make changes 

in your practice 

a. yes 

b. no 

If yes, please describe the changes 

you intend to make: _____________ 

_______________________________ 

What barriers to change do you 

anticipate ______________________ 

_______________________________ 

What strategies or mechanisms will 

you apply to overcome these barriers 

_______________________________ 

_______________________________ 

3. The information in the article 

was fair, balanced, free of 

commercial bias and supported by 

scientific evidence. 

a. yes 

b. no 

If no, describe the nature of the issue: 

_______________________________ 

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Gastroenterology 

Beware the 

Irritable Bowel 

Deciphering the overlap of symptoms 

By Susan Andersen, PhD, RN, FNP-BC 

➼ As Sharon sat in the lobby waiting 

to be called for her annual exam, she 

realized she was checking off questionnaire 

answers in nearly every body system. 

Headaches, diarrhea, constipation, 

bloating, flatulence, abdominal pain and 

cramping, frequent mouth sores, fatigue, 

depression, an itchy rash that would not 

go away … How long had she felt this 

way She couldn’t remember. “Just how 

sick am I” she wondered. 

This is a typical scenario for a patient 

presenting with a functional bowel disorder, 

which despite its symptomatic 

nature has no identifiable mechanical 

cause. Functional bowel disorders include 

irritable bowel syndrome (IBS), functional 

diarrhea and chronic constipation. 

Celiac disease and gluten sensitivity 

cause symptoms similar to those of IBS, 

but these are not considered functional 

bowel disorders. 

The fact that 33% to 90% of people 

who experience IBS symptoms do not 

consult a healthcare provider contributes 

to the variability in prevalence estimates. 2 

Most IBS patients in Western countries 

are never diagnosed, with the exception 

of the United Kingdom and Italy, where 

about half of positive cases are identified. 

Predictors of healthcare-seeking include 

severity of abdominal pain and distention, 

Rome criteria status (http://romecriteria. 

org/assets/pdf/19_RomeIII_apA_885-898. 

pdf) and impact on mood and lifestyle. 

Studies show that patients experience 

symptoms between 5 and 13 years prior 

to diagnosis. Although comorbidity with 

other GI disorders or mortality is not 

associated with IBS, no cure has been 

identified. One review found the mean 

direct costs of IBS management to be 

$619 per patient annually, with total direct 

costs of $1.35 billion. 6 Productivity losses 

in the United States range from $335 to 

$748 per patient, for an annual total of 

$205 million due to lost workdays. Costs 

to patients with celiac disease were $4,000 

(all patients) to $10,000 (men) higher 

annually than for healthy controls. 7 From 

these numbers, we can extrapolate that 

if 1% of the U.S. population is affected 

by IBS, the annual healthcare costs are 

$124.4 million to $311 million. 

IBS negatively affects quality of life and 

social function. Patients may experience 

increased anxiety, depression, pain and 

discomfort. 8 Patients in whom constipation 

predominates among IBS symptoms 

have significantly lower quality-of-life 

scores on physical and mental components 

Epidemiology 

IBS is diagnosed in 1 in 5 Americans 

each year. 1 Among adults, IBS incidence 

peaks between ages 30 and 50. 2 Women 

are affected twice as often as men at 

younger ages, but men and women are 

at equal risk later in life. 2 The estimated 

prevalence of IBS in Western countries 

varies widely, from 5% to 15%. 3-5 Italy has 

the highest prevalence among developed 

countries. 3-5 

tom whalen 

Susan Anderson is a family nurse practitioner 

who is an associate professor in the 

School of Nursing at Texas Tech University 

Health Sciences Center in Lubbock, Texas. 

She has completed a disclosure statement and 

reports no relationships related to this article. 


21


Table 1 

Common and Red Flag Differential Diagnoses for IBS 

Disorder Signs & Symptoms Diagnostic Tests 

Ulcerative colitis Peaks ages 15 to 35 

Sigmoidoscopy, colonoscopy, barium enema 

Bloody diarrhea with mucus, fever, abdominal pain, 

tenesmus, weight loss 

Crohn’s disease Onset ages 15 to 35 or 70 to 80 

Sigmoidoscopy, colonoscopy, barium enema 

Fever, abdominal pain, diarrhea, fatigue, weight loss 

Anorectal fissures, fistulae, abscesses 

Infectious diarrhea Chronic diarrhea with cramps with or without blood Microscopy, stool studies, sigmoidoscopy 

and mucus 

Diverticulitis Lower left abdominal pain, fever, altered bowel habits Complete blood count, computed tomography, barium 

enema 

Colorectal 

malignancy 

Age 50 or older 

Rectal bleeding, altered bowel habits, abdominal or 

back pain, anemia, occult blood in stool, weight loss 

Colonoscopy 

Medication side 

effects 

Antacids, laxatives, selective serotonin reuptake 

inhibitors, thyroid hormones, metformin, narcotics, 

calcium-channel blockers, anticholinergics 

History of concordance of symptoms with medication 

initiation; trial of drug holiday or reducing dosage; 

rechallenge confirms 

and significantly more work and activity 

impairments than people without IBS. 9 

People with IBS take more time off work, 

resulting in significant economic effects. 

Chronic ongoing life stress can predict 

the prognosis of patients with IBS. 7 

Significant overlap among functional 

bowel disorders exists; 42% to 87% of 

patients with IBS also experience functional 

dyspepsia, with symptoms of 

epigastric pain, nausea, vomiting, weight 

loss and early satiety. 7 Most people with 

IBS experience functional constipation, 

functional diarrhea, or both. People 

with IBS are four times more likely to 

also have celiac disease. 7 Therefore, it is 

important to maintain a high degree of 

suspicion about the presence of gluten 

sensitivity as an underlying cause of 

pathology. 

Etiology 

A current theory about the pathophysiologic 

origin of IBS is visceral hypersensitivity 

resulting from disturbances in 

gastrointestinal serotonin metabolism. 10 

Serotonin, released by enterochromaffin 

cells in the gastrointestinal mucosa, is 

the principal mediator of gut motility 

and visceral sensation. Patients with IBS 

also exhibit differences in central pain 

processing, as measured by functional 

brain magnetic resonance imaging. 

Other causes may include inflammation, 

intestinal permeability, food sensitivity, 

lack of dietary fiber and antibiotics. 

Genetic factors or role modeling may 

influence the development of IBS, since 

clustering within families has been documented. 

10,11 Psychological factors also 

may play a role. 10,11 IBS can develop after 

enteric infections, suggesting the importance 

of peripheral neurologic processes, 

with or without psychological triggers. 10,11 

Neuromotor dysfunction has also 

been investigated as a symptom trigger. 

Increasing evidence shows that chronic, 

low-grade inflammation is associated 

with IBS. Up to 30% of patients with 

a GI infection develop persistent lowgrade 

inflammation and IBS symptoms, 

prompting consideration of the role of 

bacterial overgrowth. 12 

Gluten and Lactose 

The role of food-related irritation in 

IBS symptoms is supported by numerous 

studies. In one of these, researchers 

found IgG4 antibodies to wheat in 60% 

Table 2 

Common Comorbidities 2 

Chronic fatigue syndrome 92% 

Fibromyalgia 77% 

Temporomandibular joint 

disorder 

64% 

Chronic pelvic pain 50% 

of patients who had IBS, compared with 

27% of healthy people. 12 Contributing to 

the confusion and lack of clarity about 

the causative role of food in IBS is that 

controlled trials often do not support 

this contention. 11 The ubiquity of glutencontaining 

foods in the Western diet 

makes it difficult for people with IBS 

symptoms to identify this as a causative 

agent. Other contributing factors may 

also be at work, such as unique physiologic 

and genetic characteristics that 

interact with food and the environment. 

Pathological and clinical symptoms in 

IBS can vary from subtle to severe due 

to gluten sensitivity, and this variation 

is not explained by mucosal damage. 13,14 

Patients who have gluten sensitivity simply 

respond positively to a diet free of 

gluten, which is found in wheat, barley, 

rye and perhaps oats. (Whether oats 

contain gluten is controversial. Some 

experts maintain that reaction to oats 

by some patients with gluten sensitivity 

is due to cross contamination during the 

refining process. However, some cultivars 

of oats may contain gluten.) 

Some evidence suggests that subtle 

immunopathologic changes may occur 

in the intestine when it is exposed to 

gluten. 16 Changes may include increased 

intraepithelial lymphocytosis, increased 

IgA deposition in the intestinal villi, 

changes in the microvillus border, and 

increased secreted antibodies directed 



Table 3 

Pharmacologic Therapy 

Purpose When to use Class Examples Indication 

Pain Control 

First line 

(mild symptoms) 

Second line (mild to 

moderate symptoms) 

Antispasmodics 

Tricyclic antidepressants, 

SSRIs* 

Dicyclomine, hyoscyamine, 

encapsulated peppermint oil 

Amitriptyline, fluoxetine* 

Reduce spasms and pain 

Reduce pain and diarrhea 

Constipation First line Bulking agents Psyllium Restore stool motility 

Chloride-channel activator Lubiprostone Severe, refractory constipation 

Diarrhea First line Antidiarrheal Loperamide Reduce stool 

Second line Serotonin-3 antagonist Alosetron Severe, refractory diarrhea 

*few placebo controlled trials to support 

against gliadin, a glycoprotein found in gluten-containing 

cereals. Often, these disorders occur in patients carrying the 

same human leukocyte antigen (HLA) genotypes associated 

with celiac disease, DQ2 and DQ8. 

This immunopathology was found earliest in family members 

of people with celiac disease who, despite not having villous 

atrophy, had evidence of immune responsiveness to gluten 

(i.e., diarrhea after gluten ingestion). 15 This finding supports 

the emerging consensus that gluten sensitivity is an abnormal 

immune response to gluten that can occur without the intestinal 

damage seen in celiac disease. However, some patients who are 

sensitive to gluten but have negative biopsies and serology may 

eventually develop mucosal damage. 16 No therapeutic guidelines 

for gluten sensitivity have been published. 

Lactose intolerance also causes IBS symptoms of diarrhea, 

abdominal pain, flatulence and bloating. The prevalence of 

lactose intolerance is unknown, 17 but it affects many racial and 

ethnic groups in the United States. Symptoms are caused by 

malabsorption of lactose due to a deficiency in lactase, which 

is required to digest lactose. Lactase metabolizes lactose into 

two simpler sugars, glucose and galactose, which are readily 

absorbed into the bloodstream. This enzyme is produced by 

expression of the lactase-phlorizin hydrolase gene in the cells 

lining the small intestine. 17 

Infants normally produce lactase and digest lactose in human 

milk or infant formulas. After weaning, most children are 

genetically programmed to produce less lactase. The symptoms 

of lactose intolerance are caused by bacterial fermentation of 

undigested lactose in the colon. 17 

The demonstration of lactose malabsorption does not necessarily 

indicate that a patient will be symptomatic. Many variables 

determine whether a person develops symptoms, including 

the amount of lactose ingested, the residual intestinal lactase 

activity, the ingestion of food along with lactose, the ability of 

the colonic flora to ferment lactose, and individual sensitivity 

to the products of lactose fermentation. 17 

Diagnosis 

Functional GI disorders are diagnosed clinically. IBS is a 

chronic, relapsing gastrointestinal syndrome diagnosed using 

current Rome criteria. 3 Behavioral features of IBS that can help 

diagnose it are: symptoms for more than 6 months; “frequent 

flyer” visits for non-GI symptoms; prior medically unexplained 

symptoms; and intensification of symptoms with stress. 

Red flags for more significant or life-threatening diagnoses 

(i.e., age older than 50, recent symptom onset, weight loss, 

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thorough consideration. In the presence of these factors, 

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23


Table 4 

Lifestyle and Behavioral Therapy 

◗ Exercise regularly 

◗ Cognitive–behavioral therapy (stress management, relaxation training) 

◗ Diet modification 

◗ Increase dietary fiber (25 g/day) 

◗ Avoid common culprits: alcohol, chocolate, caffeine, dairy products, sugar-free 

sweeteners, gas-forming foods, fatty foods 

◗ Avoid chewing gum or drinking through a straw, which can cause air swallowing and 

increase gas 

◗ Eat smaller meals, especially patients with diarrhea 

◗ If lactose intolerant, substitute yogurt for milk or use an enzyme 

◗ Drink plenty of fluids, especially water 

Alternative therapy 

◗ Acupuncture 

◗ Probiotics 

◗ Hypnosis 

◗ Yoga, massage, meditation 

further diagnostic testing is prudent to 

rule out more serious diagnoses (Table 1). 

Non-GI symptoms reported by IBS 

patients include lethargy, backache, headache, 

urinary tract symptoms (nocturia, 

frequency, urgency, incomplete bladder 

emptying) and in women, dyspareunia. 

Half of patients with IBS are depressed, 

anxious or hypocondriacal. 2 Be aware of 

chronic pain syndromes that can coexist 

with IBS (Table 2). Patients with these 

syndromes may have more severe IBS. 

Many other somatic conditions are 

also reported by patients affected by IBS: 

mood disorders, anxiety about health, 

stressful life events, decreased quality 

of life and frequent healthcare seeking. 2 

Systematic assessment is important to 

identify IBS patients who also have a 

psychiatric disorder. 

Comorbidities in gluten sensitivity that 

may increase clinical suspicion include 

geographic tongue, frequent aphthous 

ulcers, dermatitis herpetiformis and 

chronic iron deficiency anemia. Fatigue 

and depression are common to both gluten 

sensitivity and celiac disease. Anemia 

due to folic acid, B 12 or iron deficiency 

may occur in celiac disease. Other symptoms 

that should increase clinical suspicion 

for celiac disease include dental 

enamel defects, osteopenia or osteoporosis, 

fatigue, bone or joint pain, tingling 

of hands or feet, migraine headaches, 

and infertility. 2 

Celiac disease is typically diagnosed 

by serology and small intestine biopsy. 

Although both gluten sensitivity and 

celiac disease are caused by an inability 

to digest gluten, most people with gluten 

sensitivity have normal biopsies and those 

with celiac disease have small bowel 

villous atrophy. Serology tests include 

HLA DQ2/DQ8, which has a sensitivity 

of 90% to 95%. The specificity for this 

test is poor. 2 

Antibody tests (endomysial, gliadin) 

are now recommended as first line due 

to high sensitivity and better specificity. 

Endoscopy (small intestinal and upper 

gastrointestinal with biopsy) is also recommended 

to determine the presence of 

tissue damage. 1 

People with lactose intolerance do 

not seem to have the variety of systemic 

symptoms experienced by patients with 

gluten sensitivity and celiac disease. 17 

Elevated levels of breath hydrogen, produced 

by bacterial fermentation of lactose 

in the colon, help confirm diagnosis 

of lactose malabsorption. For this test, 

patients ingest a standard dose of lactose 

while in a fasting state. Other tests 

include intestinal biopsy (to determine 

lactase activity) and genetic testing for 

the common polymorphism that is linked 

to lactase nonpersistence. 

Management 

The goal of therapy is to manage symptoms 

enough to allow patients to live as 

close to normally as possible. Few pharmacologic 

agents reduce all symptoms 

of IBS (Table 3). Antispasmodics may be 

used for pain management. The addition 

of an antidepressant can be helpful. 2 

Antidiarrheals or bulking agents can 

help improve quality of life, depending 

on symptomology. 2 Patients who experience 

IBS due to intolerance of gluten or 

lactose must abstain from the offending 

substance. 

Enzyme supplements taken prior to 

the ingestion of dairy products can prevent 

IBS symptoms. Patients can also 

drink milk products in which lactose has 

been prehydrolyzed with lactase enzyme. 

Although the availability of gluten-free 

food products has increased in recent 

years, these products can be more expensive 

than traditionally prepared foods. 

Patients with gluten sensitivity may 

find they need to abstain from dairy 

products, not due to lactose intolerance, 

but due to casein, a protein that seems to 

cause digestive upsets similar to gliadin. 

The clinician must become a detective to 

ferret out all potential sources of gluten 

and casein. For example, casein is found 

in many wines. 

Lifestyle and behavioral therapy (Table 

4) can assist patients with IBS. Cognitive 

behavioral therapies can help reduce 

stress and anxiety. Dietary modifications, 

including increased fiber and fluids and 

avoidance of foods that exacerbate symptoms, 

can reduce the overall burden of the 

disease. The role of alternative therapy is 

unproven, but some interventions may 

benefit some patients. 

Sharon’s Case 

Sharon’s physical examination was unremarkable. 

She took no medications other 

than occasional acetaminophen for aches 

and pains. Due to the range and variety of 

Sharon’s symptoms, her clinician decided 

to try an elimination diet starting with 

dairy and progressing to gluten. Sharon’s 

complete blood count revealed mild iron 

deficiency anemia. Her clinician ordered 

antigliadin antibody (IgG and IgA) serology 

testing. The IgG results were positive 

and the IgA results were normal. 

Endoscopy revealed no abnormalities, 

and duodenal biopsy was normal. 

Sharon started taking oral iron supple- 

Continued on page 32 


Diabetes 

Dave Perillo 

Inpatient 

Hyperglycemia 

A lesson in selecting the correct protocol 

By Heidi Rymaszewski, DNP, ANP-BC, BC-ADM, CDE 

➼ William, a 49-year-old black 

man, presented to the emergency department 

with a 1-week history of polyuria, 

polydipsia, blurred vision, dizziness and 

a 1-day history of vomiting and diarrhea. 

His serum blood glucose level at the time 

of admission was 1,087 mg/dL. Arterial 

pH was 7.34, serum bicarbonate was 

25 mEq/L, serum osmolality was 425 

mOsm/kg, serum ketones were positive, 

and HbA 1c was 12.2%. 

The patient had no personal or family 

history of diabetes. He reported a past 

medical history significant for cardiomyopathy, 

heart failure (ejection fraction of 

20%), pacemaker implant, hypertension, 

obstructive sleep apnea and depression. 

William was unemployed and receiving 

disability payments. He was unmarried, 

had no children and lived alone. 

His oven did not work and he did not 

have a microwave. Most of his meals 

were convenience foods purchased at 

the gas station and heated on a hot plate. 

He quit smoking about 5 years ago. His 

alcohol intake was approximately three 

12-ounce beers per week, usually during 

the weekend. He reported that he did not 

use drugs. His exercise was limited due 

to shortness of breath. 

Physical and Systems Review 

The review of systems was negative except 

for constitutional symptoms. William said 

he felt fatigued and that he had lost about 

10 pounds over the past 2 to 3 months. 

Heidi Rymaszewski is an adult nurse practitioner and certified diabetes educator who works 

in the Diabetes and Nutrition Education Department at Aurora Medical Group in Milwaukee. 

She has completed a disclosure statement and reports no relationships related to this article. 

The patient also reported having blurred 

vision for the past week; he had not seen 

an eye doctor or dentist in years. William 

reported one episode of diarrhea and vomiting 

of undigested food in the last week. 

He complained of poor appetite for the 

past month. He usually ate two meals daily, 

with multiple snacks of junk food. He did 

not have a schedule for meals, and he often 

ate late into the night. He frequently drank 

juice and regular cola. He reported that 

he had been urinating about five times 

per night. He complained of cramping 

in both feet, especially in the evening. 

William’s physical examination was 

normal except for a weight of 260 pounds 

(BMI 36.2), blood pressure of 170/90 

mm Hg, and a mildly elevated pulse at 

92 beats per minute. His lips and buccal 

mucosa were somewhat dry. Acanthosis 

nigricans was present on his neck and 

elbows, which is a symptom of insulin 

resistance often seen in type 2 diabetes. 

The patient was diagnosed with diabetes 

(type undetermined at this point) 

based on the random blood glucose level 

greater than 200 mg/dL. He was placed 

on the emergency department’s diabetic 

ketoacidosis (DKA) protocol (Table 1) 

based on his positive serum ketones. He 

was admitted to a general medical unit. 

Inpatient Course 

William’s glucose level decreased to the 

200 mg/dL to 300 mg/dL range after 4 

hours of insulin infusion. Finger sticks 

every 2 hours showed that it remained in 

that range. Adjustment to the infusion 

rate was based on the DKA protocol. He 

was kept on the same regimen for the rest 

of that day and half of the following day, 

until he was feeling better and began to 

experience hunger. 

William ate the breakfast provided 

to him by the hospital’s dietary department, 

and his glucose level before lunch 

increased into the high 300 mg/dL range. 

Because his serum ketones were negative 

at that point, the hospitalist physician 

decided that he should be switched to 

a subcutaneous insulin regimen. The 

plan was to discharge him later that 

day. Because William’s glucose level was 

uncontrolled on the insulin infusion 


25

Diabetes 

and he had already eaten a meal, this 

data could not be used to appropriately 

calculate his subcutaneous insulin needs. 

Two protocols were available: the sliding 

scale insulin protocol (Table 2) and 

the basal–bolus insulin protocol (Table 

3). The hospitalist physician decided to 

place William on the sliding scale insulin 

protocol. After 4 more hours on this 

protocol and another meal, the patient’s 

glucose level increased to 450 mg/dL. 

Table 1 

DKA Insulin Infusion Protocol 

Serum ketones were negative. The patient 

was returned to the insulin infusion, but 

this time he was placed on a general medical 

unit insulin infusion protocol that 

allowed for a higher number of units based 

on the results of finger sticks performed 

every 2 hours. 

After another 4 hours, William’s blood 

sugars were in the 180 mg/dL range. The 

nursing staff calculated subcutaneous 

insulin doses based on insulin infusion 

1. Call provider before any of these orders are instituted. 

2. Draw STAT basic metabolic panel, magnesium, phosphorus, serum acetone (if not yet 

drawn). 

3. Discontinue all previous insulin orders. 

4. Give bolus human regular insulin IV ___________ units. Suggested dose 0.1 units/kg. 

5. Start infusion of 150 units of human regular insulin in 150 mL 0.9% NaCl (1 unit per 

mL) at appropriate insulin infusion rate. (See infusion orders below.) Run first 10–20 mL 

of infusion through tubing and waste. 

Insulin Infusion Protocol: 

CAPILLARY or BLOOD GLUCOSE INSULIN INFUSION 

> 500 14 mL/hr (14 units/hr) 

401–500 10 mL/hr (10 units/hr) 

351–400 8 mL/hr (8 units/hr) 

301–350 6 mL/hr (6 units/hr) 

251–300 4 mL/hr (4 units/hr) 

201–250 3 mL/hr (3 units/hr) 

151–200 2 mL/hr (2 units/hr) 

100–150 1 mL/hr (1 unit/hr) 

< 100 no insulin 

6. Capillary or blood glucose every hour. Record on glucose monitoring record. Adjust 

insulin infusion based on Insulin Infusion Protocol. 

7. If insulin infusion is interrupted due to glucose < 100 mg/dL, obtain capillary or blood 

glucose every hour until glucose > 100 mg/dL, then restart insulin infusion. 

8. Start IV fluids: _________________________ at __________ mL/hr. 

9. For signs of hypoglycemia: 

A. Collect STAT capillary or blood glucose. If < 60 mg/dL and symptomatic, stop insulin 

infusion and give dextrose 25 g IV (50 mL of D50W). 

B. Collect STAT capillary or blood glucose. If blood glucose < 60 mg/dL and the patient is 

asymptomatic, stop insulin infusion and give dextrose 12.5 g IV (25 mL of D50W). 

C. Recheck capillary or blood glucose in 15–20 minutes. If blood glucose < 60 mg/dL, 

repeat above procedure A or B depending on patient’s symptoms and contact physician. 

10. When the capillary or blood glucose is less than 300 mg/dL, change IV fluids to D5W 

______at ______mL/hr. 

Consider discontinuing IV fluids when tolerating by mouth diet. 

11. Ask provider about frequency of lab draw: 

Electrolyte panel every ______________ Phosphate every ______________ 

Basic metabolic panel every __________ Serum acetone every ___________ 

Potassium every ________________ Arterial blood gasses every __________________ 

Magnesium every _______________ Other: ____________every _______ 

12. Before stopping insulin infusion, call provider for subcutaneous insulin orders (must 

be given 30–60 minutes before insulin infusion is discontinued). 

Provider Signature/ID No: _____________________________________________ 

Date/Time: __________________ 

rates over the previous 4 hours, and the 

hospitalist physician started the patient 

on the basal–bolus insulin protocol. The 

nursing staff provided instruction about 

blood glucose self-monitoring and insulin 

administration, and the hospital provided 

a blood glucose meter for home use. The 

nurses instructed William to check his 

blood sugars three times per day and to 

bring his meter to the follow-up appointment 

with his primary care provider 

so that his doses could continue to be 

adjusted. He was discharged later that 

evening with a blood sugar of 203 mg/dL. 

Background 

Hospitalized patients with hyperglycemia 

are usually categorized as being previously 

diagnosed with diabetes, having unrecognized 

diabetes, or having hyperglycemia 

related to hospitalization. Hyperglycemia 

with and without diabetes has been associated 

with poor outcomes such as longer 

lengths of stay. 1 The American College 

of Endocrinologists recommends that 

elevated glucose levels (> 140 mg/dL in 

patients who are not critically ill) should 

be identified in all hospitalized patients 

and should be treated aggressively and 

as soon as detected. 2 

Previously diagnosed diabetes usually 

falls into two categories: type 1 (presenting 

as diabetic ketoacidosis; DKA) 

or type 2 (presenting as hyperosmolar 

hyperglycemia state; HHS). The diagnosis 

of diabetes has become more complex. 

The presentation can be misleading due 

to conflicting physical and objective findings. 

Often this leads to inappropriate 

treatment that produces poor outcomes, 

such as immunosuppression, endothelial 

dysfunction, inflammation, increased 

oxidative stress or thrombosis. 1 

William presented to the emergency 

department with symptoms similar to 

those of someone with type 1 diabetes 

(abrupt onset of symptoms and lack of 

family history of diabetes). He also had 

positive serum ketones, a status typically 

present in type 1 diabetes. These 

symptoms can also be present in type 

2 diabetes, as in HHS. This patient did 

not fit the typical physical presentation 

of type 1 diabetes. He was an obese black 

man with acanthosis nigricans, a condition 

often found in type 2 diabetes. 


Diabetes 

Unrecognized diabetes is often discovered 

when patients are admitted for 

a physiologic stressor such as infection 

or myocardial infarction. Hyperglycemia 

related to diabetes is usually identified 

when the first complete metabolic panel 

reveals a fasting blood glucose ≥ 126 mg/ 

dL, a random blood glucose ≥ 200 mg/ 

dL, or a hemoglobin A 1c ≥ 6.5%. 3 

Hyperglycemia related to hospitalization 

may include stress hyperglycemia 

Unrecognized diabetes 

is often discovered 

when patients are 

admitted for treatment 

of a physiologic stressor 

such as infection or 

heart attack. 

Hyperglycemia is usually 

identified in a complete 

metabolic panel. 

resulting from surgical procedures or use 

of other medications such as steroids. 4 In 

stress hyperglycemia, a patient meets the 

criteria for hyperglycemia with a random 

blood sugar ≥ 140 mg/dL, but he or she 

does not meet the hemoglobin A 1c criteria 

of > 6.5%. These patients have blood 

sugars that often return to normal after 

the stress is removed, but they should 

be monitored closely for development of 

prediabetes or diabetes after discharge. 4 

Diagnostic Criteria 

Diagnose DKA when the blood glucose is 

≥ 250 mg/dL, arterial pH is ≤ 7.30, serum 

bicarbonate is < 15 mEq/L, and positive 

serum ketones are present. 5 Diagnose 

HHS when blood glucose is 600 mg/dL or 

greater, serum osmolarity is 320 mOsm/ 

kg or greater, profound dehydration is 

present with elevated serum blood urea 

nitrogen > 30 mg/dL, small ketonuria are 

present, and bicarbonate > 15 mEq/L. 6 

Table 2 

Sliding Scale Insulin Protocol 

Reevaluate insulin orders if on protocol more than 24 to 48 hrs 

Nursing Orders 

Assessments 

__ Metered blood glucose before meals and at 2100, if able to take nutrition orally 

__ Metered blood glucose every 6 hours if patient is not eating by mouth, on total 

parenteral nutrition or continuous feedings 

__ Metered blood glucose at 0300 

__ Metered blood glucose before meals 

__ Metered blood glucose at bedtime 

__ Metered blood glucose (specify): ____________ 

Contingency 

__ Notify physician if metered blood glucose is less than 70 mg/dL. 

__ Notify physician if metered blood glucose is greater than 180 mg/dL for 2 consecutive 

checks. 

__ Notify physician of any metered blood glucose greater than 300 mg/dL. 

Interventions 

__ Discontinue all previous sliding scale insulin orders. 

__ Discontinue all current insulin infusion orders. 

__ If patient is unable to take food by mouth at any time, hold regular/aspart insulin. 

__ Administer insulin before meals only for patients taking oral nutrition. (No bedtime 

dose given unless provider orders.) 

__ Administer insulin every 6 hours for patients who are not eating by mouth, on total 

parenteral nutrition or continuous feedings. 

__ Aspart insulin should be given when food tray is available. 

Laboratory 

__ Hemoglobin A 1c (GLYH) if not performed within the last 60 days. 

Medications 

Insulin 

• Avoid sliding scale use in poorly controlled type 2 diabetes patients and in all type 1 

diabetes patients. If patient not controlled, consider using insulin infusion orders. 

• If patient continues to require correctional insulin, consider starting basal–bolus insulin 

protocol. 

__ NO insulin for metered blood glucose less than 150 mg/dL 

__ Notify provider and provide NO insulin if metered blood glucose is greater than 400 mg/dL. 

Provider Orders 

Aspart (Novolog) Insulin Regular Insulin 

- If metered blood glucose 150 mg/dL–200 mg/dL, give 2 units or (specify): ________units 





Provider Signature/ID No: _____________________________________________ 

Date/Time: __________________ 

Diagnostic Tests 

Order hemoglobin A 1c testing on all 

patients with a known diagnosis of diabetes 

if a previous value collected within 

the prior 2 to 3 months is not available. 4 

Also order this test for any patient with 

a blood glucose level > 140 mg/dL. 

Values > 6.5% suggest that the patient 

had diabetes before admission. 1 Blood 

glucose targets on noncritical care units 

are premeal < 140 mg/dL and random 

blood glucose < 180 mg/dL. 4 

Clinical Management 

In the hospital setting, insulin therapy is 

the preferred method of glycemic control 

for patients with diabetes. No data 

about the safety and efficacy of inpatient 

administration of oral agents have been 

published. 

Oral medications have a limited role 

in the management of hyperglycemia 


27

Diabetes 

when patients with diabetes are ill and 

hospitalized. 4 

Hospitalized patients are prone to large 

variances in blood glucose levels. Because 

of this, effective treatment is required to 

maintain good glucose control. There 

are, however, different schools of thought 

when it comes to the best way to treat 

hyperglycemia in the hospital setting. 

Treatment options include continuous 

insulin infusions, sliding scale insulin 

and basal/bolus insulin therapy. 4 

In the critical care setting and when 

DKA is suspected, insulin infusions are 

the standard of care. 7 When it is time to 

transition off the infusion, the insulin 

Table 3 

Basal–Bolus Insulin Protocol 

A. Discontinue all prior insulin orders 

B. Blood glucose level goals 

• Preprandial: 70–140 mg/dL 

• 2-hour postprandial: < 180 mg/dL 

C. Blood Glucose Monitoring Frequency 

• Check blood glucose within 30 minutes prior to each meal and at bedtime. 

Basal Insulin 

Breakfast 

0730 

Dinner 

1630 

Bedtime 

2100 

NPH _______ units _______ units ______units 

Glargine (Lantus) _______units _______ units _______units 

Detemir (Levemir) _______units _______units _______units 

D. Basal Insulin Dosing Schedule: Administer subcutaneously as follows 

Bolus Insulin 

Breakfast 

0730 

Lunch 

1130 

Dinner 

1630 

Aspart (Novolog) _____units ______units _____units 

E. Bolus Insulin Dosing Schedule: Administer subcutaneously as follows 

Regular (Novolin) _____units ______units ______units 

F. Bolus Insulin Correction Dose: Give in addition to scheduled bolus insulin based on the 

premeal blood glucose 

• Consider “low” dose for insulin-sensitive patients 

• Consider “high” dose for very insulin-resistant patients 

Glucose Level Low Medium High Other 

< 60 mg/dL Hold Hold Hold Hold 

61–90 mg/dL −2 units −2 units −3 units ____units 

91–119 mg/dL 0 units 0 units 0 units ____units 

120–149 mg/dL 0 units +1 unit +2 units ____units 

150–199 mg/dL +1 unit +2 units +3 units ____units 

200–249 mg/dL +2 units +3 units +4 units ____units 



350 mg/dL or > +5 units +8 units +12 units ____units 

_______________________Provider Signature Date_____ Time__________ 

infusion rates are essential to determining 

initial subcutaneous insulin doses. 7 If the 

patient has achieved blood sugar control 

on the infusion, incorrect doses may be 

calculated for subcutaneous injection. 

When a patient is ready to eat a meal 

and is on a nonacute care unit, scheduled 

subcutaneous insulin that delivers basal, 

nutritional (bolus) and correction (supplemental) 

doses are preferred. This is also 

known as basal–bolus insulin therapy. 4 

Practice Implications 

NPs and PAs need to be familiar with 

evidence-based practice for managing 

hyperglycemia in the hospital setting. 

They also need to be prepared to intervene 

quickly when a particular protocol is 

not effectively controlling hyperglycemia. 

This case study highlights the significance 

of making the right choice for each particular 

patient when managing hyperglycemia 

in the hospital setting. The correct 

choice of initial protocol — or timely 

change to an evidence-based basal–bolus 

insulin protocol when available — can 

provide better control of hyperglycemia 

earlier, thereby decreasing the patient’s 

length of stay. ■ 

References 

1. Arnold LM, Keller DL. Hyperglycemia management 

in non-critically ill hospitalized patients. J Pharm 

Pract. 2009;22(5):467-477. 

2. Handelsman Y, Mechanick JI, Blonde L, et al. 

American Association of Clinical Endocrinologists medical 

guidelines for clinical practice for the management 

of diabetes mellitus. Endocr Pract. 2011;17(Suppl 2):1-53. 

3. Bloomgarden ZT. A1C: Recommendations, debates, 

and questions. Diabetes Care. 2009;32(12):e141-e147. 

4. American Diabetes Association. Standards of 

Medical Care in Diabetes – 2012. Diabetes Care. 

2012;35(Suppl1):11-62. 

5. Kitabchi AE, et al. Hyperglycemic crises in adult 

patients with diabetes. Diabetes Care. 2009;32(7):1335- 

1343. 

6. Nugent BW. Hyperosmolar hyperglycemic state. 

Emer Med Clin N Amer. 2005;23:629-648. 

7. Moghissi E. Hospital management of diabetes: 

beyond the sliding scale. Cleve Clin J Med. 

2004;71(10):801-808. 

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for Yourself! 

Irritable Bowel 

Continued from page 24 

ments and a multivitamin. 

In the first 

week, she noticed a 

slight reduction in 

the number of loose 

stools. In the second 

week, when she 

stopped ingesting 

gluten, Sharon noticed a gradual reduction 

in all symptoms. She felt more energetic, and 

her mood improved. She gained additional 

information and self-direction through 

Internet research about gluten sensitivity. 

When she followed up with her clinician 

a few months later, she reported that her 

quality of life had improved with nutritional 

modifications. ■ 

References 

1. U.S. Department of Health and Human Services. 

National Digestive Diseases Information Clearinghouse. 

Irritable Bowel Syndrome. http://digestive.niddk.nih.gov/ 

ddiseases/pubs/ibs/. 

2. Spiller R, et al. Guidelines on the irritable bowel 

syndrome: mechanisms and practical management. Gut. 

2007;56(12):1770-1798. 

3. Longstreth GF, et al. Functional bowel disorders. 

Gastroenterology. 2006;130(5):1480-1491. 

4. Thompson WG, et al. Irritable bowel syndrome in 

general practice: prevalence, characteristics and referral. 

Gut. 2000;46(1):78-82. 

5. Müller-Lissner SA, et al. Epidemiological aspects of 

irritable bowel syndrome in Europe and North America. 

Digestion. 2001;64(3):200-204. 

6. Inadomi JM, et al. Systematic review: the economic 

impact of irritable bowel syndrome. Aliment Pharmacol 

Ther. 2003;18(7):671-682. 

7. Long KH, et al. The economics of coeliac disease: 

a population-based study. Aliment Pharmacol Ther. 

2010;32(2):261-269. 

8. Smith GD, et al. Health-related quality of life and 

symptom classification in patients with irritable bowel 

syndrome. J Nurs Healthc Chronic Illn. 2010;2(1):4-12. 

9. DiBonaventura M, et al. Health-related quality 

of life, work productivity and health care resource use 

associated with constipation predominant irritable bowel 

syndrome. Curr Med Res Opin. 2011;27(11):2213-2222. 

10. Rodrigues LA, Ruigomez A. Increased risk of irritable 

bowel syndrome after bacterial gastroenteritis: cohort 

study. BMJ. 1999;318(7183):565–566. 

11. Spiller RC, et al. Increased rectal mucosal enteroendocrine 

cells, T lymphocytes and increased gut permeability 

following acute Campylobacter enteritis and in post-dysenteric 

irritable bowel syndrome. Gut. 2000;47(6):804-811. 

12. Zar S, et al. Food specific serum IgG4 and IgE titres 

to common food antigens in irritable bowel syndrome. 

Am J Gastroenterol. 2005;100(7):1550-1557. 

13. Ferguson A, et al. Clinical and pathological spectrum 

of coeliac disease: active, silent, latent, potential. Gut. 

1993;34(2):150-151. 

14. Troncone R, et al. The spectrum of gluten sensitivity. 

Proceedings of the 8th International Symposium on 

Coeliac Disease, Naples, Italy, April 1999. 

15. Troncone R, et al. Gluten sensitivity in a subset of 

children with insulin dependent diabetes mellitus. Am 

J Gastroenterol. 2003;98(3):590-595. 

16. Verdu EF, et al. Between celiac and irritable bowel 

syndrome: The “no man’s land” of gluten sensitivity. Am 

J Gastroenterol. 2009;104(6):1587-1594. 

17. Suchy FJ, et al. NIH Consensus Development 

Conference: Lactose Intolerance and Health. Ann Intern 

Med. 2010;152(12):792-796. 


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Career Opportunities 

healthcare providers in 2011. 

—Lynn A. Kelso, MSN, APRN, 

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Looking for a new 

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LOWER —Debra SOUTH Schuerman, ATLANTIC NP, Duke University building on the skills 

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With 

in 

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the 

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November 

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the 

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Join our team at Stony Brook Medicine – the best ideas in medicine. 

MIDDLE ATLANTIC 

entry-level PA programs was 156. 

Chair • Department of Physician Assistant Education 

NP Timeline MIDDLE ATLANTIC 

Required: • Master’s degree • Graduate of an accredited PA program • Current NCCPA Board 

In 1965, Certification/Eligibility Loretta C. Ford, for RN, clinical EdD, practice and in New York State • Five years’ full-time PA program 

Henry administrative K. MIDDLE Silver, MD, experience ATLANTIC began the to include first experience in preclinical and clinical year education in a PA 

program • Five years’ experience in PA clinical practice •Ability to facilitate faculty development 

pediatric and MOUNTAIN NP manage program personnel at the • Evidence University of strong communication and decision-making skills 

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MOUNTAIN 

Preference will be given to candidates with doctoral degree, demonstrated ability to network with 

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requirements; experience with program finance, budgeting and grant development. 

NATIONAL 

At Stony Brook Medicine, our highest calling is to put the power of ideas to work in our patients’ 

lives. Stony Brook Medicine integrates and elevates all of Stony Brook University’s health-related 

NEW ENGLAND 

The best ideas in medicine 

start with the best people. 

For a full position description, application procedures or to apply online, visit 

www.stonybrook.edu/jobs (Ref. #: F-7317-12-06) or submit a State employment application, 

cover NATIONAL 

letter and résumé/CV to: 

Craig Lehmann, PhD, CC (NRCC), ATTN: Chair, Physician Assistant Education Search Committee 

School NATIONAL of Health Technology and Management 

Health Sciences Center, L-2, Room 400 

Stony NEW Brook, ENGLAND 

NY 11794-8200 

Fax#: (631) 444-7621 

Stony Brook University/SUNY is an equal opportunity, affirmative action employer. 

in the October 2011 issue 


Celebrating NPs 

GET MORE FROM 

In 2011, approximately 150,000 NPs 

were in practice in the United States, 

according to the American Academy of 

Nurse Practitioners. 

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Want to expand your leadership skills 

Be agile, embrace unity, provide 

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40. Men who do not have a history that 

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NATIONAL 

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Family Nurse Practitioner 

SOUTHWEST 

Opportunities 

Asthma SOUTHWEST Prevalence 

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chronic diseases 

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Family 

Nurse 

ment 

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Licensed RN 

with 

than 

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per 

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CENTRAL Graduate of 

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August 2011 issue of 


Inflammatory 

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Julie A. Nelson, DNP, RNC-OB, WHNP-BC, 

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and rapid progression of symptoms 

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breast cancer in the October 

2011 issue of ADVANCE for NPs & PAs. 


1-877-776-6680 

NEW ENGLAND 


Massachusetts, New Hampshire 

Come work with us! 

NURSE PRACTITIONERS 

Full-Time & Per Diem 

MIT Medical seeks nurse practitioners to 

collaborate with physicians on the provision 

of primary and urgent care to patients. Will 

assess patient’s health status through 

interview and physical exam and synthesize 

this clinical information to formulate health 

problem(s) and appropriate treatment 

strategies, and provide health maintenance 

and health promotion for patients and their 

families. Will provide these services according 

to age-specific plans of care. 

Requirements: current certification/licensure 

as a nurse practitioner, current CPR 

certification, and two years of experience as 

a nurse practitioner in a relevant age-specific 

ambulatory setting. Experience in dermatology 

a plus. Hospital-based RN experience 

preferred. 

MIT Medical is a large multidisciplinary group 

practice serving students, employees, 

retirees, and families of the MIT community. 

We have over 25 medical specialties, our own 

HMO, a JCAHO-accredited outpatient facility, 

and close alliances with some of the very 

best hospitals in the Boston area. For more 

information about MIT Medical, please visit 

our website at http://medweb.mit.edu. 

Interested candidates may apply on-line at 

http://jobs.mit.edu. Please reference job 

number mit-00008337 and indicate where 

you saw this posting. Please indicate in 

your cover letter whether you are applying 

for the Full-Time or Per Diem position. 

Nurse Practitioners & Physician Assistants 

life works here. 

Nurse Practitioners: 

• Neurology - .5 Inpatient/.5 MS Outpatient Clinic 

• Headache Clinic 

• Critical Care 

• Radiology 

• GIM 

• Cardiology 

• Palliative Medicine (.5) 

• Neonatology 

• Part-time Certified Nurse Midwife 

Physician Assistants: 

• Neurology - .5 Inpatient/.5 MS Outpatient Clinic 

• Dermatology 

• Neonatology 

Qualified candidates will have completed an 

accredited nurse practitioner or physician assistant 

program and be eligible for NH licensure. Academic 

preparation at a Masters level is preferred. 

Please apply online at: 

www.Dartmouth-Hitchcock.org 


MIT is an equal opportunity/affirmative action 

employer. Applications from women, minorities, 

veterans, older workers, 

and individuals with 

disabilities are strongly 

encouraged. 

http://medweb.mit.edu 

Planned Parenthood League of MA seeks Part-time 

Traveling Mid-Level Clinician in GYN Services to work in 

Central MA and Springfield. Provide reproductive health 

service, including medical abortion to patients in an efficient 

manner. Certifications in CPR, as adult, family or family 

planning NP, MSN. Clinical knowledge in women’s health and 

reproductive care. Strong interpersonal skills and ability to 

relate to varying demographics in a non-judgemental way. 

Ability to work in a fast paced environment and function as a 

part of a medical team. Comprehensive benefit package. 

To apply please visit our website at, www.pplm.org 

EOE 

One Medical Center Drive • Lebanon, NH • 03756 

We are an equal opportunity employer. 

DELIVERED DIRECTLY TO 

YOU —THE ADVANCE 

E-NEWSLETTER 

SIGN UP AT 


LOOKING 

FOR A NEW 

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39

l 

hile 

ed 

the 

er 

. 


NURSE PRACTITIONER OPPORTUNITY 

JOIN THE HEALTHCARE TEAM AT 

BERKSHIRE MEDICAL CENTER! 

Berkshire Medical Center, a 302-bed community 

teaching hospital and level II Trauma Center, is currently 

seeking exceptional MA licensed, or license 

eligible, Nurse Practitioners in the following areas: 

PRIMARY CARE 

CARDIOLOGY 

SURGICAL SERVICES 

OCCUPATIONAL MEDICINE 

URGENT CARE 

PSYCH GERIATRIC 

Berkshire Medical Center is the region’s leading provider 

of comprehensive health care services. With 

award-winning programs, nationally-recognized 

physicians, world-class technology 

and a sincere commitment to the community, 

we are delivering the kind of advance 

health care most commonly found in large 

metropolitan centers. 

Berkshire Health System offers a competitive salary 

and benefits package, as well as the opportunity to 

work in an environment where you will be challenged, 

supported, and respected. Relocation assistance 

offered as well. For more information about how you 

can become a part of our team, please contact: 

Antoinette Lentine 

Berkshire Medical Center 

725 North St., Pittsfi eld, MA 01201 

Phone: (413) 395-7866 

Fax: (413) 496-6817 

E-mail: alentine@bhs1.org 

Please visit our website at 

www.berkshirehealthsystems.com 

Job Satisfaction 

NPs consider continuing education support, 

monetary bonuses in addition to 

salary, and opportunity to receive compensation 

for services outside normal 

duties on the job less important than 

intrinsic factors. They are most satisfied 

by percentage of time spent in direct 

patient care, sense of accomplishment, 

and ability to deliver quality care. 

—Ann Priebe, MSN, ACNP-BC, 

in the February 2012 issue of 


Stony Brook Medicine 

www.stonybrook.edu/jobs 

PA Demand 

(See our ad on page 38.) 

The American Academy of Physician 

40 ADVANCE Assistants for NP reported & PAs in September 2011 

LOWER SOUTH ATLANTIC 


Massachusetts, New Jersey, Pennsylvania 

EOE 



MOUNTAIN 

Bridan Healthcare, a leading provider of continence and wound care management services 

in long-term care, assisted living, and independent (including in-home) facilities, is currently 

seeking to ll positions for Nurse Practitioners & Advance Practice Nurses nationwide with at 

least 2 years clinical experience with wounds care and/or continence management experience. 

MOUNTAIN 

MOUNTAIN 

NATIONAL 

Bridan Healthcare is an equal opportunity employer. We have a culture of excellence which drives 

our hiring process. We’re not just looking for the most qualied candidate; we also want to make 

sure that candidate ts into the culture of passionate patient care that we have already established. 

NATIONAL 

If you are passionate about patient care, enjoy helping to restore dignity to patients, and have 

a minimum NATIONAL of 2 years of Wound Management experience and/or certied as a WOCN or WCC, 

we would like to get to know you. Interested candidates should submit their CV or resume with 

a cover NEW letter ENGLAND including salary requirements to Aaron Fulton at fultona@bridanhc.com or mail 

directly to: 

NEW Bridan ENGLAND Healthcare | attn: Aaron Fulton | PO Box 685 | Rancocas, NJ 08073 

Bridan Healthcare: Repairing integrity; regaining control; restoring dignity. 

NEW ENGLAND 

PACIFIC 

PACIFIC North Philadelphia Health System is seeking 

motivated individuals to join our team in the following areas: 

PACIFIC Assistant Nurse Manager (Critical Care) 

This full-time position requires a minimum of 3 years critical care experience (preferably ICU). 

BSN and previous supervisory experience desired. Current PA RN license required. 

SOUTHWEST 

Compliance Auditor (Behavioral Health) 

SOUTHWEST 

Healthcare Administration degree and previous Performance Improvement experience is required. 

SOUTHWEST 

Emergency Room Nurses 

Part-time and Flex with minimum one year experience. 

UPPER SOUTH ATLANTIC 

Nurse Practitioner 

This full-time position requires a Current PA CRNP with CPR/ACLS certifi cation. 


A minimum of 5 years experience in related fi eld preferred. 

UPPER SOUTH Competitive ATLANTIC Pay Rates • Full Benefits • Free Parking and More!!! 

Qualifi ed candidates should forward their resume to: 

WEST NORTH CENTRAL North Philadelphia Health System 

WEST NORTH CENTRAL Attn: Human Resources 

WEST NORTH CENTRAL 




www.bridanhc.com 

This full-time position requires 3 years medical/surgical, critical care and behavioral health experience. BSN or 

Negative Effects 

of Smoking 

801 W. Girard Avenue, Philadelphia, PA 19122 

E-mail: sbarnett@nphs.com • Fax: 215-787-2195 

www.nphs.com 

EOE M/F/D/V 

Cigarette smoking increases the risk for 

stroke, cataracts, gum disease, acne, 

has a hand in our service excellence and growth. 

COPD, heartburn, decreased blood flow, 

ulcers, erectile dysfunction, infertility, and 

osteoporosis. It also increases the risk 

for multiple cancers throughout the body. 

Hyperglycemia 

The Interested prevalence candidates of posttransplant may submit their resume diabetes 

to HR Dept. via 

fax: 201-848-5279 or e-mail: humanresources@chccnj.org, 

301 

mellitus 

Sicomac 

after 

Avenue, 

liver 

Wyckoff, 

transplantation 

NJ 07481 

can be as high as 31% to 38%, noted 

To learn more visit our web site at www.chccnj.org 

Katherine Monday, MSN, NP, in the 

February 2012 issue of ADVANCE for 

301 Sicomac Avenue • Wyckoff, NJ 07481 EOE M/F/D/V 

NPs & PAs. 

www.chccnj.org 

Ministering to other’s needs with a warm hand could be the start of a great career. Our mission is 

focused on the broadening continuum of high-quality, family-centered services to enhance the lives 

of the elderly and mental health population—not to mention the life of every single employee who 

Why not join us and find all you’re capable of We’re currently recruiting for: 

Advanced Practice Nurse 

Full Time opportunity for an experienced APN to work in a long term care and post 

acute care setting as an independent practitioner in collaboration with the 

physician. MSN required with five years APN experience in an acute care or 

geriatric setting. NJ RN licensure with prescription authority required.

Pennsylvania, New Jersey, New York 

CRNP/CRNP Manager 

Eagleville Hospital is hiring a CRNP to manage our Gero-Psychiatric 

Department. Additional CRNP position in substance abuse 

and co-occurring disorders. Hours are flexible; may be some 

rotating weekends. The CRNP is responsible for admission physical 

exams, providing acute care medical and psychiatric services, 

and assisting in managing medications. Qualified candidates will 

have a Masters of Science in Nursing, a valid CRNP license, and 

a certification in Psychiatry. Successful candidates should have 5 

years of nursing experience. Previous experience working with 

geriatric and/or mental health patients preferred. Management 

experience and good interpersonal communication skills a plus. 


We offer a competitive salary and benefits package 

including 403(b), PTO, 

health/dental/vision insurance, EAP, etc. 

To apply, e-mail: hr@eaglevillehospital.org 

or fax: 610-539-8319. 

EOE 

FAMILY NURSE PRACTITIONER 

or PHYSICIAN ASSISTANT 

Article 28 diagnostic & treatment center 

based in Brookville, NY seeks 

Family Nurse Practitioner or 

Physician Assistant with minimum 

2 years experience treating individuals 

with intellectual and other developmental 

disabilities to provide primary care 

services to children and adults with complex 

medical/psychiatric conditions. Provider 

will be part of a multi-disciplinary practice 

with strong clinical support services in an 

innovative practice utilizing electronic 

health records. Computer proficiency 

required. 21-28 flexible hour per week 

plus some evenings required. 

Competitive salary and excellent 

benefits package. 

Fax resume to 516-686-4420 

or Email: pbirong@advantagecaredtc.org 

No Calls, Please 

We are an equal opportunity employer, 

proud of our workforce diversity. 

HEALTHCARE 

JOB LISTINGS— 

UPDATED DAILY! 


YOU CAN 

MAKE A 

DIFFERENCE 

HERE! 

EOE 

Located in the beautiful cosmopolitan town of Montclair in Essex County, NJ, 

HackensackUMC Mountainside is a for-profit community teaching facility where 

nursing is practiced in an autonomous work environment. Dedicated to patientfocused 

care, we are continuously moving forward, adding new services and 

programs, advanced technologies, and talented people. Join us! 

Nurse Practitioner 

Seeking full time individual to provide pre-operative assessment, diagnosis, 

treatment, education and post-operative care to GYN surgical oncology patients. 

We require Masters’ degree and a current NJ license as an advanced practice 

nurse with prescriptive privileges and a minimum of 2 years experience in an 

outpatient office performing gynecological exams. Experience with Oncology 

preferred. Excellent clinical and communication skills and computer proficiency 

essential. 

Join us for excellent benefits, including shared governance model in nursing, on-site 

child care, free parking, proximity to train station and NYC, and more! Interested 

applicants, please email resume to: debra.savage@mountainsidehosp.com, mail: 

HackensackUMC Mountainside, Attn: Debra Savage, RN, BA, Manager, 

Employment and Employee Relations, 1 Bay Avenue, Montclair, NJ 07042, or 

fax: 973-680-7961. 

www.mountainsidenow.com 

FAIRMOUNT 

BEHAVIORAL HEALTH SYSTEM 

NURSE PRACTITIONER 

Family Practice (Part Time and Per Diem available) 

Fairmount Behavioral Health System, a leading provider of Psychiatric 

Services for Adults, Adolescents and Children in Philadelphia, has immediate 

openings for Part Time and Per Diem Family NP. 

Responsibilities include admission physicals and daily consult care with followups 

for patients in behavioral health inpatient treatment in collaboration with 

or under the direction of a physician licensed in PA. Primary responsibilities 

will include: H&P’s as per hospital guidelines, assisting physician with medical 

consults and in the care and treatment of patients within licensure guidelines. 

Must have strong clinical skills and high motivation. 

Must be licensed Family NP in PA. Part Time and Per Diem positions are 

weekends and/or evenings. 

Interested candidates should apply via website: 

www.fairmountbhs.com, or submit resume to the HR Department. 

 

Human Resources Director, Fairmount Behavioral Health System, 

 

from hope to happiness 

HOPE 

IS HERE 

IT’S WHERE THE CAREERS GO — WWW.ADVANCEWEB.COM 


41

Pennsylvania, New Jersey, New York 


CARON TREATMENT CENTERS, internationally recognized for excellence in 

addiction treatment, is seeking the following: 

Certified Nurse Practitioner 

Responsibilities include completing medical history and physical exams on 

patients, initiating orders for medications, performing clinical procedures, initiating 

evaluation in emergency situations, providing counseling and instruction 

regarding common patient problems, and working as part of a multidisciplinary 

treatment team. Requires certification by the State of PA as a CRNP 

and the American Nurses Credentialing Center, three yrs exp. as a CRNP. Prior 

experience working in the chemical dependency field is preferred. 

We offer an excellent benefits package including a generous 401(K) plan. 

Please submit resume and salary requirements to: 

Caron Treatment Centers, Galen Hall Road, 

PO Box 150, Wernersville, PA 19565. 

Fax: 610-678-8583 

Email: recruiter@caron.org 

www.caron.org 

COME JOIN OUR TEAM 

Cardiothoracic experience NP or PA 

Full-time, day shift, rounding every other weekend. 

St. Joseph Medical Center has an opportunity for a NP or PA with 

Cardiothoracic experience to join our team. Candidate will be responsible 

for surgical assisting and vein harvesting as well as following patients of 

the floor. 

To learn more about this opportunity please visit our website at 

www.thefutureofhealthcare.org 

42 ADVANCE for NP & PAs 

St. Joseph Medical Center - Human Resources 

2500 Bernville Road, Reading, PA 19605 

Catholic Health Initiatives and its organizations are 

Equal Opportunity Employers/CB 

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professional growth and advancement. 

$94,870. 

 

 

Current NJ RN/NP license required. 

 

Salary by Gender 

Consult Liaison Virtua Health 

Men Outpatient still make more Services than St. women Clare’s. in the 

NP Flexible and PA Hours. professions, Experienced but Prescribing the gender APN. 

Current NJ RN / NP and DEA and CDS licenses required. 

gap narrowed for NPs in 2011. The 

difference 

 

in salaries paid to men vs. 

Per diem at Essex, Hudson, Middlesex, 

women dropped Camden from and 14.6% Atlantic. to 6.4% 

among We offer excellent NPs. compensation. 

Full-Time employees enjoy a 

generous benefits package. 

Call or send resume: 

Nancy DeLapo, 

Problems Director of Staff Development in 

Phone 856-797-4761 

Healthcare 

NDeLapo@cfgpc.com 

Fax 856-797-4798 

The World Health Organization deemed 

antimicrobial www.cfghealthsystems.com 

resistance one of the EOE 

three most important problems facing 

As the largest 

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medical practice 

—Lynn A. Kelso, 

on Staten 

MSN, 

Island, 

APRN, 

FCCM, FAANP, in the we February offer advanced 2012 

state-of-the-art 

issue of ADVANCE medical for NPs treatments, & PAs. 

expertise and cutting-edge technology. Our 

outpatient facilities offer the highest quality of 

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Surgical NURSE PRACTITIONERS Infection 

Oncology 

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Surgical 


site infections affect 

Anti-Coagulation 

750,000 

U.S. patients NEW GRADS every year. WELCOME! 

Our newly renovated facilities are a great place to work 

and we offer attractive salaries and benefi ts. Please send 

resume including a cover letter and salary requirements to 

hresumes@si-pp.com or Fax: (718) 816-3817. 

—Robert M. Blumm, MA, PA-C, 

DFAAPA, in the February 2012 issue 


www.si-pp.com 

EOE M/F 

Benefits of Sun 

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Exposure to sunlight helps prevent and 

treat seasonal affective disorder, and 

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Jo 

NP 

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New Jersey, Pennsylvania 

DEBORAH 

Where Healing Comes From the Heart 

Advance Practice Nurse 

Cardiology 

We are currently seeking an Advance 

Practice Nurse Cardiology who will direct, 

coordinate and evaluate the activities of 

the Pacemaker/ICD. 

Qualifications 

• Minimum 5-7 years nursing and critical 

care experience 

• Bachelors degree or greater 

• Current NJ License 

DEBORAH provides a competitive salary, 

generous benefits package and 

recognition for the importance of a good 

work/life balance. 

To apply please visit: 

Jobs.deborahcareers.org/ 

cardiologyNP 

DEBORAH Heart and Lung Center is an Equal Opportunity Employer. 

years ago 

you made 

a promise 

(so did we) 

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You set out to help people. To find a setting that encouraged you to learn, 

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HOLY REDEEMER ST. JOSEPH MANOR 

1616 Huntingdon Pike, Meadowbrook, PA 

HOLY REDEEMER LAFAYETTE 

8580 Verree Rd., Philadelphia, PA 

Nurse Practitioner - Opportunities available in Long Term Care/Short Stay Rehab 

As a Geriatric Nurse Practitioner, you will provide a high level of holistic care and services for 

the resident while serving as a clinical expert for the Interdisciplinary team and the family. You 

will act as a liaison to physicians to ensure all resident and family needs are being met. The 

successful candidate will be a graduate from an accredited Nurse Practitioner Program with a 

Master’s Degree in Nursing, and certified as a Nurse Practitioner by American Nurses Association. 

Formal education in the area of Gerontology; minimum of 2 years experience working with 

adult or geriatric population. 

To discover more about these rewarding 

positions, to apply online, and to read 

about our mission, community and our 

people, visit us online at: 

www.holyredeemer.com 

or call Alisa Cohen at 215-214-0681 

EOE 


Private physician owned and 

operated group currently 

recruiting PA/NPs at the following 

New Jersey locations: 

• Mercer County - Community hospital with 

an annual volume of 30k. Shifts are 12 hours, 

no overnights. 

• Middlesex County - Community-teaching 

hospital with a combined annual volume of 70k. 

Shifts are 12 hours. 

• Ocean County - FT position available for a 

PA or NP to provide primary care and urgent care 

coverage in an outpatient setting. 

We require a minimum of one (1) year of Emergency 

Department experience. We offer a highly competitive 

salary, CME stipend, medical malpractice and 

comprehensive benefi ts. 

Forward CV to jobs@medenhancement.com 

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Mercy LIFE 

(Living Independently for Elders) 

is seeking a full-time 

Nurse Practitioner. 

The Nurse Practitioner provides primary 

medical management in collaboration 

with the LIFE Physician(s). Provides daily 

oversight of LIFE Clinic. Rounds in 

the LIFE contracted nursing home and 

hospitals. Conducts initial assessments 

and periodic reassessments, plan of 

care, coordination of 24 hour care 

delivery, regularly informing the IDT of the 

medical, functional, and psychosocial 

condition of each participant, remaining 

alert to pertinent input from other team 

members, participant’s caregivers, as well 

as documenting changes in a participant’s 

medical record consistent with documentation 

policies established by the medical 

director. Master’s degree in nursing, 

Gerontological preferred. Licensed RN 

in the State of Pennsylvania with current 

certification as a Nurse Practitioner. 

Bilingual Spanish speaking preferred. One 

year experience in working with geriatric 

population. One year of experience with 

a frail or elderly population. 

Interested candidates 

please apply online at: 

www.mercyhealth.org 

SOUTHWEST 

SOUTHWEST 


Pennsylvania, Maryland, Washington, D.C. 









Freedom to Help 

Members of LifeBridge Health, Sinai Hospital of Baltimore, and Northwest Hospital, 

located in northwest Baltimore, Maryland, share a passion for excellence and embrace the 

family-centered care delivery model. 

Opportunities for Nurse Practitioners 

in Crisis Intervention positions 

within the Emergency Department at each location. 

Seeking a MSN NP with psychiatric specialization (PMH-NP) from an accredited institution 

to provide comprehensive and routine medical care to patients in the ED and coordinate 

psychiatric health services between the hospital, community, and home settings. Will 

consider new graduate NP. 

LifeBridge Health offers a competitive salary and benefits package, including phased-in 

retirement, domestic partner benefits, and 403-b retirement plan with employer match. 

Part time 8-hour 

night shifts available. 

Call 410-601-5670 for details. 

EOE/AA 

Visit www.lifejobs.org to learn more and apply. 

LOG ON TODAY TO 

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GIVE YOUR CAREER 

a fresh perspective! 

Nurse 

Practitioner 

• Cardiology 

The George Washington 

University Medical Faculty 

Associates (MFA), the largest 

multi-specialty physician practice in 

the Washington, DC area, is seeking a 

full-time NP for the Division of Cardiology 

in the Department of Medicine. 

The Cardiology NP will be an integral part of our academic 

cardiology team. Responsibilities include managing 

patients in our heart failure clinic and assisting with 

outpatient cardiology stress testing. 

Quali ed candidates will have a current DC license 

or eligibility and 1-2 years of general clinical experience 

as a NP, with a minimum of 1 year of experience 

in Cardiology. Experience in noninvasive stress testing 

and heart failure management is preferred. Candidates 

must have excellent critical thinking, communication 

and time management skills. 

MFA offers a competitive salary, 

a comprehensive bene ts package 

and a Monday-Friday work week. 

For more information and to apply, 

please visit our website at 

www.GWDOCS.com 

EOE 


We Continue Our Commitment to Providing 

Quality Healthcare Services for 

Over 90 Years! 

Surgical Infection 

Surgical site infections affect 750,000 

U.S. patients every year. 

antimicrobial resistance one of the 

increase FACULTY since 2000. 

three most important problems facing 

—Michelle Perron Pronsati, editor, 

Maryland, Florida, North Carolina, Texas INTERNATIONAL 

healthcare providers in 2011. 

in the October 2011 issue 

INTERNATIONAL 

—Lynn A. Kelso, MSN, APRN, 


INTERNATIONAL 

FCCM, FAANP, in the February 2012 


issue of ADVANCE for NPs & PAs. 

Consider joining our team of professionals in —Robert the following M. Blumm, MA, PA-C, 

Nurse Practitioner position: DFAAPA, in the February 2012 issue 


Oncology - Responsible for screening, clinical management and health system 

navigation for patients with, or at risk, for oncology medical conditions. Collaborates 

with facility staff to facilitate process and clinical outcomes. This position will have 

EAST primaryNORTH responsibilities CENTRAL related to MedStar Oncology 

Benefits 

Programof initiatives 

Sun 

for outpatient 

infusion patients as well as inpatients from the Georgetown University Hospital practice 

EAST NORTH CENTRAL 

and as designated by other oncology physician Exposure 

practitioners. Secondary responsibilities 

EAST of this position NORTH will CENTRAL be related to coordination Exposure of care across to sunlight the continuum helps prevent working and in 

EAST close collaboration SOUTH CENTRAL with MedStar Montgomery treat seasonal stakeholders. affective Requirements disorder, include and 

EAST MSN, NP, SOUTH and licensure CENTRAL in Maryland as Advanced UVA exposure Nurse Practitioner plus psoralen and can approval help by 

Credentials Committee; oncology experience treat is required. psoriasis. Sunlight is also essential 

for vitamin D production, which is 

EAST SOUTH CENTRAL 

FACULTY 

For immediate consideration, 

imperative 

submit 

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medstarmontgomery.org 

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18101 Prince Philip Dr. • Olney, MD 20832 

INTERNATIONAL 

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NP/PA JOB 


SEARCH 

MOUNTAIN 

HPPARTNERS.COM 

888.654.1458 

MOUNTAIN 

MOUNTAIN 

NATIONAL ENT Carolina, PA 

NATIONAL 

NATIONAL 

NEW ENGLAND 

Seeking full-time, motivated Physician Assistant or 

Nurse Practitioner to join us at our Shelby, North 

Carolina location. 

Five-physician ear, nose and throat practice with 

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physicians with all areas of patient care. Exciting 

opportunity with excellent salary and benefits. CME 

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Send NEW resume to: ENGLAND 

Jane Byrum, COPM 

Practice Administrator 

NEW ENGLAND 

PACIFIC 

ENT Carolina, PA 

2520 Aberdeen Blvd. 

Gastonia, NC 28054 

Fax: 704-868-2344 

jane.byrum@entcarolina.com 

PACIFIC 

Influenza Treatment 

Influenza affects an average of 5% to 

20% of the U.S. population and results 

in more than 200,000 hospitalizations 

annually. The best treatment is vaccination 

against the disease and its most 

common complication, pneumonia. 

—Debra Schuerman, NP, 

in the November 2011 issue of 


FLORIDA - Lake Wales & Rockledge 

Experienced NPs/PAs for EM and 

Inpatient Opportunities. Enjoy 

competitive salary, bonuses and 

group benefits. Locations just 

minutes from the beach or close to 

the Orlando theme parks! 

Contact: Molly Smith 

MSmith@hppartners.com 

NP Timeline 

NP/PA WANTED 

NEW MEXICO - Albuquerque 

Nurse Practitioners with current ED 

experience. Full time opportunities, 

lucrative compensation, group benefits 

and flexible scheduling. Great outdoors 

with biking, hiking and hot-air balloon 

flights! 

Contact: Nicole Pletan 

NPletan@hppartners.com 

In 1965, Loretta C. Ford, RN, EdD, and 

Arcadia Medical Associates is seeking an NP/PA to join our 

Henry established K. Silver, Internal MD, Medicine began practice the in first both outpatient 

pediatric and inpatient NP program settings. Full-time at the University 

position with very 

competitive salary and excellent benefits package, including 

of CME Colorado. 

and malpractice insurance. Internal Medicine experience 

preferred. New grads welcome to apply. Candidates need 

current unrestricted license in Florida. Please send CV to: 

Administrator 

Arcadia Medical Associates, P.A. 

Fax: 863-494-5491 

Email: jblackmon.ama@gmail.com 

1-877-776-6680 


Celebrating NPs 


In 2011, approximately 150,000 NPs 

were MIDDLE in practice ATLANTIC in the United States, 

according to the American Academy of 

Nurse MIDDLE Practitioners. ATLANTIC 

ORDER 


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In 1964, Eugene A. Stead Jr., MD, 


began developing N. CAROLINA a PA program – Smithfield at & 

Thomasville 

Duke UPPER University SOUTH 

Experienced building ATLANTIC 

NPs/PAs on the for skills EM and 

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staff. Close to Raleigh 

entry-level WEST PA NORTH Contact: programs CENTRAL 

Scott was Bradford 156. 

SBradford@hppartners.com 




WEST 

Senior 

SOUTH 

PsychCare 

CENTRAL 

provides evaluations, psychiatric management and mental 

health services to nursing home residents throughout the 

state of Texas. NP or PA with Geriatric or Psychiatric 

experience preferred but willing to train. TX license, PT/FT/ 

PRN available, EMR, fl exible schedules, full benefi ts. 

San Antonio, Houston, Austin, Dallas. 

dspade@seniorpsychiatry.com 

(p) 713-850-0049 x234 • (f) 713-627-7302 

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45


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Discover a healthcare system 

so technologically advanced, 

it moved time zones. 

Think innovation. 

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For more information about 

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NOW 

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Visit facebook.com/UNMHospitals 

We have an exciting career opportunity for a 

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Please take a moment to review the opportunity below, 

then call if you would like to know more! 

Family Nurse Practitioner 

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• Primary Care 

• 4-10 hr days each week, with a 4 day weekend twice a month 

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• No call, No weekends, No nights 

• Excellent Salary and Benefi ts 

• Continuing education provided annually 

• License and recertifi ction fees reimbursed 

• Will pay reasonable membership dues in two professional 

associations and subscription fees or two professional journals. 

Join our Growing Community in Southeast New Mexico 

• We are a Rural Health Clinic that qualifi es for the NHSC Loan Repayment Program 

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• New Mexico is a very favorable practice state for NPs with permissive scope of practice 

• We have many specialists such as Cardiology, Orthopedics, Urology, Podiatry, ENT, Surgery, etc. in our group 

• Bicycling, Off-Roading, Fishing, Big Game Hunting, Rock Climbing, Camping and Boating await you 

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Soon to have opportunities in Surgery and Orthopedics for a Nurse Practitioner. 

575.736.8138 • Apply online at artesiageneral.com 

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HealthCare Partners Medical Group is a multi-specialty medical group that is recognized for 

its quality of care and high rates of patient satisfaction. HealthCare Partners has over 5,000 

employees, including 650 primary care and specialty physicians, caring for more than 750,000 

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As part of our continued growth, we are currently seeking Nurse Practitioners and Physician 

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In this role, you will have the opportunity to provide care and support to 

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HealthCare Partners offers competitive salaries and a wide range of benefits to our full 

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NURSE PRACTITIONER/PHYSICIAN ASSISTANT OPPORTUNITIES 

Located in the lush Willamette Valley between the rugged Pacic 

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PeaceHealth Medical Group is seeking experienced, board certi- 

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Neurohospitalist NP • Hospitalist NP 

Urgent Care NP • PMHNP 

Cardiovascular NP/PA 

Wound and Ostomy NP 

GNP • Cardiology Outpatient NP 

MOUNTAIN 

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CareMore is hiring Nurse 

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If you are a compassionate Nurse Practitioner 

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SOUTHWEST 

SOUTHWEST 

SOUTHWEST 







WEST To SOUTH apply CENTRAL 

directly 


About/Careers.aspx 


please visit our website at: 

http://www.caremore.com/ 


PeaceHealth 

Sacred Heart Medical Center 

PeaceHealth Medical Group 

If you are looking for a career that engages your heart 

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Contact Brooke Hausmann at 541-222-2508 or e-mail at 

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TO ORDER ARTICLE 

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• Custom gifts, giveaways & promotional products 

• Exclusive healthcare designs you won't find anywhere else 

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47


MAKE A HEALTHY CHANGE 

IN YOUR LIFE 

AND YOUR PATIENTS’ LIVES. 

MinuteClinic Family Nurse Practitioners are today’s 

health care heroes treating and educating patients to 

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HEAL PATIENTS. REDEFINE HEALTH CARE. 

State 

National 

The Sign of Excellence in Emergency Medicine ® 

Current Opportunities: 

New Jersey: 

•Newton Medical Center, Newton, NJ 

New York: 

•The Kingston Hospital, Kingston, NY 

Emergency Medical Associates 

has full-time and per diem positions for 

Physician Assistants and 

Nurse Practitioners on the East Coast. 

North Carolina: 

•Southeastern Regional Medical Center, Lumberton, NC 

Rhode Island: 

•Our Lady of Fatima Hospital, North Providence, RI 

•Roger Williams Medical Center, Providence, RI 

Enjoy excellent compensation, comprehensive benefi ts (Full Health, 401k match, Profi t Sharing, PTO and Professional 

Expenses) and career growth with a nationally recognized democratic group that is committed to 

life-work balance. 

Contact: Jonathan Hughes 

877-692-4665 x1190 

HughesJ@ema.net 

www.ema.net/careers 

minuteclinicjobs@cvs.com | www.minuteclinic.jobs 

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Where We Work: 

University of New Mexico Hospitals 

More Than 80 NPs & PAs Provide Care Across Specialties 

Albuquerque 

➼ UNIVERSITY OF NEW MEXICO (UNM) 

Hospitals provides quality care to citizens of 

Albuquerque and specialized care to patients of 

all ages throughout New Mexico via the UNM 

Health System, including UNM School of 

Medicine, College of Nursing and Pharmacy 

and the UNM Medical Group. 

The hospital employs more than 80 APRNs 

and PAs who work in more than 30 primary 

care and specialty care clinics associated with 

University of New Mexico Hospitals. Staff 

APRNs and PAs work in more than 20 specialties 

including, but not limited to, primary care, 

family planning, women’s health, orthopedics, 

sports medicine, plastics, rheumatology, adult 

and pediatric neurology, adult and pediatric 

cardiology, urology, endoscopy, and diabetes. 

“We are unique in that we are a teaching 

facility, including medical assistants, nursing 

students, advanced practice registered nurses, 

physician assistants, medical residents and 

other disciplines,” said Kori Kindred, BSN, 

MSN, CFNP, DNP-S, executive director of 

ambulatory providers at UNM Hospitals. 

“We also pride ourselves on our diversity, 

ethnicity and inclusion department and have a 

very strong interpreter services department 

using live interpreters, video monitors and of 

course, access to the interpreter phones.” 

Kindred is seeking to hire six full-time PAs 

or APRNs with CPR certification for primary 

care positions at Southwest Mesa Clinic, 

Westside Clinic, After Hours Clinic and 

Internal Medicine Discharge Clinic. Specialty 

positions are open in the disciplines of orthospine, 

neurology, rheumatology, hepatitis C 

and pain management. 

The ideal candidates will be strong team 

players with a positive attitude and flexibility. 

“We value high-quality care and are proud of 

our Patient-Centered Medical Home designation 

in our primary care clinics,” Kindred said. 

New graduates are encouraged to apply. 

"We provide additional training and mentoring 

for new graduates and offer them time in 

specialty clinics if additional training is needed,” 

Kindred said. 

UNM Hospitals offers a competitive salary 

with medical benefits, incentives, tuition 

reimbursement and continuing education. ■ 

For more information, contact Kori Kindred at 

KKindred@salud.unm.edu or (505)272-9676. 

4 August 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA 


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49

Comments&Feedback 

NPs & PAs Do the Math 

By Jennifer Ford 

Readers continue to share their comments — positive and negative — on news, articles and blogs posted by ADVANCE 

for NPs & PAs. It all adds up to an excellent opportunity to network with colleagues. Here are some recent posts. 

+ 

Addition 

AANP and ACNP announced their plans to consolidate the 

two groups. Readers shared positive reactions on Facebook 

and the ADVANCE for NPs & PAs Blog: 

❝ Long overdue. ❞ 

❝ 

This is a wonderful opportunity for there is strength in 

numbers. 

❞ 

❝ Great news for the merger … we need one voice. Thanks. ❞ 

❝ 

I am excited about the possibilities associated with this 

merger. 

❞ 

❝ 

So glad to hear that these two professional associations 

will be merging and no longer have ‘divided camps.’ It is 

important now with our financial climate and ACA going 

forward that we have one collective voice in the political 

arena. Can’t wait. 

❞ 

❝ 

It’s about time. This was so confusing to have 2 organizations 

and to decide which one to join. I hope there is no 

‘squabbling’ between the two over names and who does 

what. I anticipate that our professional organizations will 

have a professional transition. 

❞ 

÷ 

− 

Subtraction 

“The Forked Tongue of Convenient 

Care” by Stephen Lyons, PA, appeared 

in Opinions & Essays at www.advanceweb.com/NPPA 

and presented a negative 

view that got a lot of attention. 

❝ 

I have been a PA since 1977 and 

have never heard of such restrictions. 

I am certain that your story was hard 

to tell, but it is even more difficult to 

believe. I could not work in such an 

environment. 

❞ 

❝ 

Stephen, thank you so much for 

the enlightenment. I will be attending 

PA school in August 2012 and it is 

very helpful to know about what circumstances 

I will have to face when I 

start working in the field and know how 

to be ready for them. There definitely 

is a dichotomy in terms of what they 

are calling convenient care and what 

really is convenient and affordable 

healthcare. Hopefully one day this can 

all be rectified. 

❞ 

Division 

In the ADVANCE for NPs & PAs video coverage of the AAPA IMPACT 2012 conference in Toronto, the separation is 

still clear between two groups of PAs: those who wish to change the name of the profession and those who don’t. 

Visit www.advanceweb.com/NPPAmultimedia to see which PA leaders said the following: 

❝ If this is an issue among so many physician assistants, they would like to see that this is being discussed. ❞ 

❝ 

In this house we spend a lot of time gazing at our navel and dissecting it … it seems to me that we need to 

be worried about more relevant issues. 

❞ 


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