Doctor of Nursing Practice (DNP) Final Projects

Background: Neonatal hypoglycemia (NH) is a common problem in the newborn period that resolves by 24-48 hours of life. Infants with known NH risk factors take longer to achieve blood glucose homeostasis. The leading cause of neonatal intensive care unit (NICU) admissions in otherwise healthy term and late preterm infants is NH.

Purpose: To determine the efficacy of dextrose gel in addition to oral feedings in NH treatment as compared to the previous practice of oral feedings alone. Lewin's change theory was used in staff education and project implementation.

Methods/Search Strategy: A keyword search of CINHAL, Cochrane, and PubMed with restrictions to English and publications within 5 years revealed supportive data for the practice change. IRB approval obtained prior to the practice change. Nurses screened all newborns for NH risk factors at birth at a tertiary hospital in the southwestern U.S. Infants with specific criteria received oral dextrose gel with timed follow-up blood glucose levels following an NH algorithm.

Findings/Results: Two groups of infants with similar gestational ages, birth weights, and risk factors for NH were compared pre and post-implementation of the EBP change. Infants in the first group (n=27) were all born prior to the start of the project and therefore were all treated with IV dextrose in the NICU after failing to maintain blood glucose levels within normal ranges with oral feedings alone. The second group of infants (n=27) was treated based on an updated NH algorithm after implementation of the use of oral dextrose gel. Of those 27 infants, 24 received oral dextrose gel for NH treatment. Of respiratory distress in addition to NH so these infants were excluded in the statistical analysis of NICU admissions. Therefore the post-implementation group only had 2 admission for primary diagnosis of NH. When comparing admission rates for hypoglycemia between the two groups, the first group had a 100% admission rate while the second group (those who received oral dextrose gel) only had a 9% admission rate for neonatal hypoglycemia (p<0.001). Upon further investigation it was found that these 2 infants admitted to the NICU with the diagnosis of NH had multiple risk factors present, including being infants of diabetic mothers which means they likely experienced refractory hypoglycemia after treatment with oral dextrose gel secondary to hyperinsulinism. Hyperinsulinism can lead to persistent and profound hypoglycemia in the newborn that is more difficult to treat, which is of clinical significance.

Implications for Practice: Early identification with timely follow-up blood glucose levels following intervention may be critical to successful treatment without requiring NICU admission. Nursing education and parental support are also paramount to success. If the change in NICU admissions for NH is statistically significant with a larger sample size, results may be shared with other facilities that traditionally transfer these infants for a higher level of care.

Implications for Research: Studies with larger sample size may generate more generalizable data with fewer outliers. Studies comparing neurodevelopmental outcomes among infants who received different NH treatments are necessary to determine long-term safety.

Introduction: More than 1.2 million children in military families face long separations from a parent due to deployment or extended assignment, which can lead to significant family dysfunction as well as behavioral, emotional, and scholastic problems for the child. The purpose of From Caring 2 Coping is to identify and provide healthcare providers of military children tools to recognize and address maladaptive and externalizing behaviors of these children, while also assisting the nondeployed parent or caregiver to provide their children with the necessary support to reduce stress and increase their own coping skills.

Materials and Methods: After approval from Arizona State University IRB, children aged 4-11 years who are currently or forecasted to be separated from a military parent due to a deployment or extended assignment, were recruited from a military pediatric clinic along with their primary caregiver. An intervention was adapted from Bowen and Martin’s (2011) Resiliency Model of Role Performance for Service Members, Veterans, and their Families to identify and improve individual assets and family communication skills, find support through social connections, and prepare for potential stressors by constructing a Roadmap of Life. The Parental Stress Scale (PSS) and Pediatric Symptom Checklist (PSC-17) were completed before and after the 4-week intervention along with a final caregiver survey to evaluate the caregiver’s perceptions of From Caring 2 Coping.

Results: Four mothers and eight children completed the program for which Wilcoxon matched-pairs signed-rank test compared results from pre- and post PSC-17 surveys from the children showing significant improvement post-intervention (p = 0.017). The post PSC-17 results were compared to post PSS results with Spearman Correlation Coefficient, r = 0.949, that is statistically significant (p = 0.05). From Caring 2 Coping is rated as an effective program by parents in a postintervention survey that is easy to incorporate into daily activities. Parents ranked highest satisfaction through use of the Family Communication Plan and Family Timeline.

Conclusions: From Caring 2 Coping intervention tools improved family communication, use of individual assets and Roadmap of Life coping skills, thereby improving child and caregiver coping response as evidenced by improved PSC-17 and PSS scores. Basing the intervention on the Resiliency Model of Role Performance which has proven successful in the military population, improves the chances for success in this target population. However, the small sample size of four families requires further study with more families at all levels of the deployment cycle in order to refine the intervention.

Obtaining a comprehensive sexual health history is an important part of the patient history taking process and is essential to providing high-quality, patient-centered, and accessible healthcare. Information gathered from the sexual health history guides delivery of appropriate education about prevention, counseling, treatment, and care. A federally qualified health center (FQHC) reported that they did not have a standardized comprehensive sexual health history taking process. To address this concern, a literature review was conducted to survey current evidence regarding both patient and healthcare provider perspective on sexual health history taking. While it is recommended for a sexual health history to be performed routinely, both healthcare providers and patients have reported sexual health is not discussed at most visits.

The findings led to the initiation of an evidence-based project implementing a comprehensive sexual health history taking tool at the FQHC. The tool assists in obtaining a comprehensive sexual history and provides an understanding of the sexual practices of the patients. If healthcare providers become aware of the sexual practices of their patients, they are better able to provide evidence-based education that could lead to better health outcomes. The participants reported they liked being asked about their sexual health, did not find the questions too personal, and reported the questionnaire addressed their sexual health concerns, and was worth their time. Taking a comprehensive sexual health history is a fundamental skill that all healthcare providers must strive to improve for the general health of their patients and the community.

Gestational diabetes mellitus (GDM) is a well-established predictor for the development of type II diabetes mellitus (T2DM) later in life. The incidence of GDM has been on the rise over the past 30 years and is the leading co-morbidity during pregnancy (Ferrara, 2007). Physical activity (PA) in combination with nutritional therapy has been shown to achieve glycemic control in women with GDM and is therefore first line therapy for management (American College of Obstetrics and Gynecology [ACOG], 2017; Center for Disease Control and Prevent [CDC], 2018).

Recommendations for PA in pregnancy include 150 minutes of moderate intensity exercise most days of the week (ACOG 2015; U.S. Department of Health & Human Services, 2018). Because of this, an innovative project was created to determine the feasibility of adding a walking plan into GDM care. Participants in the project received verbal and written instruction on an unsupervised structured walking plan set up for a beginner to gradually increase PA to the recommended time of 150 minutes per week for a total of four weeks. Eight women were interested, recruited, and enrolled in the project.

Results show that overall, participant PA increased. One hundred percent agreed that the walking plan was useful and increased their awareness about PA. The addition of a walking plan in GDM teaching is an effective strategy to lower serum blood glucose (SBG) levels and for meeting PA recommendations during pregnancy.