Introduction and Rationale: Concussions account for the majority of traumatic brain injuries in children. Currently there more than 500,000 pediatric concussions per year and that number is likely low due to under-reporting (Rose, Weber, Collen,& Heyer, 2015). Most symptoms of concussion are easily recognized to the trained pediatric primary care provider. Yet, symptom management and recommendations for rest, exercise, specialty care referral, and return to normal activities can be challenging for many providers, due to the lack of evidence and lack of formal recommendations by any organization (Rose et al., 2015; Silverberg & Iverson, 2013). Purpose and Objective: The main purpose of this Doctor of Nursing Practice (DNP) project is to develop evidence-based clinical practice guidelines (CPG) for pediatric primary care providers. The objective is to provide a CPG that offers clinical guidance when managing pediatric concussion patients in the primary care setting. This CPG will also provide clarity for pediatric primary care providers (PCP) when determining what options are available in treatment for pediatric concussions. Methods: The working framework of this project was The Appraisal of Guidelines for Research & Evaluation II (AGREE II). The American Academy of Pediatrics (AAP) procedure for reporting clinical guidelines, in the form of key action statements, was used as the model for development of the CPG. Results: The CPG was appraised using the AGREE II instrument, which provides valid and reliable scores and data used in the evaluation of CPG's. Six domains were evaluated, and the CPG yielded scores above 80% for all categories. The overall standard deviation was 0, which indicts a very low level of discrepancy between users of the instrument. Conclusion: This DNP project addresses an evidence and primary care practice gap. With a large number of pediatric concussions, a consistent management approach will ensure a safe and therapeutic recovery. A CPG was developed and evaluated using the AGREE II instrument. The CPG was found to meet the standards for general recommended use in pediatric primary care.

Childhood obesity is a national problem in the United States and has known implications as a potential cause of chronic illnesses as the child transitions into adulthood. A primary care clinic in the southwestern United States had a high percentage of obese Hispanic children within its population; therefore, the nurses and the pediatrician needed an evidence-based clinical practice guideline (CPG) to manage Hispanic children with a body mass index greater than the 95th percentile for their age. The purpose of the project was to develop a culturally competent CPG to manage childhood obesity in this primary care practice. The social cognitive theory provided the framework to develop the CPG. The final project resulted in an evidence-based CPG that was validated by an expert physician panel. The implication of this project is that nurses and providers can provide culturally competent education to the parent and child to reduce obesity among the pediatric Hispanic population. This project may create positive social change by modifying unhealthy cultural practices and behaviors, preventing chronic diseases, and reducing health care costs for the children within the selected practice.

Recovering from a cardiac surgery procedure and the transition to home can be an overwhelming experience for patients and caregivers. A tertiary care hospital's cardiothoracic surgery department suspended a nurse-practitioner-coordinated transitional care program in the 1st quarter of 2016. Following this decision, the readmission rate increased from its previous rate of 15.6% in quarter 1 to 20% in quarter 3. The purpose of this scholarly project was to develop a clinical practice guideline (CPG) that can bridge the gap in the transitional care process. The transitional care model informed the design of the project. A draft guideline was distributed to 5 stakeholders from the inpatient cardiac surgery care team for initial review. After initial review and revisions an edited version was then distributed to 5 additional stakeholders. Those stakeholders provided an assessment utilizing the AGREE II tool to assess the 6 domains of scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application and editorial independence, and overall quality. Four domains indicated a high level of agreement (96%-100%) and 2 domains indicated a response of < 76% for domains related to rigor and organizational resources. The overall guideline assessment of the quality of the CPG received a score of 96%, with a recommendation to adopt the guideline. Advanced practice nurses will utilize this guideline to provide a systematic process in bridging gaps in care for the transition of the cardiac surgery patient population from hospital to home. Social change will be promoted through improved patient management by using evidence-based transitional care, decreased readmissions, and improved health outcomes for the cardiac surgical population.

Objective: To explore adult cancer symptom management by home care nurses. Scoping review: A scoping review was conducted to describe interventions used by nurses for cancer symptom management in the home care setting. Five included studies revealed that home care nursing contributed to positive client- and system-level outcomes. Study: A mixed-methods descriptive study explored usability of a set of 13 cancer treatment-related symptom management protocols for nurses in the home care setting. Thirty-eight nurses in home care participated. Qualitative and quantitative data indicated the protocols were highly usable. Several barriers suggested they would be better used as resources to support and train nurses rather than documentation tools. Conclusions: Few studies have evaluated interventions for cancer symptom management by home care nurses. This set of protocols was well-received, but further research is required to determine their effectiveness and interventions for implementing with home care nurses providing cancer symptom management.

Objective: To explore adult cancer symptom management by home care nurses. Scoping review: A scoping review was conducted to describe interventions used by nurses for cancer symptom management in the home care setting. Five included studies revealed that home care nursing contributed to positive client- and system-level outcomes. Study: A mixed-methods descriptive study explored usability of a set of 13 cancer treatment-related symptom management protocols for nurses in the home care setting. Thirty-eight nurses in home care participated. Qualitative and quantitative data indicated the protocols were highly usable. Several barriers suggested they would be better used as resources to support and train nurses rather than documentation tools. Conclusions: Few studies have evaluated interventions for cancer symptom management by home care nurses. This set of protocols was well-received, but further research is required to determine their effectiveness and interventions for implementing with home care nurses providing cancer symptom management.

Childhood bullying can lead to adverse physical and mental health outcomes for both the victim and the bully. Risk factors for bullying can be related to gender, race, sexual preference, and having any type of disability. A pediatric primary care clinic in a large, metropolitan area, the focus for this project, did not have an evidenced-based clinical practice guideline (CPG) for providers to facilitate the management of children who presented with reported bullying. The project, guided by the Tanner'€™s integrated model of clinical judgement, addressed the question whether a CPG would facilitate the early recognition and treatment of bullying in the pediatric clinical site. Using a literature search, a CPG was developed with evidence that included 6 recommendations ranging from clinical assessment and screening to advocacy. The CPG was then evaluated by 4 expert panelists using the AGREE II tool. Panelists included 2 pediatric medical doctors, 1 pediatric school nurse, and 1 mental health nurse practitioner. The panel evaluation results revealed a score of 81 out of a possible 100, where a score of 71 was the standard for acceptable results for the 6 recommendations. Results from the expert panel were used to modify the CPG, after which the guideline was presented to the panel for final approval. One final recommendation of the panel was to include a provision for referral and follow up for children identified with bullying. The finalized CPG was presented to the medical director of the pediatric clinic for implementation. The implications of the project for positive social change include decreased variations in clinical practice, early detection and intervention of bullying, improved effectiveness and quality of care, and decreased costly and preventable adverse events.

Transition of care refers to the movement of patients between health care settings; it occurs each time patients move between providers within the same setting or between settings based on the patient's acute or chronic health care needs. Care transition includes the efficient and accurate exchange of information needed to provide high-quality continuity of care. A rural community hospital in in the northeastern region of the United States has a skilled nursing facility and an acute care hospital on one campus. This project focused on the development of a clinical practice guideline (CPG) for the hospital to improve communication during transitions of care. The Iowa model of evidence-based practice informed the development of the guideline. A project team developed the CPG. Five multidisciplinary experts reviewed the CPG using the appraisal of guidelines for research and evaluation (AGREE II) evaluative tool. Results for the 6 domains of the AGREE II tool showed experts' agreement greater than 90% with the guideline as developed. The creation of a CPG to improve communication during care transition could benefit nurses with improved clinical decision making and patients with improved outcomes. The CPG could impact social change by supporting the application of the principles of evidence-based nursing practice, which could result in improved care and patient outcomes.

Although medical practice guidelines for diabetic foot care exist globally, there is no clear guideline for nurses to direct clinical foot care practices for diabetic patients in Thailand. The purposes of this qualitative study were to explore the current practice of diabetic foot care and to develop a nursing practice guideline for effective foot care. The research design included two phases, consisting of situation exploration and practice guideline development. For the first phase, semi structured interviews were conducted among fifteen diabetic patients, five nurses, and five nurse educators at Prapokklao hospital, Thailand to discover their knowledge and practice in foot care. A content analysis approach was used in data analysis. The findings revealed that, although foot care education was available, diabetic patients lacked knowledge and had poor foot self-care practice. Nurses and educators also had inadequate knowledge about effective diabetic foot care and they had scarcely ever provided advanced practice for foot care. Moreover, patients had not been categorised regarding their foot risk level, nor had they received appropriate levels of foot care to manage their particular situations. For the second phase, a nursing practice guideline was developed. The classical Delphi technique was applied to examine experts’ agreement on the practice guideline contents. A questionnaire was developed, based on the first phase’s information and critical literature review using Soukup’s model. Twenty diabetic foot care experts from around Thailand completed the questionnaire. The acceptance of experts’ agreement was 94-100% in all aspects. A final guideline was developed which consisted of the initial risk assessment of foot ulceration and specific guidance on the interventions. This guideline, based upon local specialist expert opinion, provides a clear resource for referral and standardised procedures for evaluating footwear and screening to detect the risk of foot complications. In conclusion, this current nursing practice guideline for diabetic foot care was the first guideline for Thai nurses to care for diabetic patients in a Thai cultural context, and is based on local specialist experts’ opinion. This foundation work provides the basis for further research and evaluation concerning the prevention of foot complications and foot management for diabetic patients, including evaluating the effectiveness of the current risk assessment form and risk classification procedures.

ABSTRACT Introduction and Rationale: Atopic Dermatitis (AD) is a common skin condition, characterized by markedly pruritic eczematous lesions, that most often presents in childhood. The majority of children diagnosed with AD will have mild disease and will first present with symptoms to a primary care provider (PCP), however approximately 85% of pediatricians only provide limited initial care followed by a referral to dermatology (Eichenfield et al., 2015). While there are specialty care based treatment guidelines for childhood AD, there are no guidelines available that specifically address primary care management of childhood AD. Purpose and Objective: The primary purpose of this DNP project is to develop an evidence-based clinical practice guideline (CPG) for pediatric PCPs. The secondary purpose is to develop a corresponding atopic dermatitis action plan (ADAP) to be used by children and parents. The objective is to equip PCPs to better manage children with AD in the primary care setting and to guide patients and parents in the importance of daily control measures and in the individualized treatment plan prescribed by the PCP. Methods: The Appraisal of Guidelines for Research & Evaluation II (AGREE II) framework and Social Cognitive Theory (SCT) serve as the theoretical frameworks for CPG and ADAP development. The American Academy of Pediatrics (AAP) process for evidence based policy setting is used as a model for key action statement development. Results: Evaluation of the CPG was completed using the AGREE II tool, a reliable and validated tool for evaluating CPGs. Five of the six domains evaluated, yielded combined scores of at least 90%, with one domain a combined score of 63%. The overall standard deviation was 0.58, indicating an overall low level of user discrepancy Additions and revisions were made based on the results of the AGREE II evaluation scores with specific emphasis on the lowest scoring domain. Conclusion: This DNP Project identified the need for a CPG specific to pediatric primary care. A CPG with accompanying ADAP was developed and evaluated using the AGREE II tool. The CPG was found to meet the recommended standards and recommended for use in pediatric primary care.

Diabetes mellitus is one of the leading causes of death in the United States, contributing to rising health care costs and increased morbidity and mortality rates. Researchers demonstrated that aggressive heath measures involving ongoing diabetes self-management education are paramount in minimizing associated complications of diabetes. The management and prevention of diabetes is not standardized and providers within a health clinic in Illinois reported challenges in providing self-management education during scheduled patient appointments due to limited resources and time. The purpose of this DNP project was to develop a clinical practice guideline to be used by all providers within the health care clinic for the management of Type 2 diabetes. The goal of the developed guideline was to optimize the time providers spend with patients diagnosed with diabetes and improve the consistency and quality of education and care. The health promotion model provided a guide for the development of the practice guideline. The method and design of this DNP project involved extensive research, literature review, evidence grading, and development of an evidence-based practice guideline for Type 2 diabetes management. A selected team of 3 diabetes experts appraised the developed guideline using the AGREE II instrument, and guideline usability was evaluated by 3 nurse practitioners within the medical clinic using a 10-item questionnaire. Results of the appraisal confirmed the high quality, feasibility, and usability of the developed guideline for diabetes self-management education and support. Improving the delivery of care can bring about positive social change by improving health outcomes in individuals with Type 2 diabetes and reducing morbidity and mortality rates.