Clinical Pearls

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Words of wisdom for student and new NPs

I was inspired to write this series to serve as a guide for student and new nurse practitioners. I remember being faced with so many things to consider during the last year of my family nurse practitioner program and my first year after graduation, and wishing I had someone to guide me through that transitional time. Now that I have worked as an NP in a few different specialties, I have compiled information that I feel would benefit new NPs. I love teaching and using knowledge I’ve acquired to help others. It is my hope that this article can provide navigation for student and new NPs.

In follow-up to the fourth article, “Clinical Tricks,” the fifth and final part of this series provides words of wisdom for student and new NPs as they prepare for the next phase of their career.

Clinical Pearl #1: Sulfa Allergy and Shellfish Allergy/Shellfish Allergy and Glucosamine
Initially, I had looked this up since I was confused after having heard contradicting information as to whether someone who is allergic to shellfish may also have sensitivity to medications containing sulfa. When I was a new NP, I had a patient that had a shellfish allergy (in addition to environmental allergy and bee sting allergy, and was allergic to penicillin and erythromycin). I was considering giving her the antibiotic, sulfamethoxazole/trimethoprim (Bactrim), but needed to check to make sure there was no contraindication to sulfa medication. In the process, I found out something else that was interesting, that I was previously unaware of. First, an allergic reaction to sulfa medications does not mean that shellfish also need to be avoided since there is no sulfa in shellfish.1 Finally, glucosamine, the popular dietary supplement which is frequently taken in combination with chondroitin sulfate and used for the treatment of osteoarthritis, is often made from the shells of shrimp, crab, and lobster; therefore, people with shellfish allergy are advised against taking this supplement, even though there is no evidence glucosamine contains shellfish proteins, which are the part of the shellfish responsible for causing symptoms of food allergy.2

Clinical Pearl #2: Acetaminophen vs. Ibuprofen Taken in Addition to Daily Aspirin
When I was a new NP, I had a patient who I saw for a sinus infection. I had given him an antibiotic and also wanted to recommend something for his sinus headache and facial discomfort; however, he was already taking daily aspirin as a preventative measure. It was my understanding that ibuprofen would be contraindicated in a patient with concurrent use of aspirin; therefore, I recommended acetaminophen for him since it is not a non-steroidal anti-inflammatory drug (NSAID), does not have the platelet effects that aspirin has, nor does it have a drug interaction with aspirin. However, I also saw many patients for cholesterol screenings who, while taking their health histories, found out they were taking daily aspirin as a preventative measure and ibuprofen for arthritis concurrently. As a result, I felt I needed to research this further. According to the U.S. Department of Food and Drug Administration (FDA),3 ibuprofen can interfere with the antiplatelet effect of low dose aspirin (81mg/day) potentially rendering aspirin less effective when used for cardioprotection and stroke prevention; healthcare providers should advise patients regarding appropriate concomitant use of ibuprofen and aspirin, i.e. patients should dose ibuprofen at least 30 minutes after or eight hours prior to aspirin ingestion to avoid attenuation of aspirin’s effect.

Clinical Pearl #3: Chronic/Recurrent Bacterial Vaginosis (BV) Alternative Treatment
While I was a new NP in reproductive health, a wise midwife shared with me an alternative remedy for chronic or recurrent BV. An alternative remedy that may be considered for BV is boric acid capsules used intravaginally. Boric acid is a powder and natural antiseptic that helps to acidify the vagina and restore normal vaginal flora. The Centers for Disease Control and Prevention’s 2010 STD Treatment Guidelines, also note that intravaginal boric acid might be an option for women with recurrent BV.4 I have found this to be a very helpful and successful treatment for patients with chronic/recurrent BV. Supplies can be purchased over-the-counter (OTC) in some pharmacies, while others require a prescription.

Clinical Pearl #4: Psoriasis & Strep Throat
I had a patient when I was a new NP who, while I was taking her health history, mentioned she had developed a rare form of psoriasis following a strep throat infection. I had not previously heard of a form of psoriasis associated with strep throat, so I looked it up and found the following. According to MedlinePlus,5 one type of psoriasis called guttate psoriasis is associated with strep throat. It’s aptly named guttate which means “drop” in Latin because of its characteristic small, red, and scaly teardrop-shaped spots that appear on the arms, legs, and middle of the body. It is a relatively uncommon form of psoriasis, usually seen in patients younger then 30yo (my patient was 25yo), and is a condition which often develops suddenly, usually after an infection, most notably strep throat. Guttate psoriasis is not contagious, seems to be inherited, and may become a chronic or lifelong condition.

Clinical Pearl #5: OTC Cholesterol Therapies
While I was a new NP doing cholesterol screenings, I heard of therapies I was previously unaware of from my patients. The two OTC, alternative therapies I learned of were products called CholestOff and red yeast rice. Nature Made CholestOff Cholesterol Fighter Caplets with Reducol (proprietary blend of natural plant sterols and stanols) is a dietary supplement containing phytosterols which can help to lower LDL cholesterol by reducing the absorption of dietary cholesterol into the bloodstream.6 One of my patients who was taking CholestOff swore by it, stating previously she was on statins, went off them and has been on CholestOff instead, and for the past several years, has had normal cholesterol readings. This was the only medication she reported taking and her cholesterol readings, performed using CardioCheck, were all within normal limits. A study published in the International Journal of Food Sciences and Nutrition demonstrated a nearly 5% reduction in LDL when CholestOff was added to the National Cholesterol Education Program’s therapeutic lifestyle changes diet.7 Red yeast rice is available in the U.S. as a dietary supplement and can be used to lower blood lipids, including cholesterol and triglycerides. According to Lee,8 red yeast rice is rice that has been fermented by red yeast and has been used by the Chinese for many centuries as a food preservative, food coloring (responsible for the red color of Peking duck), spice, and an ingredient in rice wine. It continues to be a staple in China, Japan, and Asian communities in the U.S. and has been used in China for over 1,000 yrs. for medicinal purposes, described in an ancient Chinese list of drugs as useful for improving blood circulation, and for alleviating indigestion and diarrhea. Recently, red yeast rice has been developed by Chinese and American scientists as a product to lower blood lipids including cholesterol and triglycerides.8

Clinical Pearl #6: Birth Control, Antibiotics, and Condoms
I was taught in my NP training to advise patients on birth control who are prescribed an antibiotic, to use a back-up method (such as a condom) while taking the antibiotic. I wondered if that varied based on the birth control method being used and type of antibiotic prescribed, and did some research on this with a colleague of mine who is a pharmacist. According to Gold Standard,9 anti-infectives which disrupt the normal gastrointestinal flora, including amoxicillin, ampicillin, chloramphenicol, clindamycin, lincomycin, neomycin, nitrofurantoin, penicillin V, sulfonamides, and tetracyclines, may potentially decrease the effectiveness of estrogen-containing oral contraceptives, and antituberculosis drugs such as rifampin, were agents that have been clearly associated with oral contraceptive failure and pregnancy. It is also noted in Mosby’s 2014 Nursing Drug Reference, that antibiotics can decrease the effectiveness of oral contraceptives.10 Patients should be informed about the potential interaction between oral contraceptives and oral antibiotics, and recommended to use a condom or spermicide as a back-up method of contraception during the course of antibiotic treatment and for at least one week afterward.11According to Gold Standard, data regarding progestin-only contraceptives or newer contraceptive methods (e.g. patch, ring) are not available.9 Because of all the different types of birth control methods and antibiotics, and out of concern for simplistic instructions for patients, it may be safe to advise all patients using hormonal birth control methods, who are prescribed antibiotics, to use a back-up method, e.g. a condom. It only takes a moment to provide such education to our patients and that small amount of time can prevent the serious impact of an unwanted pregnancy and its potential complications.

Clinical Pearl #7: Patients Who Have Had Bariatric Surgery and Use of NSAIDs
When I worked in urgent/retail health, I had several patients with a history of bariatric surgery who came in for treatment of acute, episodic illnesses. The electronic medical record (EMR) being used in my practice at that time did not have bariatric surgery as a selection choice under medical/surgical history. As a result, no alerts were coordinated in the assessment/plan section of EMR when it came to pertinent analgesia options for recommendation. In addition, even computers are not error proof. For these reasons, it is important to know which OTCs are best when addressing pain relief in such patients, i.e. analgesia in addition to antibiotic therapy in patients with a history of bariatric surgery being treated for strep throat or an ear infection, etc.

Patients who have had bariatric surgery should be cautioned against the use of NSAIDs. This is because NSAIDs have the potential to cause ulcers and patients who have had bariatric surgery are still susceptible to NSAID-related complications; therefore, the use of NSAIDs should be avoided in patients who have undergone bariatric surgery.12 NSAIDs should also be avoided after bariatric surgery as they increase the risk of developing ulcers and after bariatric surgery, ulcers are more difficult to diagnose and treat.13 Being aware of this, I was able to pass along this information to other practitioners, in an effort to prevent complications. This is just one example of why it is important to not become too dependent and reliant on computers, and why it is important to pass along information and suggestions to other colleagues when potential snags are encountered, in an effort to counteract them and ultimately improve patient safety.

Clinical Pearl #8: Poison Ivy in the Winter
One winter, following a warming trend in mid-March, I treated a patient with rhus dermatitis (poison ivy). The patient stated she was playing Frisbee golf over the weekend with friends near a wooded area, when the Frisbee disc landed in the forest. She went in after it and had to dig through some plant life to find it, but couldn’t remember exactly what the plants looked like. Later that day, she started itching and noticed a rash on her face, ears, and arms. She took a shower and using a washcloth, rubbed vigorously all over her skin. The next day, the itching worsened and she noticed that the rash had spread to a different area on her arms and stomach. She had tried using OTC anti-itch creams and ointments which helped temporarily, but she stated she was still itching and uncomfortable even several days later.

It was an obvious case of poison ivy, though it surprised me to see poison ivy in the winter when it’s most common in the summer; however, I looked it up on the American Academy of Dermatology (AAD) website and found out the following. These plants are common in the spring and summer. Although poison ivy rash is usually a summer complaint, cases may occur in winter when people are cleaning their yards and burning wood with urushiol on it or when cutting poison ivy vines to make wreaths. All parts of the plant contain urushiol which causes the allergic response, so even contact with the leafless vines in the winter can cause a reaction. When urushiol gets on the skin, it begins to penetrate in minutes. A reaction usually occurs within a few hours to several days after exposure. There is severe itching, redness and swelling, followed by blisters. The rash is often arranged in streaks or lines where the person brushed up against the plant. In a few days, the blisters become crusted and can take 10 days or longer to heal. Poison plant dermatitis can affect any part of the body. In general, the rash does not spread by touching it unless you have urushiol on your hands, although it may seem to when it breaks out in new areas. This may happen because urushiol absorbs more slowly into skin that is thicker such as forearms, legs and trunk; from repeated exposure to a contaminated object; or if urushiol is trapped under fingernails.14

Both the AAD and FDA, recommend using a topical skin-care product that is an ivy block barrier. 14, 15  An example of this to recommend to patients who know they may come into contact with poison ivy, especially those sensitive/susceptible to poison ivy, is a product called Ivy X Pre-Contact Skin Solution, an FDA approved product available OTC that helps to prevent poison ivy, oak, and sumac rashes before they start. It is applied to the skin before risk of exposure, at least 15 min. before, and works by absorbing the urushiol before it irritates the skin.16

Clinical Pearl #9: Creative Investigation with Otitis Externa (OE)
I had a patient who presented for ear pain and who upon investigation of risk factors (i.e. recent swimming, incorrect/misuse of cotton tip applicators for cleaning ears, scratching ears, etc.) reported none. He was perplexed how he could have “swimmer’s ear” when he hadn’t been swimming. He later asked me if using an iPod could be a risk factor for OE. I explained that OE means an infection of the outer ear and that it’s also called swimmer’s ear because it is common in swimmers, though one wouldn’t have to have been swimming in order to get this infection. I explained to him that anything that causes a break in the skin of the ear canal, can allow bacteria or fungi to get in and flourish leading to an infection, and this could plausibly be a scratch from an ear piece/ear bud of such a device. Goguen17 supports this noting that wearing devices that occlude the ear canals can increase the risk of OE (if worn frequently) by injuring the skin. Oftentimes, we think of a scratch coming from incorrect/misuse of cotton tip applicators for cleaning ears, or scratching ears but we need not rule out other causes, as it can include anything that results in a break in the skin; therefore, it is to our benefit to get a detailed history from our patients and allow them to share certain questions or concerns with us, which can assist in identifying risk factors to better help them.

Clinical Pearl #10: Asthma and NSAIDs
When I was in my FNP training during clinicals, one of my preceptors routinely advised acetaminophen in patients with asthma versus ibuprofen, as a precaution. After practicing as an NP for a while, I encountered many patients with asthma who took ibuprofen for occasional pain/discomfort without any problems. I decided to research this further to gain more knowledge into who to recommend which analgesic to. Patients with asthma may have aspirin-sensitive asthma (representing about 10-20% of asthmatics) which may be associated with severe and sometimes life-threatening bronchospasm; since cross-sensitivity reactions between aspirin and other NSAIDs have been reported, NSAIDs should not be administered to patients with aspirin-sensitive asthma.18, 19, 20 So, for patients with asthma who have never experienced a reaction to aspirin or NSAIDs, they may not need to worry about it; however, since a reaction can occur at any time, and if they do not know whether they are sensitive, or are unsure whether they have ever had a reaction to aspirin or NSAIDs, they may be better off avoiding these medications or checking with their healthcare provider before taking them. In this case, acetaminophen is usually a safer alternative for these patients; however, even acetaminophen, though very rarely, may also trigger/exacerbate asthma.18, 19, 20

Clinical Pearl #11: Alternative Treatment for Chronic, Recurrent Sinusitis
I had a patient who was a firefighter that dealt with recurrent sinus infections. I recommended he use a SinuCleanse Neti Pot since I was concerned that his occupational exposures to smoke, dust, and other airborne irritants were a predisposing or risk factor for his  recurrent sinus infections. He presented several months later to let me know that the first time he used the Neti Pot, “a lot of black gunk” came out of his nose and that he had been using it regularly, and felt that was the reason he has had fewer sinus infections. I had another patient who traveled regularly to an area overseas with poor sanitation and pollution who stated that every time she traveled there, she returned with a sinus infection. I recommended she use a SinuCleanse Neti Pot as I was concerned environmental exposures were a risk factor for her sinus infections. She presented upon returning from her next trip to let me know it was the first time she was able to return without a sinus infection and felt that the Neti Pot was the reason she didn’t get one. As I mentioned in a previous article, the SinuCleanse Neti Pot is an OTC nasal saline irrigation system/nasal-sinus wash which is a natural way to relieve congestion and sinus symptoms, and is indicated for a variety of conditions, including but not limited to sinusitis.21 Saline nasal irrigation has proven to be effective in chronic rhinosinusitis and is recommended by different otolaryngologic societies.22 Mechanical saline irrigation may reduce the need for pain medication and improve overall patient comfort, especially in patients with frequent sinusitis, and evidence indicates some decrease in time lost from work and symptom relief.23 If you have patients who suffer from chronic or recurrent sinusitis, providing they are candidates for this therapy, consider recommending they use an OTC sinus wash/flush, e.g. as maintenance therapy or at the first sign of sinusitis symptoms, to prevent a viral sinusitis from developing into a bacterial sinusitis. It may mean the difference as to whether or not the patient would need an antibiotic for a bacterial sinus infection.

Clinical Pearl #12: Acetaminophen vs. Ibuprofen for Greater Antipyretic Activity
It was my understanding that, although both are analgesics, acetaminophen is more antipyretic and ibuprofen is more anti-inflammatory. I had wondered if one was necessarily better than another in reducing fevers and if so, what the difference was in degrees Fahrenheit/Celsius (°F/°C) of fever-reducing capabilities of acetaminophen compared with ibuprofen. As a new NP, I decided to research this. According to earlier information published by Wahba,24 in children, acetaminophen produced a greater initial body temperature reduction (0.2°C) at one half hour after intervention compared with ibuprofen; however, ibuprofen provided a longer duration of antipyretic effect than acetaminophen four hours after intervention and the initial temperature decrement lasted longer. Additional information published on the University of Michigan Department of Pediatrics website, indicates that ibuprofen is more effective  at achieving temperature normalization than acetaminophen, though both effectively lower temperatures greater than 1.5°C in most patients with standard dosing.25 Interestingly, according to recent information from the Cleveland Clinic,26 when Tylenol (acetaminophen) and Advil (ibuprofen) were pit against one another, studies suggest that ibuprofen is better for fever.

Clinical Pearl #13: Viewing Those “Zebras” as an Opportunity to Learn
When I was a new NP, I had an adolescent male patient that I treated for sinusitis. He had a history of Gilbert’s Disease (aka Gilbert’s Syndrome). I didn’t remember learning about this condition during my FNP training, so I looked it up as I needed to gain necessary knowledge about it in order to most effectively and safely treat this patient. I verified with my patient that he is not monitored by a specialist for his condition, that he is not on any medications for his condition, and that he does not have any restrictions. For those unfamiliar with this condition, Gilbert’s Disease is a genetic disorder of hepatic function, in which the liver doesn’t properly process bilirubin. It can affect up to 10% of some Caucasian populations and is more common in males than females. Gilbert’s Disease can cause mild jaundice that may come and go throughout a person’s lifetime but many also show no symptoms at all, and often such affected individuals only find out by accident when they have a blood test that shows elevated bilirubin levels. Considered a benign condition, it usually doesn’t require treatment or lead to any complications, nor is it a progressive disorder. The main importance of making the diagnosis is to rule out other potentially more serious causes of jaundice such as hepatitis. Patients with Gilbert’s Disease are advised to tell their healthcare provider if they have this condition prior to taking any new medications because it can affect the way their bodies process certain medications with the potential to increase side effects.27, 28

In the medical community, the term “zebra” is used in reference to a rare or unique disease or condition. The aforementioned guttate psoriasis and Gilbert’s Disease could be viewed as such zebras. The moral of this story (the pearl) is that in NP school, we’re not going to learn about all medical conditions and it’s up to us to continue the learning process throughout our careers. It is important to view those “zebras” as an opportunity to learn and I recommend keeping a journal just for documenting such experiences encountered throughout practice.

In closing, I hope that upon reading this guide, it will be as helpful and interesting to you, as it was to me in writing it. Good luck in your practices and may you never stop learning!

References
1. Kagan S. Allergy to sulfa drugs. Allergy and Asthma Newsletter. (2013).   www.allernet.com/NEWSLETTER/q10/0032.html

2. More D. Glucosamine and shellfish allergy. www.allergies.about.com/od/medicationallergies/a/glucosamine.htm

3. U.S. Department of Food and Drug Administration. Information for healthcare professionals: Concomitant use of ibuprofen and aspirin.  http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm125222.htm

4. Centers for Disease Control and Prevention. 2010 STD treatment guidelines: Diseases characterized by vaginal discharge. http://www.cdc.gov/std/treatment/2010/vaginal-discharge.htm

5. MedlinePlus. Psoriasis-guttate. http://www.nlm.nih.gov/medlineplus/ency/article/000822.htm

6. Nature Made CholestOff. http://www.naturemade.com/supplements/cholestoff

7. Maki KC, et al. Lipid-altering effects of a dietary supplement tablet containing free plant sterols and stanols in men and women with primary hypercholesterolaemia: A randomized, placebo-controlled crossover trial. International Journal of Food Sciences and Nutrition, 2012;63(4).476-482.

8. Lee D. Red yeast rice and cholesterol. http://www.medicinenet.com/red_yeast_rice_and_cholesterol/article.htm

9. Gold Standard. Drug interaction report for healthcare professionals. Retrieved by pharmacist from local CVS pharmacy.

10. Skidmore-Roth L. (2014). Mosby’s 2014 nursing drug reference (27th ed.). St. Louis, MO: Elsevier Mosby.

11. Walgreens pharmacy. Do antibiotics reduce the effectiveness of birth control pills? http://www.walgreens.com/topic/faq/questionandanswer.jsp?questionTierId=600006&faqId=600022

12. American Association of Clinical Endocrinologists, The Obesity Society, & American Society for Metabolic and Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. http://asmbs.org/2013/04/aace-tos-and-asmbs-medical-guidelines-for-clinical-practice-for-the-perioperative-nutritional-metabolic-and-nonsurgical-support-of-the-bariatric-surgery-patient/

13. University of California San Francisco Medical Center. Life after bariatric surgery. http://www.ucsfhealth.org/education/life_after_bariatric_surgery/

14. American Academy of Dermatology. Poison ivy. http://www.aad.org/dermatology-a-to-z/diseases-and-treatments/m—p/poison-ivy/signs-symptoms

15. U.S. Department of Food and Drug Administration. Outsmarting poison ivy and other poisonous plants. http://www.fda.gov/forconsumers/consumerupdates/ucm049342.htm

16. Ivy X. www.coretexproducts.com/ivyx_b

17. Goguen LA. Patient information: External otitis (Including swimmers ear; Beyond the basics). http://www.uptodate.com/contents/external-otitis-including-swimmers-ear-beyond-the-basics

18. American Academy of Allergy, Asthma, and Immunology. Medications may trigger asthma symptoms. http://www.aaaai.org/conditions-and-treatments/library/asthma-library/medications-that-can-trigger-asthma-symptoms.aspx

19. American Academy of Family Physicians. Asthma: Medicines that can make it worse. http://familydoctor.org/familydoctor/en/diseases-conditions/asthma/prevention/medicines-that-can-make-it-worse.html

20. WebMD. Aspirin and other drugs that may trigger asthma. http://www.webmd.com/asthma/guide/medications-trigger-asthma

21. SinuCleanse. http://www.sinucleanse.com/

22. Hildenbrand T, et al. Nasal douching in acute rhinosinusitis. Laryngorhinootologie, 2011;90(6).346-351.

23. Hwang PH, & Patel ZM. Acute sinusitis and rhinosinusitis in adults: Treatment. http://www.uptodate.com/contents/acute-sinusitis-and-rhinosinusitis-in-adults-treatment

24. Wahba H. The antipyretic effect of ibuprofen and acetaminophen in children. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 2004;24(2).280-284.

25. Lorenz C. Ibuprofen is more likely to normalize temperature than acetaminophen, though both are safe and effective antipyretics for short-term use in children.  http://www.med.umich.edu/pediatrics/ebm/cats/ibuprofen.htm

26. Cleveland Clinic. Acetaminophen vs. ibuprofen: Which works better? http://health.clevelandclinic.org/2013/09/acetaminophen-vs-ibuprofen-which-works-better/

27.  Mayo Clinic. Gilbert’s syndrome. http://www.mayoclinic.org/diseases-conditions/gilberts-syndrome/basics/definition/con-20024904

28. MedlinePlus. Gilbert’s disease. http://www.nlm.nih.gov/medlineplus/ency/article/000301.htm

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About Author

Jenni Hoffman, DNP, FNP-C, CLNC

Jenni L. Hoffman is an assistant professor at Eastern Michigan University School of Nursing and a Nurse Practitioner with the Washtenaw County Department of Public Health.

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