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Fitzgerald Health
Education Associates, Inc
FHEA News
Volume X, Issue IX
September, 2010
Certification Question and Answer:
What Types of Questions are on the
NP Exams?
by Margaret A. Fitzgerald
DNP, FNP-BC, NP-C, FAANP, CSP
Question: What kind of questions will I find on the NP
certification exams?
Response: The NP certification exams are comprised
of multiple-choice questions; there are no true/false,
fill-in-the-blank, essay or matching test items.
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Exam Review Courses
Question: Are all of the exam questions at the same
level of complexity or difficulty?
Response: Exam questions are written on a number of
levels of difficulty and depth, with the lowest level usually the fact-oriented or knowledge questions. This type
of question tests generalizations, principles and widely
recognized theories. When answering the question
below you might read the question and instantly recognize the correct answer from a piece of information that
was memorized long ago. The following is an example
of a fact-oriented question:
Pupillary constriction in reaction to light is in part a
function of cranial nerve:
A) I.
B) II.
C) III.
2010 Schedule
09/10/2010
Oak Brook, IL
09/15/2010
Manhattan, NY
09/15/2010
Atlanta, GA
09/24/2010
Philadelphia, PA
(Also Acute Care)
10/01/2010
Orlando, FL
11/05/2010
Kansas City, MO
11/11/2010
Dallas, TX
12/01/2010
Sacramento, CA
12/04/2010
Huntsville, AL
2011 Schedule
D) IV.
Correct answer- C
(Continued on page 5)
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01/04/2011
North Andover, MA
01/07/2011
Baltimore, MD
01/07/2011
Chicago, IL
01/11/2011
Atlanta, GA
01/14/2011
Oakland, CA
01/21/2011
Cleveland, OH
02/01/2011
Manhattan, NY
02/26/2011
Minneapolis, MN
03/11/2011
Charlotte, NC
03/17/2011
Philadelphia, PA
03/23/2011
San Diego, CA
Click Here to See the Complete
2011 Schedule
Take advantage of information and discounts available
only to FHEA Facebook
fans!
Inside this issue:
Benefits to Breastfeeding:
A Review, by Marie Bosco
2
NCC Urges Healthcare
Providers to Aid in
Chlamydia Awareness, by
Jaclyn Fitzgerald
2
Getting Ready For School:
Food Allergy Emergency
Action Plans, by Christy
Yates
3
System Maintenance
3
Aphthous Stomatitis:
Part 2, by Chris Steward
4
Special Offer
4
Contact Hour Tracker
4
New and Updated
Products
5
Educational Travel
7
Margaret A. Fitzgerald’s
Speaker School
8
Advanced Pathophysiology
Course
9
Clinical Pharmacology
Course
10
Need a Speaker?
13
Margaret Fitzgerald’s
Upcoming Speaking
Engagements
13
FHEA News
Benefits to Breastfeeding: A Review
by Marie L. Bosco, BSN, RNC, IBCLC
Page 2
NCC Urges Healthcare Providers to Aid
in Chlamydia Awareness
by Jaclyn Fitzgerald, Assistant Editor
The benefits of breastfeeding for both mother and child are
numerous, but many of these benefits may be overlooked by
mothers who are still deciding whether or not to breastfeed.
The International Lactation Consultant Association consolidated recent studies that measure the valuable impact of
breastfeeding on both mothers and their children.
Benefits to the Child Include:
1.
Reduced risk of adult obesity
2.
Lower blood pressure
3.
Reduced risk of osteoporosis
4.
Improved lung function
5.
Reduced risk of SIDS
Benefits to the Mother Include:
1.
Lower blood pressure
2.
Less stress
3.
Reduced risk of rheumatoid arthritis (women who breastfed for more than 13 months were half as likely to get
rheumatoid arthritis)
4.
Reduced risk of metabolic syndrome (women who
breastfed for 9 months were less likely to be diagnosed
during a 20 year study)
5.
Reduced risk of cardiovascular disease (in post menopausal women, increased duration of lactation is linked to
lower prevalence of HTN and cardiovascular disease)
Breastfeeding rates continue to rise in the United States. With
appropriate education and support, nursing mothers, their
infants, and the country will reap the benefits of breastfeeding. This simple, organic, and “green” practice is the best
choice for mothers and feeding infants. Integration of knowledge in healthcare practice will be beneficial not only to the
health of mothers and their children, but to the health of the
country as a whole.
References:
10 More Reasons to Breastfeed. (2009). Retrieved August
10, 2010, from International Lactation Consultant Association:
http://www.ilca.org/files/resources/
promotional_materials/10MoreReasons_BW_Bleed.pdf
Since 2008, the National Chlamydia Coalition (NCC) has
been making strides to increase awareness about the
most widespread sexually transmitted bacterial infection in
the United States, chlamydia, which is transmitted to an
estimated 3 million people each year. The NCC was created when the Centers for Disease Control and Prevention
aligned with Partnership for Prevention and various other
healthcare organizations. The mission of NCC is to improve chlamydia screening rates by generating awareness
about this infection among healthcare providers and the
general public.
Although chlamydia can be contracted by both sexes, it is
exceptionally prevalent in sexually active women age 25
and younger. Despite the fact that the most common way
of detecting chlamydia is by having a healthcare provider
perform a simple urine or swab test, a mere 40% of
young women are tested for this infection each year.
Based on these numbers, healthcare professionals estimate that in addition to the 3 million people that are diagnosed with chlamydia each year, there are millions more
who are undiagnosed because it is typically asymptomatic. An estimated 70% of females with chlamydia experience no symptoms at all. However, those who do experience symptoms will notice them within 1 to 3 weeks
after exposure. Symptoms include dysuria as well as
atypical vaginal or penile discharge; symptomatic women
report dyspareunia. If left untreated in women, chlamydia
can lead to pelvic inflammatory disease (PID), which often
leads to infertility or ectopic pregnancy. Chlamydia can be
treated with antibiotics and early treatment can reduce the
risk of PID by 60%.
The NCC recommends that healthcare providers offer
screening for chlamydia at least once annually during office visits with men and women age 25 and younger,
whether or not the office visit is for sexual health reasons.
People over the age of 25 who have multiple sexual partners or who have had sexually transmitted infections before should also be tested regularly. Healthcare providers
are urged to keep pamphlets about sexually transmitted
infections in exam rooms so that patients can access this
information privately.
For additional information on NCC, please visit:
http://ncc.prevent.org/index.html.
For the NCC’s Implementation Guide for Healthcare Providers, please visit:
http://ncc.prevent.org/download/4providers/WhyScreenFor
Chlamydia_Web25.pdf.
FHEA News
Page 3
Getting Ready For School:
Food Allergy Emergency Action Plans
By Christy Yates, MSN, FNP-BC, NP-C, AE-C
Family Allergy & Asthma Family Health Center
Louisville, KY
Senior Lecturer, Fitzgerald Health Education Associates, Inc.
Christy Yates,
MSN, FNP-BC,
NP-C, AE-C
This fall many children will be returning to
school. For children with food allergies,
healthcare providers often need to complete forms indicating what food(s) the
child must avoid and what the emergency action plan will be if accidental
ingestion occurs. Though forms vary
somewhat across the country and even
between school districts locally, they all
ask the same type of questions. Some of
these questions include the following:
2.
What symptoms are most likely to be seen during
an allergic reaction?
Mouth
itching, swelling of lips and/or
tongue
Throat*
itching, tightness/closure, hoarseness,
change in voice
Skin
itching, hives, redness, swelling of the
face or extremities
Stomach
vomiting, diarrhea, abdominal cramps
1.
What is the food the child must avoid?
Lung*
shortness of breath, coughing, wheezing
2.
What symptoms are most likely to be seen during
an allergic reaction?
Heart*
weak pulse, dizziness, passing out*
3.
What medication(s) should be given if an allergic
reaction occurs?
*Symptoms can be life-threatening. ACT FAST!
4.
Where should you keep the epinephrine autoinjector and who should administer the epinephrine?
Remember:
How would you answer these questions for Aiden, a 5year-old boy with a peanut allergy who is entering school
this fall? This situation requires consideration of multiple
factors. At age 1, Aiden experienced facial swelling, throat
tightening, and hives on his face and neck immediately
after eating a peanut butter cracker. His allergy skin prick
testing revealed high IgE reactivity to peanut. His ImmunoCAP IgE to peanut was >100kU/L (>95% predictive of
clinical reactivity).
Considerations When Answering Questions for a
Food Allergy Action Plan
1.
What is the food the child must avoid? The child
should avoid the food that caused the allergic reaction. In Aiden’s case, he must avoid peanuts. He is 5
years old now and it is highly unlikely he has
“outgrown” his peanut allergy. Children are less likely
to “outgrow” allergies to problematic foods such as
peanuts, tree nuts, and seafood. This is particularly
true if the initial level of allergen-specific IgE to a food
is high, as was Aiden’s testing. Upon recheck, Aiden
has continued to have a high level of allergen-specific
IgE to peanuts and therefore needs to continue strict
avoidance of them. Whether or not he should avoid all
nuts is individualized and determined by the healthcare provider; prudent practice is to avoid all nut ingestion in order to avoid accidental allergen ingestion
or contamination.
●
Only a few symptoms can be present
●
Severity can change quickly
●
All of the symptoms can potentially progress to a lifethreatening situation.
Aiden had facial swelling, throat tightening, and hives after
eating peanut butter. To provide more detailed information
to the school personnel regarding his allergic reaction,
these symptoms can be highlighted. However, all symptoms, can be chosen since he, like other children, may
have different symptoms with future reactions.
3.
What medication(s) should be given if an allergic
reaction occurs? Remember the most important
medication in an anaphylactic reaction is epinephrine!
(Continued on page 6)
Notice of System Maintenance for Testing and
Learning Site
Routine maintenance is scheduled for September 18,
2010. FHEA is committed to providing our customers
maximum uptime, reliability, and security for our On-line
Testing and Learning Site. Regular system maintenance
is critical to achieving this goal. System maintenance is
normally performed the third Saturday of each month.
FHEA News
Page 4
Aphthous Stomatitis (Aphthous Ulcer)—
Assessment and Treatment for the Nurse Practitioner: Part 2
By Christopher Steward, DMD, MA, FNP-BC
Oral Surgeon and Family Nurse Practitioner
Editor’s Note: The first half of this article focused on assessment of the aphthous ulcer. It was featured in the August edition of FHEA News. Click here to read Part 1.
Treatment
The first line in aphthous stomatitis therapy is
minimizing or eliminating exposure to triggers. If lesions occur, a variety of therapies
are helpful in minimizing discomfort and
avoiding complications. Due to increased
discomfort, oral hygiene is often comproChris Steward,
mised because patients are sensitive to
DMD, MA, FNP-BC
brushing, flossing, and mouth rinses. The use
of an antibacterial oral rinse such as PerioGard (chlorhexidine)
oral rinse and a soft toothbrush can provide improved oral hygienes while minimizing tissue damage. Avoidance of toothpastes containing sodium lauryl sulfate is recommended as
this may serve as an irritant to the eroded tissue; many even
believe that this may even be a trigger in the initiation of the
disease process itself. In severe cases, dehydration and malnutrition can occur due to poor oral intake; therefore, hydration
status needs to be carefully monitored (Vincent, 1992).
There are multiple nonsteroidal and topical corticosteroid treatment modalities. From my years of practice in general dentistry, oral surgery, and as a family nurse practitioner in treating
these and other oral maladies, I have found the following routine to be effective.
Have the patient rinse or swab the ulcer with chlorhexidine
gluconate, 0.12% (available at Colgate PerioGard) to disinfect
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and reduce the risk of any possible secondary infection(s) of
the ulcerated area. The frequency of application depends upon
the severity but will likely need to be administered 4 to 5 times
per day. There is also a product known as Cora-Caine, a topical anesthetic in an adherent base, which the patient should
apply onto the involved area in order to provide pain relief.
Cora-Caine use is contraindicated in individuals with a history
of allergy to the local anesthetics with the “-caine” suffix. This
product can usually be purchased through a dental supply
company or pharmacist and does not need a prescription. Apply this to the involved area 4 to 5 times per day after the
mouth rinse.
An excellent quick remedy and palliation for minor ulcers is
amlexanox (Aphthasol®). It is in the form of an adherent paste
that holds well to the oral mucosa. The strength is 5% and it
comes in a 5 gram tube; adult dosing is 0.5 cm-1/4 inch. Place
directly on ulcers 4 times a day following oral hygiene, after
meals, and at bedtime. This is an excellent product to use after
the PerioGard regiment listed above. It has a Category B pregnancy listing (Khandwala).
For more aggressive recurrent or major aphthous ulcers, an
excellent regimen is Kenalog® (triamcinolone 0.1%) in Orabase®, available in a 5 gram tube, which is also a paste and
(Continued on page 7)
Upcoming Suturing Conference
The Art of Wound Repair—
Suturing for NPs and PAs
Instructor: Robert M. Blumm, MA, PA-C
Location: New York, NY
Date: February 2, 2011
Class hours: 8:30AM - 4:30PM
Wound repair is a necessary skill for all NPs and
PAs. It is usually placed into their academic curriculum with the knowledge that there will be an
extensive period of practical application as they
continue their studies and move forward into
rotations. However, NPs and PAs graduate from
their programs and pass their boards without acquiring this
useful and billable skill.
This workshop will be a full-day course with the utilization of
a pig's foot, anesthesia tips, 4-0 nylon suture, a disposable
stapler. Dermabond and other newer products about to
come on the market will be covered, as an introduction to
the use of a bio-adhesive in the care of lacerations.
Click here for more information
Page 5
FHEA News
(Certification Question and Answer: Continued from page 1)
Comment: Mnemonics or other memory aids can be helpful in
answering a fact-oriented question. However, the certification
exams will likely contain many more complex types of question that require application of clinical assessment and management skills. Examples of these include the comprehension
question, where you must interpret the fact. An example of a
comprehension question is as follows.
The person with Bell palsy has paralysis of cranial nerve:
A) V.
B) VI.
C) VII.
D) VIII.
Correct answer- C
Comment: In order to respond correctly to this question, you
must know that Bell palsy is a condition where the facial nerve
(cranial nerve VII) is affected.
Application questions are the most commonly found questions
on the certification exam. For these questions you must analyze the information then decide what is pertinent to the given
situation. Look for key words in the stem (the question itself)
that help set a priority. These include words such as “first,”
“initially,” or “most important action.” If you are having difficulty
ascertaining which action should be done first, particularly
when the question poses many plausible actions, you should
ask yourself, “What is the greatest risk in this situation?” Here
is an example.
You are seeing Ms. Thomas, a 53-year-old woman who
presents for a health exam. She smokes cigarettes with a
45 pack-year history, currently smoking 1.5 packs per
day, and has a family history of premature heart disease.
The most important part of her assessment is:
stage is set for her to be at high risk for cardiovascular disease. Another assumption is that the best evaluation is one
that picks up early disease. Now, look at the answers given
and think what you may expect for results. In assessing Ms.
Thomas, a chest x-ray could reveal lung cancer or findings
consistent with tobacco-related lung disease. However, these
changes will not be evident until these diseases are advanced; in earlier disease the chest x-ray is usually without
specific findings. The presence of extra heart sounds would
likely indicate systolic (S3) and/or diastolic (S4) cardiac dysfunction, again a marker of significant, usually advanced cardiac problems. However, blood pressure measurement is critical, as it can detect hypertension in its asymptomatic, earliest
state; the presence of hypertension will significantly increase
Ms. Thomas’s risk of heart disease. While screening for cervical neoplasia is important, diagnosing and intervening in hypertension would more likely improve this woman’s short-term
health. After pulling together the facts, the best answer is
clearly option C, blood pressure measurement.
Comment: A multiple-choice question has a number of components. Often, the first sentence is an introduction of a clinical scenario. Here is an example of a rather lengthy introduction, rich with information.
You see 18-year-old Sam who was seen approximately 36
hours ago at a local walk-in center for treatment of ear
pain. Diagnosed with (L) acute otitis media, amoxicillin
was prescribed. Today, Sam states that he has taken 5
amoxicillin doses since the medication was prescribed
but continues to have discomfort in the affected ear. Left
TM is red and immobile. He is without fever and denies GI
distress or other symptoms.
(Continued on page 11)
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C) Blood pressure measurement.
D) Cervical examination with Pap testing.
Comment: When looking at this question, you may be struck
with the fact that you would certainly perform a cardiac exam
and Pap test. With the limited amount of information available
on this patient, no indication for chest x-ray is evident.
So, how do you set the priority of the most important part of
the assessment? Start with teasing out the facts and assumptions. In the information presented, Ms. Thomas has two
clearly apparent risk factors for cardiovascular disease, cigarette smoking and family history of premature heart disease
Assume she is postmenopausal, since the average woman
reaches this stage by age 51 years. This gives her an additional cardiovascular risk factor. In addition, heart disease is
the leading cause of death in American women. Thus, the
Physical Assessment & Health History of the
Child Cue Cards, 7th Edition
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process of performing and verbalizing findings on a comprehensive child exam in addition to taking a comprehensive child health
history.
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FHEA News
Page 6
(Getting Ready for School: Continued from page 3)
Epinephrine
EpiPen Jr®
0.15 mg IM or SC
33-66 lbs (~15-30 kg)
EpiPen ®
0.30 mg IM or SC
>66 lbs (~ 30 kg)
TwinJect®
0.15 mg IM or SC
0.30 mg IM or SC
33-66 lbs (~15-30 kg)
>66 lbs (~ 30 kg)
Adrenaclick®
0.15 mg IM or SC
0.30 mg IM or SC
33-66 lbs (~15-30 kg)
>66 lbs (~ 30 kg)
Epinephrine
auto-injector
(generic)
0.15 mg IM or SC
33-66 lbs (~15-30 kg)
0.30 mg IM or SC
>66 lbs (~ 30 kg)
this needed information. Another consideration is legislation regarding the management of food allergies in
schools in your area (for more information visit:
www.foodallergy.org/page/legislation).Virtually every
state has passed legislation allowing students, with
appropriate consent, to carry their epinephrine. But
these laws vary in terms of whether this permission
extends to school activities outside of the school
building.
If school personnel will be administering emergency
medication, then it will be kept either in the classroom,
with an adult (usually a teacher) and carried throughout the day, or in the school office. Regardless of the
location, the emergency medication must be close
and easily accessible. The personnel administering
the medication must be trained to recognize signs and
symptoms of an acute allergic reaction/anaphylaxis,
and must know the proper use of epinephrine autoinjectors. Getting the parents’ input is also important.
*IM preferred over SC
*May repeat in 5-10 minutes if needed
Antihistamine: Diphenhydramine (Benadryl) 1-2
mg/kg orally (maximum dose= 50 mg)
Other:
Albuterol MDI 2 puffs; repeat every 20 minutes x 3 if
difficulty breathing, chest tightness, wheezing, and/or
cough is present
As consistent with many 5-year-old children, Aiden
was not yet ready to self-administer and/or keep track
of the epinephrine injector at school. Therefore, the
best choice for Aiden was to keep the injector in the
classroom. When he changes rooms, and when he
goes to lunch and plays outside or in the gym, the
auto-injector is easily accessible. The teacher is well
educated on food allergies and has demonstrated
proper technique of the epinephrine auto-injector.
There is no certain age in which a child can selfadminister the injection. Most children can use it properly and responsibly in middle-school, but it is highly
variable and dependent on many factors.
For Aiden, his plan of care includes:
(1) Epinephrine via auto-injector (EpiPen®), 0.30 mg
IM to the outer thigh (may repeat in 5 to 10 minutes if needed)
(2) Diphenhydramine (Benadryl) 12.5 mg/5ml; 10 ml
(3) Albuterol (ProAir) MDI 2 puffs and may repeat
every 20 minutes x 3 if he is having difficulty
breathing, has chest tightness, wheezing, and/or
cough
Action
If the child is exhibiting any signs of anaphylaxis do not
hesitate to give epinephrine and call 911!
Notify school personnel trained in CPR/first aid
Notify parent(s)
4.
Where should you keep the epinephrine autoinjector and who should administer it?
The location depends on who is going to administer
the injection. If the student is going to self-administer
the epinephrine, then the student must be responsible
enough to be in possession of the medication during
the school day, field trips, and all extracurricular activities. Obtaining parental input is important to determine
if the child can do this. In addition to being responsible
and having the skills to administer the injection, the
child’s emotional maturity needs to be considered.
How likely is it the child will panic during an emergency and be too scared to self-administer the injection, or do it incorrectly? The parents can provide
Epinephrine Auto-injector Clinical Pearls
Using a demonstrator, teach children, parents, and school
personnel how to use the auto-injectors. Have them return
the demonstration so they feel comfortable with the device. Ask hypothetical questions to children to assess their
level of understanding regarding emergencies, epinephrine use, and to assess their emotional readiness to handle emergencies.
Examples of questions include:
●
If you were outside playing at school and had just
eaten lunch, and you started itching, your throat was
getting tight and you were having trouble breathing,
what would you do?
●
What do you think made you feel this way?
●
Would you be nervous about giving yourself a shot (or
someone else giving it to you)?
(Continued on page 12)
FHEA News
Page 7
(Aphthous Stomatitis: Continued from page 4)
should be used after meticulous PerioGard oral hygienes.
Advise the patient to apply about a 1/4" ribbon to the lesion.
Instruct the patient to dab it on the lesion just enough to get
off the finger and onto the lesion; the product is pregnancy
risk factor category C, as are all topical corticosteroids.
Another economical remedy that is an excellent over-thecounter product and should be kept in any dental/medical
office is Debacterol® manufactured by EPIEN Medical, Inc.
This is a cauterization product that contains 50% sulfonated
phenolics, 30% sulfuric acid, and water. This product gives
the patient instant relief complete resolution of the area in 3
to 5 days. Continued debridement with PerioGard prior to
use of this product is recommended. The patient can purchase Debacterol®, but in the majority of minor or even
some major aphthae, only one treatment is needed. When
using this product, it is critical that a proper diagnosis be
made to ensure that you are treating an aphthous ulcer and
not a vesicular lesion such as herpes simplex type 1 or 2
(Rhodus, 1998).
In severe or persistent cases, other immunomodulators,
including thalidomide in variable doses (50 to 300 mg/day)
have shown efficacy; however, thalidomide has an X pregnancy risk factor and should never be used in females. Thalidomide (Thalomid) is a known teratogen; effective contraception must be used for at least 4 weeks before initiating
therapy, during therapy, and for 4 weeks following discontinuation of thalidomide for women of childbearing potential.
Educational Travel
Update on Events for 2011
By Marc W. Comstock, CEO
Fitzgerald Health Education Associates, Inc.
Upcoming Course Location
Sheraton Maui Resort and Spa,
Lahaina, HI
March 15 and 16, 2011
8:00 a.m. to 1:00 p.m.
Due to the overwhelming success of the Pharmacology
Update in Maui in March of this year, FHEA is offering the
2011 version of this seminar on Maui’s Ka’anapali beach
at the Sheraton Maui Resort & Spa. Be sure to book your
air and hotel reservations early as this is a very busy season in Hawaii!
Featuring:
●
The latest in treatment options
●
In-depth pharmacologic information on clinical conditions you encounter in practice
There are several “Magic Mouthwash” recipes available.
The Prescribers Newsletter provides a number of the more
common mixtures. Personally, I vary these depending on
the severity of the lesion and anticipated patient compliance. Avoid tetracycline use when treating pregnant
women and children. The first mixture listed below is more
palatable and tends to have greater patient compliance. A
pharmacist can also flavor the mix to mask some of the
taste and smell if the patient finds it offensive.
Magic Mouthwash Recipes
Option 1:
Ingredients
Amount
Diphenhydramine (Benadryl)
12.5mg/mL
240 ml
Hydrocortisone
60 mg
Nystatin Powder
6 million units
Tetracycline
1.5 g
Maalox or Mylanta
80 ml
Sig: Swish and spit 5 ml QID
Option 2:
Ingredients
Amount
Viscous lidocaine 2%
80 ml
Mylanta or Maalox
(magnesium, aluminum hydroxide,
simethicone)
Diphenhydramine 12.5 mg/5 mL
80 ml
80 ml
Nystatin suspension
80 ml
Prednisolone 15 mg/5ml
80 ml
Distilled water
80 ml
Sig: Swish, gargle and swallow to 10 ml Q6H
Option 3:
(A great mouth rinse for oncology patients)
Ingredients
Amount
Diphenhydramine 12.5 mg/5 mL
1 part
Viscous lidocaine 2%
1 part
Maalox or Mylanta
1 part
Sig: Swish and swallow 5 mL no more than QID.
Click here for more
information
(Continued on page 8)
FHEA News
Page 8
(Aphthous Stomatitis: Continued from page 7)
A topical corticosteroid suspension recipe is as follows:
●
Triamcinolone acetonide 0.1% aqueous suspension,
Disp 200 ml, Sig 5 ml oral rinse and expectorate after
meals and at bedtime. Do not eat or drink for 1 hour
after using. (Directions to the Pharmacist: Injectable
triamcinolone QS into water for irrigation, add 5 ml of
ethanol to increase solubility) May alter suspension to
include viscous lidocaine as a topical anesthetic.
Note: The most common complication/side effect of
long-term topical triamcinolone use is oral candidiasis.
In these cases, an antifungal such as nystatin can be
used in the topical triamcinolone suspension
(replacing the water).
When the aforementioned therapies are not sufficient,
consultation with an oral-maxillofacial surgeon should be
considered. Additional therapeutic options include a prednisone burst (40 mg q.d. in the morning 30 minutes after
arising for 5 days, then 20 mg q.o.d. also 30 minutes after
arising for an additional 1 to 2 weeks), and dapsone, colchicine, and azathioprine (Imuran). Evaluate for signs of
secondary infection around the initial lesion on the
nonkeratinized tissue.
If these regimens do not bring considerable relief to the
patient then inquiry should be made about family history of
systemic lupus erythematosus (SLE), inflammatory bowel
disease (IBD), or Behçet disease.
The following labs should then be considered: Complete
blood count, rapid plasma reagin test, antinuclear antibody,
Tzanck stain (herpes virus), celiac disease serology,
evaluation of HIV status and micronutrient deficiency test
focused on vitamins B6 and B12, serum iron and folate.
References
Khandwala A, Van Inwegen RG, Charney MR, et al., “5% Amlexanox Oral Paste, A New Treatment for Recurrent Minor Aphthous
Ulcers: II. Pharmacokinetics and Demonstration of Clinical
Safety,” Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1997,
83(2):231-8.
Porter SR, Scully Cbe C. Aphthous ulcers (recurrent). Clin Evid
(Online). 2007;2007.
Product information for First Mouthwash BLM. Cutis Pharmaceutical. Woburn, MA 01801. February 2008.
Regezi RA, Sciubba JJ, Jordon, CK: Oral Pathology, Clinical
Pathologic Correlations, ppg. 36-38, 2008
Rhodus, N.L, Quintessence Int. 1998 Dec; 29(12):769-73.
The Erie St. Clair Palliative Care Management Tool. January
2007. http://www.ccacont.ca/Upload/esc/General/Palliative_Care_Managment_Tool_v3.
2.pdf (accessed October 11, 2009).
Vincent SD, Lilly GE: Clinical, historic and therapeutic features of
aphthous stomatitis. Oral Surg Oral Med Oral Path, 74:79-86,
1992. “Magic Mouthwash Recipes,” The Prescribers Newsletter
(July 2007; Vol: 14(7):230703).
Study with a Master
Dr. Margaret A. Fitzgerald's Speaker School
Fitzgerald Health Education Associates Conference Center
85 Flagship Dr, North Andover, MA 01845
March 3–4, 2011
Earn 14 Contact Hours!
If you have ever wanted to share your practice expertise by speaking to other providers, or if you just
want to improve your "platform skills," this is the
seminar for you! This two-day intensive workshop
will be led by Dr. Margaret Fitzgerald, one of the
most experienced, well-known, and skilled NP
speakers in the country. With more than one thousand presentations to her credit, she has been recognized by the NP community for her dynamic speaking abilities.
Dr. Margaret Fitzgerald also earned the coveted Certified Speaking Professional (CSP) designation from the National Speakers
Association.
Dr. Margaret A. Fitzgerald's Speaker School will make extensive
use of recorded practice presentations prepared by participants,
recorded in the FHEA studio, and critiqued by instructors and
peers. Hands-on presentation preparation and slide development
techniques will be covered. Also learn how to improve your
"speaking voice." The workshop is limited to twenty participants. A
personal laptop equipped with Microsoft PowerPoint will be required.
Click here for more information
FHEA News
Page 9
5 ¾ Day Advanced Pathophysiology for NPs and Advanced Practice Clinicians
Manhattan, NY
July 18-23, 2011
More Information Here
Presented by:
Sally K. Miller, PhD, ACNP-BC, ANP-BC, FNP-BC, GNP-BC, CNE, FAANP
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP
Earn 45 Contact Hours!





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Presented by highly acclaimed clinician-educators who currently maintain clinical practice, thus bringing clinical relevance to the
classroom in addition to their knowledge and teaching skills in pathophysiology.
FHEA instructors consistently rank at the top of speaker ratings at national conferences.
Both the course material and testing material are kept up-to-date on subject matter. The electronic components of this program
are updated as needed to reflect the current state of practice.
Test items are professionally developed and are subject to rigorous validity and reliability review.
Meets the needs of a geographically dispersed student population using on-line lectures with full audio-visual content.
On-line version allows students to proceed at their own pace and earn contact hours as they complete each module.
Topics Presented by Sally K. Miller
Unit I Cellular Pathophysiology
I.
Cell structure and function
II. Mechanisms of cellular transport
III. Membrane and action potentials
Unit III Mechanisms of Cell Trauma
I.
Reversible injury
II. Irreversible injury
III. Hypoxia
IV. Physical trauma
V. Infectious trauma
VI. Chemical trauma
Unit IV Cellular Response to Injury
I.
Adaptation
II. Inflammation
Unit V Pathophysiology of the Hematologic System
I.
Hematopoiesis
II. Microcytic anemias
III. Macrocytic anemias
IV. Hemoglobinopathies
V. Primary hemostasis
VI. Secondary hemostasis
Unit VI Pathophysiology of the Nervous System
I.
Synaptic transmission
II. Neurotransmitter
III. Post-synaptic processes
IV. Selected disorders
Unit VIII Pathophysiology of the Cardiovascular System
I.
Cardiac action potential
II. Contractile tissue
III. Non-contractile tissue
IV. Cardiac conduction
V. Contractile fibers and the sarcomere
VI. Electromechanical coupling
VII. Cardiac muscle tasks
VIII. Selected disorders
IX. Lipid synthesis and transport
X. Selected dyslipidemias
Unit IX Pathophysiology of Endocrine Disease
I.
Types of hormones
II. Hormone receptors
III. Feedback mechanisms of secretion
IV. Maintenance of plasma glucose concentration
V. Maintenance of thyroid hormone concentration
VI. Maintenance of adrenal cortex/
medullary hormone concentration
VII. Selected disorders
Unit X Pathophysiology of Pulmonary Disease
I.
Anatomy and physiology of airways
II. Vascular and lymphatic anatomy
III. Autonomic nervous system regulation
IV. Compliance and recoil
V. Airflow and resistance
VI. Ventilation and perfusion
VII. Selected obstructive/restrictive diseases
Unit XI - Pathophysiology of Renal Disease
I.
Anatomy and physiology of the nephron
II. Regulation of blood pressure, calcium, and
erythropoietin
III. Regulation of renal function; tubuglomerular
feedback
IV. Cortical and medullary flow
V. Acute renal failure
VI. Chronic kidney disease
VII. Electrolyte imbalance
VIII. Regulation of acid/base balance
Unit XII - Pathophysiology of Digestive System
Disease
I.
Anatomy and musculature of the gastrointestinal track
II. Neural control systems
III. Chemical control systems
IV. Myogenic control systems
V. Oropharyngeal/esophageal motility
VI. Gastric motility and control
VII. Gastric acid secretion
VIII. Selected disease states
Topics Presented by Margaret A. Fitzgerald
Unit VII - Pathophysiology in Reproduction
I.
Factors influencing impaired female fertility
II. Factors influencing impaired male infertility
III. Pathophysiologic problems encountered in
pregnancy: Recurrent pregnancy loss, pregnancy induced hypertension, placental disorders, others
Click here for more information about this course
FHEA News
Page 10
5 ¾ Day Clinical Pharmacology for NPs and Advanced
Practice Clinicians
Presented by:
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP and
Sally K. Miller, PhD, ACNP-BC, ANP-BC, FNP-BC, GNP-BC, CNE, FAANP
Presented live in the following cities:
Topics covered in this course:
Atlanta, GA— October 27 to November 1, 2010
Manhattan, NY—February 14 to 19, 2011

National legal and practice issues.
Dallas, TX— October 25 to 30, 2011

Principles of safe prescribing: Pharmacokinetics,
pharmacodynamics, pharmacogenomics, drug interactions.

Prescribing in special populations: Pregnancy, lactation, children, older adults.

Hormonal contraception and post menopausal hormone therapy.

Pharmacologic management in type 1 and type 2
DM: Oral agents, insulin and non-insulin preparations.

Principles of antimicrobial therapy: Intervention in
bacterial infection.

Drugs that affect the respiratory system: Beta2
agonists, methylxanthines, anticholinergics, mast
cell stabilizers, inhaled and systemic corticosteroids, leukotriene modifiers, over-the-counter cough
and cold medications.

Evaluation and intervention in common thyroid disorders.

Assessment and intervention in common anemias.

Drugs that affect the cardiovascular systems: Antihypertensives, antianginals, dysrhythmics, medications used in the management of heart failure.

Pharmacologic treatment of lipid abnormalities and
drugs that affect clotting.

Drugs that affect the GI system: H2 receptor antagonists, proton pump inhibitors, antacids, prokinetics, antidiarrheals, including over-the-counter
medications.

Management of viral, fungal and protozoal infection.

Management of pain; opioids, NSAIDs and others
including over-the-counter medications.

Management of eye, ear, and skin disorders.
Can’t attend a live course?
This program is also available on-line*
Click here for more information
This course addresses the growing need for a thorough
course in the principles of pharmacotherapeutics. Prescribing has become a major part of the role of advanced practice nurses while at the same time, prescribing has become
more complex and polypharmacy is more prevalent with the
possibility of adverse interactions. Thus, a course of this
caliber is critical to the preparation of advanced practice
nurses.
The course is taught in an intensive format by two of the
nation’s most respected NP educators. The instructors have
taught this curriculum at several universities most recently at
Pennsylvania State, Pace University, Neumann College,
Georgia College and State University. In addition, recorded
lectures of this course form the basis for other university NP
pharmacology courses. The material constitutes the equivalent of a three credit university course in pharmacology.
Pharmacology contact hours: 45.0**
Code: PCON — standard $799; advance: $7501;
early bird: $6992
Note 1: Registrations received or postmarked between two months
and two weeks prior to the start of the course qualify for this rate.
Note 2: Registrations received or postmarked more than two months
prior to the start date of the course qualify for this rate.
Upon receipt of your enrollment and full payment, you will receive a
confirmation of registration and directions to the course. A fee of
$50.00 will be charged for cancellation. No refunds will be granted
within two weeks of the starting date. All cancellations and changes
must be received in writing.
* Contact hours differ from the live course. See www.fhea.biz for
details.
**Because states’ requirements vary, it is important that you contact
your Board for details regarding educational requirements for
prescriptive authority.
For more information visit: www.fhea.biz
FHEA News
Page 11
(Continued from page 5)
When responding to this question, remember that test questions are designed to have one best, though perhaps not perfect, answer. In clinical practice, you would likely gather more
information than is given here. During the certification examination you have to decide on the best response given the
information presented while applying sound clinical judgment.
Here are the clinical points as they relate to this particular
question.
Consider the following:

As inflammation and purulent exudate forms in the middle ear, a small space rich with pain receptors, otalgia is
an expected finding in AOM. This usually resolves after 2
to 3 days of antimicrobial therapy.

Tympanic membrane immobility is a cardinal sign of
AOM that in spite of antimicrobial therapy does not resolve for a number of weeks. Patient report of otalgia is
also needed to make the AOM diagnosis.
The next part is the statement that poses the question to be
answered.

Since no chronic health problems are mentioned, assume Sam is a young adult who is typically in good
health.

Acute otitis media (AOM) is common episodic illness usually caused by S. pneumoniae, H. influenzae, M. catarrhalis or respiratory virus.


One of the first-line antimicrobials for AOM treatment is
amoxicillin. When given in an adequate dose, this antibiotic is effective against S. pneumoniae, and non-betalactamase producing H. influenzae and M. catarrhalis.
Nearly all M. catarrhalis and about 30% of H. influenzae
produce beta-lactamase, rendering amoxicillin ineffective.
Clavulanate is a beta-lactamase inhibitor and when given
in conjunction with amoxicillin is an effective treatment
option when AOM fails to respond to amoxicillin alone.
A) Advise Sam to discontinue the current antimicrobial and
start course of amoxicillin with clavulanate.
12th ANNUAL
B) Perform tympanocentesis and send a sample of the exudate for culture and sensitivity.
Iowa Nurse Practitioner Society Conference
presented by:
Iowa Nurse Practitioner Society
Location:
The Marriott at West Des Moines Hotel
1250 Jordan Creek Drive
Des Moines, IA 50266
Dates:
November 3-5, 2010
Purpose:
This CEU program is designed to provide ARNPs with the latest
information related to a variety of practice settings.
Objectives:
1. Understand current and evolving information in health care
2. Identify concepts relevant to Individual practice
3. Interact with Iowa NPs to promote relationship building
Your next best action is to:


This is an action-oriented question, directing you to consider Sam’s care and chief complaint.
Choosing this response infers amoxicillin treatment failure. However, AOM antimicrobial treatment failure is usually defined as persistent otalgia with fever after 72 hours
of therapy. Sam has taken less than 2 days of therapy;
too short an interval to assign continued symptoms to
ineffective antimicrobial therapy.
AOM antimicrobial therapy is based on choosing an
agent with activity against the most likely organisms,
bearing in mind the most common resistant pathogens.
Tympanocentesis is indicated only with treatment failure
after 10 to 21 days of antimicrobial therapy with a second-line agent, with the goal of detecting a significantly
resistant organism; at that point, culture and sensitivity of
middle ear exudate would be appropriate. With less than
2 days of treatment, tympanocentesis is not indicated.
C) Have Sam return in 24 hours for reevaluation.

Certainly, if Sam’s condition worsens in the next day,
reevaluation is prudent; however, choosing this option
ignores Sam’s complaint of pain.
D) Recommend that Sam take ibuprofen for the next 2 to 3
days.

Choosing option D infers that treating Sam’s pain is the
most appropriate intervention. This is the best response
and therefore the correct answer.
The highlights of the conference include, exciting PreConference Boot Camps in 3 specialty areas. A variety of breakout sessions will appeal to all specialties.
The Fitzgerald Nurse Practitioner Certification Exam Review and Advanced Practice Update has helped more than
55,000 NPs nationwide achieve certification and improve
their clinical assessment skills since its inception in 1988.
Fitzgerald Health Education Associates is the nation's
leading provider of certification preparation.
Registration is available online at: http://www.iowanpsociety.org
Click here for more information
Keynote Speaker: Wendy Wright will be presenting updates on
drug changes and malpractice.
Page 12
FHEA News
(Getting Ready for School: Continued from page 6)
●
Where is your epinephrine shot now?
●
Show me how you would use it if you would need it
(use a demonstrator).
Check the expiration date; often the child’s epinephrine
auto-injector has expired. The expiration date is usually
one year from purchase. Do not change the type of autoinjector without making sure the patient, parent(s), and/or
school personnel know how to use the different brand.
These devices differ a bit. If you demonstrated how to use
one type of injector, and the child receives a different type
at the pharmacy, the child, family, and caregivers might
not know how to use it. With the recent release of the generic epinephrine auto-injector, a pharmacy could give the
patient a different version than was written on the prescription.
Being Proactive: Clinical Pearls for Parents of a Child
with Food Allergy
●
Communicate to teachers and other school personnel
that your child has a food allergy and the emergency
plan.
●
Encourage your child to take on more age-appropriate
responsibility for their safety.
●
Have your child wear a medical alert bracelet.
●
Encourage epinephrine auto-injectors be kept in
classrooms, the school office, and the cafeteria.
●
Consider prescribing two-pack epinephrine autoinjectors in order to have an additional injection in
case it is needed and/or to have the second injector at
home. The two-pack prescription is usually available
for the same co-pay as the single auto-injector. Investigate coverage for a two-pack, dispense #2 prescription for four auto-injectors if a child goes to multiple
locations. As always, consider the child’s risk and individualize the plan.
●
●
Purchase a hard plastic, puncture-proof case for the
auto-injector to avoid accidental exposure and injection. The Food Allergy & Anaphylaxis Network (FAAN)
(available at: www.foodallergy.org) provides resources for the many styles available on the market.
Utilize resources, such as the Food Allergy and Anaphylaxis Network.
Food Allergy Facts
The prevalence of food allergies as perceived by the public is 12to 13%, with some studies reporting as high as
25%. The prevalence as confirmed by healthcare providers in children is 6%. Eight foods account for 90% of all
food allergic reactions in the U.S: milk, eggs, peanuts,
tree nuts, wheat, soy, fish, and shellfish. Peanuts, tree
nuts, fish and shellfish are responsible for the majority of
severe allergic reactions/anaphylaxis.
Fatal Food-Induced Anaphylaxis
Prevalence
100 to 200 deaths per year in the
United States
Risk factors
Symptom denial
Delayed epinephrine administration
Underlying asthma
Previous severe reaction
Adolescents
History
Ingestion of a known allergen
Key foods
Peanut and tree nuts (approximately
90% fatalities), fish, and shellfish
Location
Most occurred away from home
Clinical features
Respiratory symptoms were prominent
Cutaneous symptoms may be absent
Biphasic reaction may contribute to
the problem
For additional resources and examples of food allergy
action plans, visit the links below:
http://www.foodallergy.org/files/FAAP.pdf
http://www.aaaai.org/members/resources/anaphylaxis_too
lkit/action_plan.pdf
References:
Chapman, J., Bernstein, L. et al. Food Allergy: A practice parameter. Ann Allergy Asthma Immunol. 2006;2006: Vol 96. Accessed on
July 1, 2010 from http://allergyparameters.org/file_depot/010000000/3000040000/30326/folder/73825/2006%20Food%20Allergy
Food allergy education for health professionals. Food Allergy &
Anaphylaxis Network. Accessed June 30, 2010 from
http://www.foodallergy.org/section/for-health-professionals1
Lieberman, P. & Kemp, S., et al. The diagnosis and management
of anaphylaxis: An updated practice parameter. Joint Task Force
on Practice Parameters. J Allergy Clin Immunol.2005;115:S483:S23. Accessed July 1, 2010 from
http://www.aaaai.org/professionals/resources/pdf/anaphylaxis_200
5.pdf.
Additional information available at:
Adrenaclick website: www.Adrenaclick.com, accessed July 2, 2010
EpiPen website: www.EpiPen.com, accessed July 2, 2010
Twinject website: www.TwinJect.com, accessed July 2, 2010
Fitzgerald Health
Education Associates, Inc.
FHEA News
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North Andover, MA
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Editorial Staff
Dr. Margaret Fitzgerald’s Upcoming Speaking Engagements
Date
Managing Editor:
Marc Comstock
Editor:
Emily Paquin
September 9, 2010
Click here for more information
September 15, 2010
Nurse Practitioner Certification Exam
Review and Advanced Practice Update
DoubleTree Atlanta Buckhead
3342 Peachtree Road NE
Atlanta, GA
Click here for more information
September 18, 2010
8th Annual Central Georgia United
Advanced Practice Registered Nurses
Fall Seminar
Hanger One—Museum of Aviation
Hwy. 247 & Russell Pkwy.
Warner Robins, GA
Click here for more information
October 1, 2010
33rd Annual Nurse Practitioners of
Oregon Education Conference
Salishan Spa & Golf Resort
7760 Highway 101 North
Gleneden Beach, OR
Click here for more information
October 27, 2010
Clinical Pharmacology for NPs &
Advanced Practice Clinicians
DoubleTree Atlanta Buckhead
3342 Peachtree Road NE
Atlanta, GA
Click here for more information
November 11, 2010
Nurse Practitioner Certification Exam
Review and Advanced Practice Update
InterContinental Dallas
15201 Dallas Parkway
Addison, TX
Click here for more information
December 1, 2010
Nurse Practitioner Certification Exam
Review and Advanced Practice Update
Sacramento, CA
Click here for more information
Contributors
Margaret A. Fitzgerald
DNP, FNP-BC, NP-C,
FAANP, CSP
Marie L. Bosco, BSN, RNC,
IBCLC
Open Forum
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news, comments and ideas
from its readers!
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