Mastering the
Differential Diagnosis for Nurse Practitioner Students
Stephanie
C. Davis & Rosanne H. Pruitt
Abstract
One of the most difficult tasks for a new nurse practitioner (NP) student
is the transition from nursing diagnoses to the level of advanced diagnostic
reasoning required for advanced practice nursing. Establishing a differential diagnosis based
on the analysis and synthesis of assessment data as a critical component of NP
practice is addressed in the American Association of Colleges of Nursing (AACN)
The Essentials of Doctoral
Education for Advanced Nursing Practice and The Essentials of Master’s
Education in Nursing.
The authors have utilized a strategy to assist in this transition over
the past three years in advanced nursing practice and specialty classes
receiving favorable responses from NP student audiences. The purpose of this paper is to demonstrate a
method developed and utilized by the authors to aid NP students in mastering
the differential diagnosis.
O |
ne of the most
difficult tasks for a new nurse practitioner (NP) student is the transition
from nursing diagnoses to the level of advanced diagnostic reasoning required
for advanced practice nursing. Students
are often initially overwhelmed when they realize they are responsible for a
medical diagnosis that includes consideration of all possible alternatives. The
associated skill level with the development of the differential diagnosis and
ultimately the correct final diagnosis affects quality patient outcomes. Coupled with this quandary is the dilemma of
ordering appropriate diagnostic tests that will help establish the correct
final diagnosis within reimbursement guidelines.
Establishing a differential diagnosis based on the analysis and synthesis
of assessment data as a critical component of NP practice is addressed in the
American Association of Colleges of Nursing (AACN) The Essentials of Doctoral Education for
Advanced Nursing Practice (2006) and The Essentials of Master’s
Education in Nursing (2011). The National Organization of NP Faculties (NONPF)
NP Core Competencies (2011/2012) include critical analysis of data and evidence. The National Task Force (NTF) now requires
validation of differential diagnoses and disease management as a component of
the NP education program on the certification application. The test plans for
the two largest national NP certifiers, American Academy of NPs (AANP) and
American Nurses Credentialing Center (ANCC), require successful application of
advanced diagnostic reasoning.
Utilizing a guide within each system to determine feasible alternative
diagnoses promotes the level of critical thinking necessary to move toward
advanced diagnostic reasoning. The authors have utilized a strategy to assist
in this transition over the past three years in advanced nursing practice and
specialty classes receiving favorable responses from NP student audiences. Presentation at the
NONPF conference (2011) yielded positive NP faculty response. The purpose of
this paper is to demonstrate a method developed and utilized by the authors to
aid NP students in mastering the differential diagnosis.
Case Presentation
NP students work
along-side preceptors in order to develop and hone their skills before
graduating and taking on the responsibility of caring for patients. A critical
component of this preceptored experience is the case presentation. NP students typically assess the patient, physically
examine the patient, and then develop differential diagnoses to guide the next
steps of the visit. The case presentation allows the inexperienced NP student
to get a more experienced clinician’s opinion about the patient (Coralli, 2006).
According to Coralli, components of a good case presentation include: an
introduction, the history of present illness, a physical examination, potential
diagnostic studies, differential diagnoses, a management plan, and summary of
the findings. Differential diagnoses are essential to determining the next
steps of the visit (i.e. ordering labs or other diagnostic testing, treatment
options). Enhancing NP students’ ability to use diagnostic reasoning to define
the potential differential diagnoses is often a difficult task for NP faculty.
For this reason, the authors have developed the G-INVESTMENT acronym.
G-INVESTMENT
G-
Genetic I-Inflammatory/ischemic/infection/idiopathic N-Neurological V-Vascular E-Endocrine S-
Systemic (autoimmune) T-Trauma M-Metabolic E-Environmental N-Neoplasm T-Treatment
G-INVESTMENT
is an acronym developed and utilized by the authors on a regular basis to guide
NP students in the consideration of all potential etiologies for a symptom or
chief concern expressed by a patient. The authors give each student a laminated
card with the acronym to use first in classroom and simulated settings then in
clinical practice.
The following is a deconstruction
of the acronym with possible etiologies for the symptom headache. Appendix A depicts the model for three different symptoms.
This sampling is not meant to be in all inclusive. There are potentially many
more causes not listed here. Note that some etiologies may fall in more than
one category.
The letter “G” represents possible genetic
causes of the symptomatology.
G: Glaucoma, familial migraines, poor eyesight
I: Flu, encephalitis, meningitis, strep, sinusitis
“I”
represents the etiologies of inflammatory responses, ischemia, infections, and
idiopathic (no known) causes.
“N” represents neurological etiologies of
headaches in this example.
N: Seizure, Meniere’s disease
V: Hypertension, stroke, carotid stenosis,
atherosclerosis, aneurysm, atrial fibrillation, vascular migraine
The
letter “V” represents vascular etiologies.
The first “E” in G-INVESTMENT represents
possible endocrine causes of headaches.
E: Hypothyroidism, anemia, hypoglycemia
The letter “S” represents systemic, or
autoimmune, etiologies.
S: Lupus, multiple sclerosis, Hashimoto’s thyroiditis
The
first “T” in the acronym represents traumatic etiologies.
T: lumbar puncture, head injury, surgery, skull
fracture, motor vehicle accident (whiplash)
The
letter “M” represents metabolic causes for the symptom headache.
M: Diabetes mellitus, hypertension, hormonal changes
E: Intercourse (coital or orgasmic headaches), allergies
(smoke, perfumes)
The
second “E” in G-INVESTMENT represents environmental etiology.
The
second letter “N” in the acronym represents neoplastic causes.
N: Brain tumor,
oral tumors, cholesteatoma, metastasis
T: Drug
reactions (nitroglycerine), drug toxicity (digoxin), oral contraceptives, surgery,
traction
The
final letter, the second “T”, represents treatment etiologies for headaches.
Strategies to Integrate Differential
Diagnoses into Class and Clinical
Several strategies have been used to assist in the transition from
professional nurse to nurse practitioner provider over the past three years in
advanced nursing practice and specialty classes receiving favorable responses
from NP student audiences. On the first day of Advanced Assessment class,
G-INVESTMENT, is introduced to the students. As mentioned earlier, each student
is given a laminated copy of the mnemonic to use for class and keep with them
in the clinical setting. G-INVESTMENT is introduced with a consistent graphic
organizer to assist students in thinking through each component. Several classroom activities have been used
to enhance student participation.
Group assignments: The class is evenly divided into several groups with each group assigned
several letters of G- INVESTMENT so that all areas are covered for a particular
symptom. This approach has yielded the largest number of diagnoses as students
are informally competing against their peers. Students are asked to justify
their choices if the symptom is not a primary or obvious characteristic.
Further discussion often occurs related to a particular diagnosis and the
incidence and prevalence of the presenting symptom. Students are encouraged to
use their texts and electronic resources during these informal discussions.
Students or faculty members who have cared for individuals with the diagnosis
are encouraged to contribute to the discussion.
Pair and share is a variation of the group assignment in which two students will be
assigned one area of the symptom to discuss and share with the class. Abdominal
pain, for example, offers an opportunity to review anatomy and the pain
associated with different organs in the abdominal region as well as the
relationship of pain to eating and other bodily functions.
Class discussion is the
most frequent application of G-INVESTMENT in the advanced assessment course. A
symptom is selected and the class generates the list which serves as content
review and application of the system covered in class. Students are strongly
encouraged to read assignments and prepare prior to class so that they can be
more engaged in these discussions and problem based learning.
Preceptor
involvement: Students in the clinical management courses are
encouraged to share G-INVESTMENT with their preceptors. Students and their
preceptors may compare and contrast other mnemonics with a certain
condition. These comparisons have been
favorable toward G-INVESTMENT. The authors have engaged the student and
preceptor in discussion of the utilization of G-INVESTMENT when time has
allowed during direct observation clinical site supervision.
Examination: Students are alerted to inclusion of the content on the midterm and
final evaluation to emphasize importance of integration of the differential
diagnosis into learning.
Simulation: G-INVESTMENT is a component of the case presentation with a standardized
patient or a focused physical examination on a human patient simulator.
Students also use G-INVESTMENT to assist with the differential diagnoses
required with scenarios utilizing Harvey, the heart and lung simulator.
Clinical Practice
Logs: Each student in Advanced Assessment is expected to
submit a focused examination in writing, including G-INVESTMENT, to demonstrate
critical thinking processes used to acquire the final diagnosis. Students are
also expected to describe how the diagnostic testing and treatment plans were
related to the differential diagnoses.
Peer Grading: Since students take Advanced Assessment prior to their clinical
management courses, the initial history and physical is performed on a friend
or family member including the systems covered by that point in the semester.
As novice NP students, they are instructed in advance to refer any patients
with abnormalities to the patient’s primary care provider (PCP). Following the
midterm examination student work is randomly assigned to a classmate as a peer
evaluator. Random assignment is used to minimize the possibility of students
favorably grading the paper of a friend or exchanging papers with a mutual
expectation to grade favorably.. Graded papers, which include student author’s
name and student evaluator’s name, are then submitted to faculty for a final
review. A second assignment is required later in the semester to address the
remaining body systems. This course utilizes a reverse class format with some
content presented on BlackBoard via Mediasite lecture capture to allow for more
discussion of integration of content and hands on practice.
CONCLUSION
Novice NP students
need assistance as they made the critical transition from professional nurse to
NP provider. Helping students internalize memory aids to thoroughly address a
presenting system, assists them in avoiding potentially harmful shortcuts in
the diagnostic process as they progress through their program and into the role
of NP. The G-Investment acronym can be
integrated into more advanced management courses as students evaluate the need
for diagnostic tests for certain complaints. As a recent graduate quipped,
moving from the emergency room to primary care, you cannot order a scan on
every patient in primary care, developing competence and confidence in
diagnostic reasoning is essential. Application of G-INVESTMENT can assist that
transition. A G(ood) INVESTMENT of time and energy.
About
the Authors:
Stephanie C. Davis, PhD, RN, FNP-BC is Associate Professor and Graduate Program
Coordinator at Clemson University. Contact Dr. Davis at stephad@clemson.edu;
Rosanne H. Pruitt, PhD, RN, FNP-BC is Associate Dean, Professor and Director of
School of Nursing at Clemson University. Contact Dr. Pruitt at prosan@clemson.edu
Keywords: Diagnoses, differential, nurse
practitioner, students
References
American Association of Colleges of Nursing ([AACN], 2011). The Essentials of Master’s
Education in Nursing. Retrieved 7/19/2012. Available: http://www.aacn.nche.edu/education-resources/MastersEssentials11.pdf
American Association of Colleges of Nursing ([AACN], 2006). The Essentials
of Doctoral Education for Advanced Nursing Practice. Retrieved 7/19/2012.
Available: http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf
Coralli, H.C., (2006) Effective case
presentations—An important clinical skill
for
nurse practitioners Journal of the
American Academy of Nurse Practitioners; 2006;18(5),
216-220,
National
Organization of Nurse Practitioner Faculties ([NONPF], 2011/Revised 2012). Nurse
Practitioner Core Competencies. Retrieved 8/30/2012. Available:
http://www.nonpf.com/associations/10789/files/NPCoreCompetenciesFinal2012.pdf