This presentation discusses the differences between family/primary care/acute care nurse practitioners. It will help readers understand more about the definition of nurse practitioner, independent practices and skill training among nurse practitioners. The novice nurse practitioners should know the above information and LACE to avoid legal ramifications.

1. Discussing LACE, the APRN
Scope of Practice and
Differences: Family NP,
Adult-Gerontology Primary
Care and Acute Care NP
RICKY PHAN, DNP, ACNPAG-C, CCRN, TCRN

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3. Objectives
 Define common terms in nursing
 List population-foci nurse practitioner categories.
 Define family nurse practitioner, adult gerontology primary care/ acute care nurse
practitioner.
 Comprehend LACE during credential and privilege
 Differentiate independent practice scope of family nurse practitioner, adult
gerontology primary care/ acute care nurse practitioner.
 List common trained procedures for family nurse practitioner, adult gerontology
primary care/ acute care nurse practitioner.

4. Common terms
 “Nurse practitioner” means an advanced practice registered nurse who meets board
education and certification requirements and possesses additional advanced practice
educational preparation and skills in physical diagnosis, psycho-social assessment,
and management of health-illness needs in primary care, and/or acute care.
 “Primary care” means comprehensive and continuous care provided to patients,
families, and the community. Primary care focuses on basic preventative care, health
promotion, disease prevention, health maintenance, patient education and the
diagnoses and treatment of acute and chronic illnesses in a variety of practice
settings.
 “Acute care” means restorative care provided by the nurse practitioner to patients
with rapidly changing, unstable, chronic, complex acute and critical conditions in a
variety of clinical practice settings.
(California Board of Registered Nursing, 2019)

5. Common terms
 “Clinically competent” means the individual possesses and exercises the degree of learning,
skill, care and experience ordinarily possessed and exercised by a certified nurse practitioner
providing healthcare in the same nurse practitioner category.
 “Category” means the population focused area of practice in which the certified nurse
practitioner provides patient care.
 Categories of nurse practitioners include:
Family/individual across the lifespan
Adult-gerontology, primary care or acute care
Pediatrics, primary care or acute care
Neonatal
Women’s health/gender-related
Psychiatric-Mental Health across the lifespan
(California Board of Registered Nursing, 2019)

6. APRN regulatory model

7. Introduction of FNP, AGPCNP, AGACNP
 Family nurse practitioner: provide primary care to manage the health of urban
families, emphasis of this specialty is on health promotion, disease prevention,
and management of common acute episodic illnesses and chronic health problems
among culturally diverse clients across the life span. Care for individuals, families
and the community is experienced through direct advanced nursing care,
consultation, collaboration, coordination and referral in a variety of community-
based and ambulatory care settings.
 Adult gerontology primary care nurse practitioner: provide primary care to
manage the health of individuals from 12 years of age through old age. The focus
of this specialty is on health promotion, disease prevention, and management of
common acute episodic illnesses and chronic health problems.
(CSULA – AGPCNP, 2016)
(CSULA- FNP, 2016)

8. Introduction of FNP, AGPCNP, AGACNP
 Adult-Gerontology Acute Care Nurse Practitioners (AG ACNP) are to provide
advanced nursing care for adult geriatric patients with acute, critical, and/or
complex chronic health conditions in a variety of acute care settings including
clinics, emergency departments, acute hospital-based settings, intensive/critical care
units, acute and sub-acute care wards, specialty clinics, or any combination of the
above.
 The focus of the ACNP is the provision of restorative, curative, rehabilitative,
palliative, and/or supportive end-of-life care as determined by patient needs. Goals
include patient stabilization for acute and life-threatening conditions, minimizing or
preventing complications, attending to comorbidities, and promoting physical and
psychologic well-being.
(AACN, 2012)
(CSULA – AGACNP, 2016)

9. Consensus model for APRN regulation

10. Relationship between Licensure, Accreditation,
Certification and Education (LACE)
Licensure:
 Board of nursing solely responsible for licensing NP.
 Graduates of accredited graduate programs that prepare graduates with the NP
core, role and population competencies.
 Successful completion of a national certification examination that assesses NP
core, role and population competencies for APRN licensure.
 An NP was licensed when education and certification are congruent.
 A license NPs as independent practitioners with no regulatory requirements for
collaboration, direction or supervision.
 At least one NP representative position on the board and utilize an NP advisory
committee.
(The APRN Consensus Work Group and the APRN Joint Dialogue Group, 2008)

11. Relationship between Licensure, Accreditation,
Certification and Education
Accreditation:
 NP education programs including graduate degree-granting and post-graduate
certificate programs will be accredited, evaluated, and monitored by accrediting
agency.
 The NP core, role core, and population core competencies meet accreditation
standards and process.
(The APRN Consensus Work Group and the APRN Joint Dialogue Group, 2008)

12. Relationship between Licensure, Accreditation,
Certification and Education
Certification:
 Be accredited by a national certification accreditation body.
 Follow the criteria of National Council of State Boards of Nursing.
 Assess the NP core and role competencies across at least one population focus of
practice.
 Enforce congruence (role and population focus) between the education program
and the type of certification examination.
 Provide a mechanism to ensure ongoing competence and maintenance of
certification.
 A mutually agreeable mechanism to ensure communication with boards of nursing
and schools of nursing. (The APRN Consensus Work Group and the APRN Joint Dialogue Group, 2008)

13. Relationship between Licensure, Accreditation,
Certification and Education
Education:
 Follow established educational standards and ensure attainment of the APRN
core, role core and population core competencies.
 Be accredited by a nursing accrediting organization that is recognized by the U.S.
Department of Education (USDE) and/or the Council for Higher Education
Accreditation (CHEA).
 Ensure that graduates of the program are eligible for national certification and
state licensure; and official documentation (e.g., transcript) that specifies the role
and population focus of the graduate.
(The APRN Consensus Work Group and the APRN Joint Dialogue Group, 2008)

14. Population-Focus Care
Family-/Primary-care NP
 Family NP: patients of all ages and families in
all stages of the family life cycle; demonstrate
a commitment to family –centered care and
understand the relevance of the family’s
identified community in the delivery of
family- centered care.
 AG PCNP: adult-gerontology population
which includes adolescents, young adults, and
frail, older adults; provide comprehensive,
chronic, continuous care characterized by a
long term relationship between the patient and
AG PCNP.
 Both: provide primary care services from
wellness to illness, including preventive,
chronic, and acute care.
Acute Care NP
 Adult –gerontology patients adult-
gerontology population which includes
adolescents, young adults, and frail, older
adult with acute, critical, and/or complex
chronic illnesses who may be physiologically
unstable, technologically dependent, and
highly vulnerable for complications.
 Stabilize patients for acute and life-
threatening conditions, minimizing or
preventing complications, attending to
comorbidities, and promoting physical and
psychologic well-being in acute care and
hospital-based settings, including subacute
care, emergency care, and intensive care
settings, the continuum of acute care services
spans the geographic settings of home,
ambulatory care, urgent care, rehabilitative
care, and palliative care.
(Thomas, et al., 2013)
(Thomas, et al., 2016)
(AACN, 2012)

15. Family NP
 Obtains and accurately documents a relevant health history for patients of all ages and in all
phases of the individual and family life cycle.
 Performs and accurately documents appropriate comprehensive or symptom focused physical
examinations on patients of all ages (including developmental and behavioral screening,
physical exam and mental health evaluations).
 Identifies and plans interventions to promote health with families at risk.
 Assesses the impact of an acute and/or chronic illness or common injuries on the family as a
whole and facilitates family decision-making about health.
 Distinguishes between normal and abnormal change across the lifespan and synthesizes data
from a variety of sources to make clinical decisions regarding appropriate management,
consultation, or referral.
 Plans diagnostic strategies and makes appropriate use of diagnostic tools for screening and
prevention, with consideration of the costs, risks, and benefits to individuals.
(Thomas, et al., 2013)

16. Family NP
 Identifies health and psychosocial risk factors and formulates comprehensive differential
diagnoses and manages common acute and chronic physical and mental illnesses across the
lifespan to minimize the development of complications, and promote function and quality of
living.
 Prescribes medications & therapeutic devices with special populations, such as infants and
children, pregnant and lactating women, and older adults.
 Adapts interventions to meet the complex needs of individuals and families arising from
aging, developmental/life transitions, comorbities, psychosocial, and financial issues.
 Assesses and promotes self-care in patients with/without disabilities and applies principles of
self-efficacy/ empowerment in promoting behavior change.
 Plans and orders palliative care and end-of life care, as appropriate.
(Thomas, et al., 2013)

17. Family NP
 Performs primary care procedures.
 Analyzes the impact of aging and age-and disease-related changes in sensory/perceptual
function, cognition, confidence with technology, and health literacy and numeracy on the
ability and readiness to learn and tailor interventions accordingly.
 Demonstrates knowledge of the similarities and differences in roles of various health
professionals proving mental health services.
 Evaluates the impact of life transitions on the health/illness status of patients and the impact of
health and illness on patients.
 Develops patient-appropriate educational materials that address the language and cultural
beliefs of the patient.
 Monitors specialized care coordination to enhance effectiveness of outcomes for individuals
and families.
(Thomas, et al., 2013)

18. Primary Care NP
 Independently manages common complex, acute and chronically ill patients across the spectrum
of adolescence to the older adult, including the frail older adult.
 Provides age appropriate wellness promotion and disease prevention services weighing the costs,
risks, and benefits to individuals.
 Uses correct diagnostic evaluation and management billing codes for care of the adult and older
adult populations across settings.
 Assesses the individual’s and family’s ability to cope with and manage developmental (life stage)
transitions.
 Manages geriatric syndromes and changing conditions using evidence- based guidelines.
 Manages common cognitive behavioral and mental health conditions in adolescents, adults, and
older adults.
(Thomas, et al., 2016)

19. Primary Care NP
 Provides interventions adapted to meet the complex needs of individuals and families considering
cost benefit and patient preference.
 Collaborates with the patient, family and others to provide palliative and end- of -life care.
 Develops a plan for long-term management of chronic health care problems with the individual,
family, and health care team.
 Collaborates, as appropriate, with others to diagnose and manage acute complications of chronic
and/or multi-system health problems.
 Evaluates individual’s and/or caregiver’s support systems.
 Safely performs procedures common to adult and geriatric primary care clinical practice.
(Thomas, et al., 2016)

20. Primary Care NP
 Provides education based on appropriate teaching learning theory to individuals, families,
caregivers, and groups regarding adolescent, adult, and gerontological issue.
 Adapts teaching approaches based on learner’s physiological and psychological changes,
developmental stage, readiness to learn, literacy, the environment, and resources.
 Educates individuals, families, caregivers, and groups regarding strategies to manage the
interaction among normal development, aging, and mental and physical disorders.
 Provides consultation to health professionals and others regarding care of adolescents, adults, and
older adults.
 Uses interventions to prevent or reduce risk factors for diverse and vulnerable adult populations,
particularly adolescents and frail older adults.
(Thomas, et al., 2016)

21. Primary Care Procedures Taught in FNP
program
 Fluroscein staining of the eye
 Local infiltration of anesthetics
 Splinting of extremities
 Interpretation of arterial blood
gases
 Interpretation of 12 Lead
electrocardiogram
Cole, et al., 2003
 Pap smear
 Visual acuity
 Audiometry
 Tympanometry
 Single layer wound closure

22. Acute Care NP
 Independently identifies and manages complex acute, critical, and chronically-ill adult and older
adult patients at risk for urgent and emergent conditions, using both physiologically and
technologically derived data, to manage physiologic instability and risk for potential life-
threatening conditions.
 Promotes health and protection from disease and environmental factors by assessing risks and the
presence of comorbidities and the potential for rapid physiologic and mental health deterioration
or life-threatening instability and the risk for iatrogenesis.
 Diagnoses common behavioral and mental health and substance use or addictive disorder/disease
in the context of complex acute, critical, and chronic illness.
 Prioritizes diagnoses during rapid physiologic and mental health deterioration or life threatening
instability and implements interventions to support the patient based on advanced Cardiac Life
Support, Fundamentals of Critical Care Support.
 Employs treatments and therapeutic devices to support the patient to regain and maintain age-
specific physiologic and psychological stability consistent with the patient’s goals of care as
indicated, including, not limited to: oxygen, noninvasive and invasive mechanical ventilation,
prosthetics, splints, pacers, circulatory support, adaptive equipment.
(Thomas, et al., 2016)

23. Acute Care NP
 Performs diagnostic and therapeutic interventions including, but not limited to: interpretation of
EKG and imaging studies, respiratory support, hemodynamic monitoring, line and tube insertion,
lumbar puncture, wound debridement and closure.
 Prescribes medications and conducts a pharmacologic assessment & monitor pharmacogenetic
risks, complex medical regimens, drug interactions and other adverse events, especially in high-
risk and vulnerable populations.
 Uses pharmacologic and nonpharmacologic management strategies to ameliorate physical and
behavioral symptoms in individuals who have mental health and substance misuse disorders.
 Collaborates with intra-professional and interprofessional team and informal caregivers to achieve
optimal patient outcomes during acute, critical and/or complex chronic illness.
 Assesses the individual’s and family’s ability to cope with developmental (life stage) transitions
and applies principles of crisis and stress management in assisting the patient and family
experiencing complex acute, critical, and chronic physical and mental illness during changes in
status
(Thomas, et al., 2016)

24. Acute Care NP
 Collaborates with the individual, family, and caregivers and adapts teaching-learning approaches
based on physiological and psychological changes, age, developmental stage, cognitive status,
readiness to learn, health literacy, the environment, and available resources to develop educational
interventions
 Educates individuals, families, caregivers, and groups regarding strategies to manage the
interaction among normal development, aging, and mental and physical disorders.
 Evaluates the effect of therapies including but not limited to: physical therapy, occupational
therapy, speech therapy, home health care, palliative care, nutritional therapy
 Initiates discussion of sensitive issues, such as advanced directives and end-of-life decisions, with
the individual, family and other caregivers.
 Coordinates evidence-based comprehensive care in and across care settings for patients who have
acute, critical and chronic physical and mental illness.
 Practices within the national, state, and institutional credentialing and scope of practice for AG
ACNPs based upon education, certification, and licensure criteria.
(Thomas, et al., 2016)

25. Invasive Procedures Taught in ACNP program
 Critical Care: endotracheal/nasotracheal intubation, chest tube insertion/removal,
arterial line, central line placement, lumbar puncture, paracentesis, thoracentesis,
peripherally inserted central catheter.
 Emergency Care: nerve blocks, joint needle aspiration, diagnostic peritoneal
lavage, needle decompression of the chest, lumbar puncture, chest tube insertion,
cricothyrotomy, and tracheostomy, suturing lacerations and wounds, splinting
injuries.
 Trauma Critical Care: endotracheal intubation, central line placement, pulmonary
artery line placement, needle thoracostomies, chest tube insertion/removal,
cricothyrotomies.
(Kleinpell, et al., 2006; Jalloh, et al., 2016)

26. SOP can be expendable???
 RN experience may be a plus as background support, but does NOT expand APRN SOP--RN
didn’t make diagnoses or directly order medical interventions/radiology diagnostic test/lab.
 NP residency or fellowship or specialty certification…does NOT expand APRN SOP but may
establish depth of expertise
 Preparation cannot replace educational preparation in the role or one of the six population foci.
 Preparation can not expand one’s scope of practice beyond the role or population focus.
(Stanik-Hutt, 2019)
(The APRN Consensus Work Group and the APRN Joint Dialogue Group, 2008)