Australian Capital Territory
Health (Scope of Practice for Nurse Practitioner Positions) Approval 2006 (No 1)*

Notifiable instrument NI2006-286
made under the
Health Regulation 2004 - section 11 (Scope of Practice for Nurse Practitioner Positions)

1.	Name of instrument

This instrument is the Health (Scope of Practice for Nurse Practitioner Positions) Approval 2006 (No 1).

2.	Commencement

This instrument commences on the day after notification.

3.	Scope of Practice for nurse practitioner positions

Under section 11, scope of practice for nurse practitioner position: I have approved the scope for an Aged Care Nurse Practitioner, Aged Care and Rehabilitation Service, ACT Health.

The scope of practice for the nurse practitioner position is attached.
As this position is ‘new’ the clinical practice guidelines and medication formularies are a work in progress and may change. These will be finalised within the first three months of the position being established after they have received the endorsement of the ACT Nurse Practitioner Clinical Practice Guideline Development Standing Committee.

	Dr Tony Sherbon
Chief Executive
28 July 2006

Guideline A: Comprehensive Geriatric Assessment

The prevalence of co-morbidities in this population lends itself to a client-focused model in establishing therapeutic goals, which lead to a comprehensive problem solving and life enhancing approach. This means that the older person may consult the nurse practitioner with an individual health concern in any one or more of the following areas and the assessment will be tailored to the individual.  Consideration will always be given to issues that may arise in relation to cultural and linguistic differences.

B
Cognition

	C
Pain Management

	D
Continence

 	E
Mobility and Falls

	F
Infection

1. Assessment

Consider conditions for  referral to other health care professional.

Any conditions outside scope of practice eg emergency conditions.

	
		Patient history
Presenting Issue

Physical Health
Functional Ability
Family/social History
Pharmacological History
Informant History
Nutrition and Hydration		Examination as appropriate

Cognition MMSE GDS GCS
Sensorium
CNS
Respiratory
CVS
GIT
Genitourinary
Musculoskeletal/Skeletal
Mobility
Skin 
		Investigations for consideration

Pathology and medical imaging as 
indicated eg FBC, UEC, axial
skeleton .	

2. Diagnosis			

		

3. Management

		
3a. Conditions for referral to other health care professional:
compromising exacerbation or new presentation

Cardiac Failure
Diabetes
Malignant Hypertension
Parkinson’s 
disease/parkinsonism
Dementia
Arthritis
Depression
Psychosis
Myocardial infarction
Cerebrovascular accident
Fracture
Sepsis
Any other condition outside scope of practice		
3b. Treatment/Management options 

Cognition (Guideline B)
Reversible causes within scope of practice.

Pain (Guideline C)
Environmental, Pathophysiological, 
Spiritual
Emotional  

Continence (Guideline D)
       Constipation /Impaction
       Diarrhoea 
       Faecal Incontinence 
       Urge and Stress 
       Incontinence
       Neuropathies

Mobility(Guideline E)
Falls
Isolation 
  Transport

Polypharmacy
      Compliance
Over The Counter
Multiple Prescribers
Adverse Drug Reactions/interactions

Infections (Guideline F)
 Skin
       Genitourinary tract
       Respiratory
       Enteric
       Eye 
       Mouth 
		
3c. Health Promotion/Illness Prevention

Integrated Management of Co morbidities/Risk management
Falls Screen
Waterlow Scale
Osteoporosis
Pain Management
Polypharmacy
Mild Cognitive Impairment
Depression
Smoking Cessation
Substance Abuse
Sensory Input
Weight Management
Exercise
Oral Hygiene
Care of Skin 
Continence Promotion
Advanced Care Directives
Elder Abuse/Restraint
Family/Carer Support
Social Integration.

	

			

					
		Non-pharmacological approaches 

Rest 
Sleep 
Hygiene
Optimal Positioning
Identifying pain behaviour 
Diversional Therapy
				Pharmacological agents

Antibiotics
Antifungals
Antiemetics
Analgesia
Laxatives
Vitamins and Supplements
Osteoporosis Prevention
Bronchodilators
Ocular Lubricants
Vaccinations
Topical Agents
Complimentary Medicines

				
			
4. Follow up
Review as clinically
Indicated:

Monitor test results
Evaluate therapeutic 
response
Refer as appropriate.		

Guideline B: Cognition

In Australia there was over 162,000 people with dementia in 2002. The prevalence of dementia is growing rapidly and the socio-economic and disability burden of dementia is significant. People with dementia have higher than average use of medical services, longer hospital stays and increased pharmaceutical costs. Depression in later life is a significant public health problem, albeit under treated and under recognized, particularly in non psychiatric settings such as primary care practice, general hospitals and nursing homes Delirium occurs frequently in older hospitalised patients and is implicated in increased mortality and morbidity, prolonged hospital stay and risk of institutionalisation. The recognition and management of elderly individuals with dementia and/or depression who experience a superimposed delirium is a complex challenge across the aged care continuum.

1. Assessment

Consider conditions for urgent referral to other health care professional 
Eg, any condition outside the scope of practice 
eg life threatening
depression

	
		Patient history

Undertake Comprehensive
Assessment.
Collaborative Assessment (See glossary)
Cognitive Assessment
Family/Social History

		Examination as clinically indicated and inclusive of:

MMSE 
GDS 
RUDAS 
GCS

		Investigations for consideration
as clinically indicated eg

Dementia Screen

			
2. Diagnosis/
Interpretation		

				

					
3. Management

		3a. 
Conditions for referral to other health care professional:

Compromising exacerbation or new presentation

Any condition outside of scope
of practice eg psychosis.		3b. 
Conditions for treatment/Management 

Hydration
Electrolyte and metabolic disturbances
Pain
Constipation
Infection
Carer Stress
Elder Abuse
 		3c. 
Health Promotion / Illness Prevention

BPSDManagement
Communication
Guardianship and Administration
Referral to other support agencies.
Eg, Alzheimer’s Association, ACAT, Carers Association, Day Care Programs Office of Public Advocate.	

		

Non-pharmacological approaches

Environmental
Pain Management

				

Pharmacological agents

Hydroxocobalamin Chloride
Folic Acid
Thiamine
Address all reversible causes; refer to pharmacological agents in Guideline C, D, E and F.

				
			
4. Follow up
Review as clinically
Indicated:

Monitor test results
Evaluate therapeutic
response
Refer as appropriate.

Guideline C: Pain Management

It is estimated that up to 140,000 people in Australia’s 3000 Government subsidised residential aged care facilities have pain. The management of pain in the elderly patient presents many challenges: pain syndromes are often due to chronic diseases that are not curable; the metabolic and pharmacodynamic changes that accompany aging complicate the prescribing of analgesics; cognitive dysfunction compounds pain assessment; functional ability may be impaired; and psychosocial issues often need to be addressed. 

1. Assessment

Consider conditions for urgent referral to other health care professional, 
eg
any condition outside
the scope of practice
eg, unexplained or 
uncontrolled pain.

	
		Patient history

Pain History
Review medications i.e. current analgesia 
Mobility
Pain limitations
Cognition
		Examination as appropriate

Select Pain Assessment tool

		Investigations for consideration
as clinically indicated
eg, 
medical imaging for suspected
fracture.

			
2. Diagnosis/
interpretation	

				

					
3. Management

		3a. 
Conditions for referral to other health care professional:
Compromising exacerbation or new presentation

Any condition outside of scope 
of practice 
eg acute medical/surgical
presentations such acute
abdomen.		3b. 
Conditions for treatment/management 

Inadequate pain management
Osteoarthritis
Lower back pain
Constipation
Acute post-operative/procedural
pain.		3c. 
Health Promotion/Illness Prevention

Exercise
Weight Loss
Social Integration
Referral to other support agencies
eg, pain clinics	

		

		Non-pharmacological approaches

Heat and cold packs
Massage
Gentle Exercise
Aromatherapy
Diversional therapy				Pharmacological agents

Analgesia
Paracetamol
Codeine phosphate with paracetamol
Antiemetics
Domperidone
Metoclopramide hydrochloride
Osteoporosis Management
Calcium Carbonate
Ergocalciferol

	

4. Follow up

Review as clinically 
Indicated:

Evaluate therapeutic
response.
Refer as appropriate.		

Guideline D: Clinical Practice Guideline for Continence 

30% of people over the age of 80 are reported to have incontinence.  Incontinence often plays a major part in the decision to place people into residential aged care. It is further complicated in the target population by co morbidities. 

1. Assessment

Consider conditions for urgent referral to other health care professional, 
eg
any condition outside
the scope of practice eg
gross haematuria	

		Patient History

Reproductive History
Enuretic History
Patterns of Elimination
Bladder and bowel diary
Mobility
Relevant Surgical/Medical 
History		Examination as appropriate

Abdominal Palpation/auscultation
Bladder Palpation
PR Examination
Perineal Examination		Investigations for consideration
As clinically indicated eg
MSU 
Stool Cultures
Bladder Scan

				
			
2. Diagnosis/
interpretation	

				

					
3. Management

		3a. 
Conditions for referral to other health care professional:
Compromising exacerbation or new presentation.
Any condition outside of scope 
of practice eg; urinary retention
		3b. 
Conditions for treatment/Management 
UTI 
Constipation
Simple Diarrhoea
Functional Incontinence
IDC / SPC catheter changes
		3c. 
Health Promotion/Illness Prevention
Good bladder and bowel habits
Product/equipment advice
Dietary advice
Environmental cues
Funding options (CAAS and ACTES 
applications)
Education around catheter changes 
and management.	

		

		Non-pharmacological approaches

Toileting Regimen
Pelvic Floor Exercises
Bladder Retraining
Nutrition/Hydration
Psychosocial Support
Equipment
Cranberry Supplements				Pharmacological agents

Management of UTI’s
Trimethoprim
Cephalexin
Amoxycillin Trihydrate& 
Clavulanate
Management of Urge and Stress Incontinence.
Oestriol Cream
Management and Prevention of Constipation
Frangula Sterculia
Psyllium Hydrophillic Mucilliod
Sorbitol
Movicol
Docussate Sodium
Bisacodyl
Sennosides A&B
Glycerine Suppositories
Sodium Magnesium Enema
Phosphate Enema	

4. Follow up
Review as clinically
Indicated:
Monitor test results
Evaluate therapeutic
response
Refer as appropriate.		

Guideline E. Clinical Practice Guideline for Mobility and Falls

Australian and overseas studies of community dwelling older people have identified that one in three people aged 65 years and over fall each year. The rate of falls and associated injuries is even higher in hospitals and residential settings. The effect of falls is costly to the individuals in terms of health, function and quality of life.

1. Assessment

Consider conditions for urgent referral to other health care professional, 
eg
any condition outside
the scope of practice, 
eg, traumatic fracture. 

	
		Patient history
*
Falls History
Review medications which may
contribute to falls
Mobility
Pain limitations
Cognition
Nutrition/hydration		Examination as appropriate

Falls Kit
Lying and Standing Blood 
Pressure.
		Investigations for consideration
As clinically indicated 
eg,
Vitamin D level, UEC’s.

			
2. Diagnosis/
interpretation	

				

					
3. Management

		3a. 
Conditions for referral to other health care professional.
Compromising exacerbation or new presentation
Any condition outside of scope 
of practice eg epilepsy 		3b. 
Conditions for treatment/Management 
Treatment of underlying cause, eg,
Pain.
Osteoporosis 
Pressure Injury
Incontinence issues
Infections		3c. 
Health Promotion/Illness Prevention
Hip Protectors
Lifestyle Modification
Mobility Aids
Referral to falls clinic/
community exercise programs	

		

		Non-pharmacological approaches
Strength and balance program
Risk Management
Glucosamine

				Pharmacological agents
Osteoporosis Management
Calcium Carbonate
Ergocalciferol
Analgesia
Paracetamol
Codeine Phosphate withParacetamol

Ocular Lubricants
Hypromellose  0.5%
Polyvinyl Alcohol 1.4%
Carbomer 980 0.2%

				
			
4. Follow up
Review as clinically
indicated

Monitor test results
Evaluate therapeutic
response
Refer as appropriate.		

Guideline F. Clinical Practice Guideline for Infections 
Infectious disease is widespread among elderly people and has potentially devastating consequences.  Infections are major reasons of hospitalisation for the aged and old people suffer greater morbidity and mortality from infections than do younger adults.

1. Assessment

Consider conditions for urgent referral to other health care professional. 

Any condition outside
the scope of practice eg
septicaemia, DVT,
upper urinary tract 
infections, human bites.

	
		
Patient history

Simple Cellulitis
-	Previous History
-	Relevant medical/surgical history
-	Onset and clinical symptoms

Urinary Tract Infection
-	Previous History
-	Relevant medical/surgical history
-	Onset and clinical symptoms 
-	Pain

Community Acquired
Pneumonia
-	Previous History
-	Relevant medical/surgical history
-	Onset and clinical symptoms

Animal Bites
-	Onset and clinical symptoms 

Examination as appropriate

Examination area of cellulitis 

Chest Auscultation
Examination of Sputum

Examination of bite area		
Investigations for consideration
As clinically indicated eg
CRP, Microbiology
	
		Eye Infections 
-	Previous History
-	Relevant medical/surgical history
-	Onset and clinical symptoms

Fungal Infections
-	Previous History
-	Relevant medical/surgical history
-	Onset and clinical symptoms

		Examination of affected eye

Examination of affected area			

2. Diagnosis/
interpretation	

				
							
3. Management

		3a. 
Conditions for Referral to other health care professional:
Compromising exacerbation or new presentation
Any condition outside of scope
of practice eg infections with
systemic sequelae		3b. 
Conditions for Treatment/Management 
UTI
Cellulitis without systemic complications
Community acquired pneumonia
mild
Fungal Infections
Bacterial Eye Infections
Animal Bites		3c. 
Health Promotion/Illness Prevention/ Education
Vaccination
Smoking Cessation
Food Handling
Perineal Hygiene
Eye Hygiene
Referral to nutritionist, physiotherapist, occupational therapist, speech therapist	

		

		Non-pharmacological approaches

Rest
Elevation of effected limb
Wound Dressings
Hydration
Hygiene
Chest Physiotherapy
Nutrition				Pharmacological agents

Management of Urinary Tract Infection.
Trimethoprim
Cephalexin
Amoxycillin Trihydrate &
Clavulanate
Management of Simple Cellulitis
Dicloxacillin Sodium
Cephalexin
Amoxycillin Trihydrate &
Clavulanate
Metronidazole
Management of Animal Bites.
Amoxycillin Trihydrate & 
Clavulanate
Metronidazole
Management of Community Acquired Pneumonia
Amoxycillin
Roxithromycin
Bronchodilators
Tiotropium Bromide
Salbutamol Sulphate
Immunisations
ADT
Pneumococcal Vaccine
Influenza Virus Vaccine
Management Bacterial Eye Infections
Chloromycetin Drops/ointment
Fungal Infections
Nystatin
Clotrimazole	

4. Follow up
Review as clinically
Indicated:

Monitor test results
Evaluate therapeutic
response
Refer as appropriate.		

GLOSSARY

ACAT – Aged Care Assessment Team

BPSD – Behavioural and Psychological Symptoms of Dementia

CAM – Confusion Assessment Method

Collaborative History – A collaborative or informative history is an 
essential part of diagnosing moderate cognitive disorder.  It involves interviewing persons well known to the individual who can report on changes over time of which the individual may not be aware.

CRP – C Reactive Protein

FBC – Full Blood Count

GCS – Glasgow Coma Scale

GDS – Geriatric Depression Scale

MMSE – Mini Mental State Examination

MSU – Mid Stream Urine

OTC – Over The Counter (refers to medications)

PR – Per Rectum

UEC – Urea Electrolytes Creatinine.

MEDICATION FORMULARY.

Vitamins and Supplements
Hydroxocobalamin Chloride
Folic Acid
Ferrous Sulphate
Thiamine
Ergocalciferol
Calcium Carbonate

Ocular 
Hypromellose 0.5% eye drop
Polyvinyl Alcohol 1.4% eye drop
Carbomer 980 0.2%
Chloramphenicol\

Topical
Oestriol Cream

Analagesia
Paracetamol
Codeine Phosphate with Paracetamol

Antiemetics
Domperidone
Metoclopramide hydrochloride

Antibiotics and Antifungals
Amoxycillin
Trimethoprim
Cephalexin
Dicloxacillin Sodium
Amoxycillin Trihydrate &Potassium Clavulanate
Metronidazole
Roxithromycin
Nystatin
Clotrimazole

Bronchodilators
Salbutamol Sulphate
Tiotropium Bromide

MEDICATION FORMULARY

Laxatives
Frangula Sterculia
Psyllium Hydrophillic Mucilliod
Sorbitol
Movicol
Docusate Sodium
Sennosides A &B
Bisacodyl
Glycerine Suppositories
Sodium Magnesium Enema 
Phosphate Enema

Immunisations
ADT
Pneumococcal Vaccine
Influenza Virus Vaccine

Complimentary Therapies 
Cranberry tablets
Glucosamine