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Exemplar 14-2 Direct Clinical Practice and Core Competencies of the

Clinical Nurse Specialist

I (CC) perform the preoperative history and physical examination in the clinic, order appropriate radiographs,
laboratory tests, and consultations, and obtain cephalometric measurements and photographs for patients undergoing
surgery for craniosynostosis. On the day of surgery, I notify the staff nurses who will be caring for the patient about
pertinent findings and specific needs. Postoperatively, I assess the patient for adequate pain control, dietary needs, vital
sign changes, incision status, swelling, and neurologic function. I facilitate discussions about these findings, staff
nurses’ concerns, parents’ concerns and plan of care among care team members. I adapt standing orders for each patient
in collaboration with the neurosurgeon.

I am frequently consulted by staff nurses, referring physicians, or other APNs to assess misshapen heads by physical
assessment or reviewing radiographs. These consultations provide opportunities to teach health care professionals how
to recognize the differences between positional plagiocephaly and craniosynostosis, leading to earlier referrals for
improved outcomes.

Guidance and Coaching

The Internet can be an excellent resource for families seeking health care information about medical conditions and
treatment options. To help families learn more about craniosynostosis, I created a website that describes the various
types of craniosynostosis and treatment options, including a new, less invasive technique. As a result, I receive many
inquiries from families seeking information about this new technique for their babies. Providing accurate information
on the website is critical so that families can make informed decisions about surgery. Much of the preoperative teaching
is done by telephone or in the clinic because parents and other family members have many questions.
I have educated nurses about the early recognition of craniosynostosis, surgical options, and positional
plagiocephaly through professional journal articles, a book chapter, presentations at national nursing conferences,
teaching at the school of nursing, and in-service education programs for the staff nurses. Mentoring graduate students
has provided additional opportunities for role modeling.

Evidence-Based Practice
Collaboration on research with the pediatric neurosurgeon has yielded data demonstrating that the new surgical
technique decreases patients’ hospital stays, lowers costs, and improves patient outcomes. When parents noticed a
sharp decrease in fussiness in their baby immediately after surgery, I developed a questionnaire to survey parents’
perceptions of fussiness and irritability in their baby before and after surgery. Statistically significant decreases in
fussiness and irritability were found postoperatively, suggesting that babies with craniosynostosis experience increases
in intracranial pressure.

In this unique role, I can provide care throughout the continuum, using clinical pathways to help families navigate the
hospital system in an efficient manner. Bringing a baby to an unfamiliar city for surgery by surgeons that they have
never met is a daunting experience for most parents. My leadership skills are put to the test coordinating preoperative
donor-directed blood, arranging lodging at the Ronald McDonald House, scheduling preoperative workups and follow-
up appointments with the neurosurgeon, plastic surgeon, ophthalmologist, and anesthesiologist, and coordinating the
postoperative molding helmet.

Collaboration occurs at many levels. First, I have a collaborative practice agreement with the pediatric neurosurgeon, as
required by hospital policy and the state board of nursing. I collaborate with the staff nurses who care for the babies
with craniosynostosis, providing in-service educational programs about the disorder and conducting rounds with them
on the postoperative patients. Collaboration also occurs with other members of the craniofacial team, such as
ophthalmologists, genetic counselors, plastic surgeons, and orthotic designers. I confer with referring health care
providers to provide continuity after the patient leaves the hospital and between follow-up visits.

Ethical Decision Making

Although this new surgical treatment for craniosynostosis results in minimal blood loss, an infant will occasionally
present with a low hemoglobin level or experience excessive intraoperative blood loss. Some families refuse blood
transfusions for religious reasons, requiring more intensive preoperative preparation to minimize the need for a blood
transfusion. Being present for the conversations that the neurosurgeon has with the family who refuses blood
transfusion assists in understanding the reasons for refusing a blood transfusion and allows the CNS to reinforce the
plan of care should the child need blood during or after surgery. A protocol for preoperative erythropoietin injections
can be sent to the patient’s pediatrician in an attempt to increase the hemoglobin level.
A great deal of preparation is required for a family to bring their baby to the hospital for this type of surgery. The
CNS is instrumental in facilitating this process, using the core competencies and spheres of influence.

NACNS Core Competencies