Action Types with Examples

 

CONCLUDE

  • If thrombocytopenia is accompanied by other cytopenias or splenomegaly and is mild (>50,000

cells/mm3), hypersplenism caused by infectious causes or coincident liver disease should be suspected.

  • Females aged between 1 and 2 years presenting with fever without source should be considered at risk

for having a urinary tract infection.

  • Asthma should be considered well controlled if (1) asthma symptoms are twice a week or less; (2)

rescue bronchodilator medication is used twice a week or less; (3) there is no nocturnal or early morning

awaking; (4) there are no limitations of work, school, or exercise; (5) the patient and physician consider

their asthma well controlled; and (6) the patient’s peak expiratory flow (PEF) or forced expiratory volume

in one second (FEV1) is normal or his or her personal best.

 

  • HIV-infected patients with CD4+ lymphocyte counts of <200 cells/microL or those patients with counts of

>200 cells/microL with unexplained fever, weight loss, or thrush who have unexplained cough should be suspected of having Pneumocystis pneumonia, tuberculosis, and other opportunistic infections, and should be evaluated accordingly.

 

  • Distinguish between acute otitis media (AOM) and otitis media with effusion (OME) in making therapeutic

decisions.

 

  • Clinicians should exclude other treatable, reversible causes of change in mental status before a

diagnosis of HIV-associated dementia (HAD) can be made.

 

  • Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of

an acute headache.

  • In a patient with an acute respiratory infection manifested predominantly by cough, with or without sputum production, lasting no more than 3 weeks, a diagnosis of acute bronchitis should not be made unless there is no clinical or radiographic evidence of pneumonia and the common cold, acute asthma, or an exacerbation of chronic obstructive pulmonary disease (COPD) have been ruled out as the cause of cough.

 

DOCUMENT

  • Each co-surgeon must adequately document his/her respective preoperative, intraoperative, and

postoperative participation according to Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) standards.

 

  • When reporting results of immunoassay screening, there must be proper notation given that the assay

used is considered as a “screening test” and that any positive results

are to be considered as “presumptive”.

 

 

EDUCATE/COUNSEL

 

  • The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive

counseling and behavioral interventions to promote sustained weight loss for obese adults.

 

  • All patients should receive education on the importance of lifestyle changes (e.g., engaging in regular

weight-bearing exercise, quitting smoking, avoiding excessive alcohol intake), as well as vitamin D and

calcium supplementation.

 

  • Parents should be advised that home cardiorespiratory monitoring has not been proven to prevent

sudden unexpected deaths in infants.

 

  • The primary care clinician should instruct patients and caregivers on how to maintain oral hygiene.
  • With high-risk patients, evaluate and discuss the pros and cons of changing to a power wheelchair

system as a way to prevent repetitive injuries.

  • Individuals at high risk for developing diabetes need to become aware of the benefits of modest weight

loss and participating in regular physical activity.

  • Parents of children with otitis media with effusion should be advised to refrain from smoking.
  • Nurses with experience and expertise in breastfeeding should provide support to mothers. Such support

should be established in the antenatal period, continued into the postpartum period and should involve

face-to-face contact.

 

EXAMINE

  • The foot examination can be accomplished in a primary care setting and should include the use of a

monofilament, tuning fork, palpation, and a visual examination.

  • Perform a comprehensive neurological examination according to International Standards for Neurological

and Functional Classification between 3 and 7 days after injury.

  • For women in their 20s and 30s, it is recommended that clinical breast examination (CBE) be part of a

periodic health examination, preferably at least every three years.

  • Check the adolescent annually for scoliosis and kyphosis.
  • Digital cervical examination should not be performed in patients with PROM who are not in labor and in

whom immediate induction of labor is not planned.

 

INQUIRE

  • Older people who are carers of people with intellectual or other disabilities should be assessed

for health and support needs.

  • Conduct a comprehensive assessment of the social factors specific to spinal cord injury.
  • Complete a comprehensive history of presenting symptoms with particular attention to history of onset,

duration, morphology of nail, predisposing factors, and prior treatments and outcomes.

  • Clinicians giving women information on contraceptive options should enquire about current and previous

drug use; prescription, nonprescription and herbal drug use; and specifically about use of drugs which

induce liver enzymes and non-liver enzyme-inducing antibiotics.

  • Clinicians should assess adherence and be alert for signs of hepatotoxicity in HIV-infected patients

receiving HAART who are concurrently using recreational drugs.

  • Ask tobacco users about status of tobacco use at each visit.
  • Assess current eating, exercise behaviors, history of weight loss attempts, and psychological factors

contributing to weight gain.

MONITOR

 

  • Vision screening should be performed at the earliest possible age and at regular intervals during

childhood as recommended by the American Academy of Pediatrics (AAP).

 

  • Health practitioners should provide workers at risk of occupational asthma with health surveillance at

least annually and more frequently in the first two years of exposure.

 

  • Patients with persistent dysphagia should be reviewed regularly, at a frequency related to their individual

swallowing function and dietary intake, by a professional

skilled in the management of dysphagia.

 

  • Follow-up: For patients at lower risk of recurrence (stages I and Ia) or those with co-morbidities impairing

future surgery, only visits yearly or when symptoms occur are recommended.

 

  • Reassess ulcers at least weekly to determine the adequacy of the treatment plan.

 

  • Benefits and side effects of corticosteroid therapy need to be monitored. Timed function tests, pulmonary

function tests, and age at loss of independent ambulation are useful to assess benefits.

An offer of treatment with corticosteroids should include a balanced discussion of potential risks.

Potential side effects of corticosteroid therapy (weight gain, cushingoid appearance, cataracts, short

stature [i.e., a decrease in linear growth], acne, excessive hair growth, gastrointestinal symptoms, and

behavioral changes) also need to be assessed.

 

  • Continuous monitoring of arterial blood pressure via an arterial line is recommended during the early

postoperative period.

 

  • Clinicians should obtain a complete blood count and monitor serum ALT at 2- to 4-week intervals in

patients receiving anti-HCV therapy.

 

 

PERFORM THERAPEUTIC PROCEDURE

 

  • Clinicians should obtain a complete blood count and monitor serum ALT at 2- to 4-week intervals in

patients receiving anti-HCV therapy.

 

  • In adult patients with PAH and complex congenital heart disease who are undergoing transplantation,

HLT is the procedure of choice.

 

  • In adult patients with PAH and complex congenital heart disease who are undergoing transplantation,

HLT is the procedure of choice.

 

  • Liver transplantation for metastatic neuroendocrine tumors should be confined to highly selected patients

who are not candidates for surgical resection in whom symptoms have persisted despite optimal medical therapy.

 

  • Liver transplantation for metastatic neuroendocrine tumors should be confined to highly selected patients

who are not candidates for surgical resection in whom symptoms have persisted despite optimal medical therapy.

 

  • For patients with more advanced NSCLC (stages III and IV), external beam radiation and/or

chemotherapy should usually be offered.

 

  • For patients with more advanced NSCLC (stages III and IV), external beam radiation and/or

chemotherapy should usually be offered.

 

  • Women with early stage (stages I and II) breast cancer who have undergone breast conservation surgery

should be offered postoperative breast irradiation.

 

  • A patient with a solitary peripheral lesion that is even moderately

suspicious for lung cancer, who appears to have early-stage disease (i.e., negative findings on a chest

computed tomography [CT] of the mediastinum) and is a surgical candidate, should undergo excisional

biopsy and subsequent lobectomy if a resectable lung cancer is confirmed.

 

  • Women with uncomplicated breech at 37 to 40 weeks should be offered external cephalic version (ECV)

to increase the likelihood of cephalic presentation and vaginal birth.

 

  • For the endoscopic treatment of esophageal varices, variceal ligation is used as the preferred modality in

the majority of cases.

 

  • It is strongly recommended that patients with an acute EDH in coma (GCS score <9) with anisocoria

undergo surgical evacuation as soon as possible.

 

PREPARE

  • Begin planning for the transition to adulthood with the child and family as early as possible, but no later

than 12 years of age.

 

  • The clinical laboratory should be prepared to provide serum or plasma iron results on a stat basis to aid

in the diagnosis of iron overdose.

 

  • All schools should implement age-appropriate and culturally sensitive curricula on changing students’

patterns of dietary intake, physical activity, and smoking behaviors.

 

  • Institutional policies should be developed for provision of patient- and family-centered care through

environmental design, practice, and staffing in collaboration with patients and their families.

 

  • The clinician should have an awareness and understanding of the operations of the juvenile correctional

facility and the issues affecting it, including the interface with multiple systems

(e.g., police, probation, family/juvenile courts, social services, and child welfare agencies) and the

existing educational and health care systems within the facility .

 

PRESCRIBE

 

  • Pregnant patients with a history of isolated venous thrombosis directly related to a transient, highly

thrombogenic event (orthopedic trauma, complicated surgery) in whom an underlying thrombophilia has

been excluded may be offered heparin prophylaxis or no prophylaxis during the antepartum period.

However, they should be counseled that their risk of thromboembolism is likely to be higher than the

normal population. Prophylactic warfarin should be offered for 6 weeks postpartum.

 

  • Raloxifene is appropriate therapy for women with established osteoporosis to prevent osteoporotic

fractures.

 

  • Periconceptional folic acid supplementation is recommended because it has been shown to reduce the

occurrence and recurrence of neural tube defects (NTDs).

 

  • For patients with INRs of >9.0 and no significant bleeding, hold warfarin therapy and administer a higher

dose of vitamin K1 (5 to 10 mg orally) with the expectation that the INR will be reduced substantially in 24

to 48 hours.

 

  • For patients with symptom duration <6 hours, the guideline developers recommend the administration of

alteplase or tenecteplase over streptokinase .

 

  • Prednisone has been demonstrated to have a beneficial effect on muscle strength and function in boys

with Duchenne dystrophy (DD) and should be offered (at a dose of 0.75 mg/kg/day)

as treatment .

 

  • If docetaxel and capecitabine are used in combination, the recommended starting dose for most patients

is 950 mg/m2 twice daily of capecitabine (75% of full dose) on days 1 to 14 plus docetaxel 75 mg/m2

intravenously on day 1 of a 21-day cycle.

 

  • Consider aspirin therapy (75 to 162 mg) in intermediate-risk women as long as blood pressure is

controlled and benefit is likely to outweigh risk of gastrointestinal side effects.

 

  • In procedurally uncomplicated, elective PCI, where the risk of adverse sequelae is low, use of a GP IIb/IIIa inhibitor is not recommended

unless unexpected immediate complications occur.

 

  • If blood pressure remains >130/80 mm Hg then the addition of a diuretic is recommended, followed by a

calcium antagonist or other antihypertensive drugs.

 

  • Candidemia and Acute Hematogenously Disseminated Candidiasis: For clinically stable patients who have not recently received azole therapy, fluconazole (>6 mg/kg per day; i.e., >400 mg/day for a 70-kg patient) is another appropriate choice.

 

  • It is recommended that patients who have been treated with fludarabine receive irradiated blood products

because of the risk of transfusion related graft versus host disease.

 

 

REFER/CONSULT

 

  • Refer high-risk patients to foot care specialists for ongoing preventive care and lifelong surveillance.

 

  • Children and adolescents with newly suspected and/or recurrent malignancy should be referred to a

pediatric cancer center for prompt and accurate diagnosis and management.

 

  • Advice on the management of these rare tumours should be sought from the appropriate registration

centre.

 

  • Clinicians should refer patients with HAD who present with accompanying depression, mania, psychosis,

behavioral disturbance, or substance use for psychiatric consultation to assist in psychopharmacologic treatment and management.

 

  • It is recommended that all children who have had a first non-febrile seizure should be seen as soon as

possible by a specialist in the management of the epilepsies to

ensure precise and early diagnosis and initiation of therapy as appropriate to their needs.

 

  • Pharmacologic management should be conducted by or in collaboration with physicians who have

expertise in the area of substance use disorders.

 

TEST

 

  • Routine screening for IUGR in low-risk patients should comprise classical clinical monitoring techniques.

Ultrasound evaluation of the fetus is appropriate in patients determined to be at high risk.

  • Offer screening with FOBT every year combined with flexible sigmoidoscopy every 5 years.
  • All adults and adolescents with chronic kidney disease (CKD) should be evaluated for dyslipidemias.
  • Assess the size and the degree of intravesical prostatic protrusion (IPP) with transabdominal ultrasound

scan.

  • Although an increased cancer risk has not been established in patients with Barrett’s esophagus and lowgrade dysplasia, endoscopy at 6 months and yearly thereafter should be considered .
  • Assessment:It is recommended, in children age 6 to 18 years and weight >18 kg [>40 lbs] (for

whom surgery is being considered, that an AP pelvis x-ray also be obtained, to evaluate the status of

growth plates near the proximal femur as well as to aid in ruling out the presence of femoral neck

fracture.

  • Hysteroscopy with biopsy is preferable as the first line of investigation in women taking tamoxifen who

experience post-menopausal bleeding.

  • The laboratory screening test should consist of a 50-g, 1-hour oral glucose challenge at 24�28 weeks

of gestation, which may be administered without regard to the time of the last meal.

  • Women with elevated serum alpha-fetoprotein levels should have a specialized ultrasound examination

to further assess the risk of NTDs.

TRANSFER

  • Pregnant patients with unintentional exposure to less than 1 mg of LAAR active ingredient should be

evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an

emergency department or clinic is not required.

  • Patients with stated or suspected self-harm or who are the victims of a potentially malicious

administration of beta-blocker should be referred to an emergency department immediately.

 

ADVOCATE

  • The panel recommends the following:Formation of a federation of celiac disease societies, celiac disease

interest groups, individuals with celiac disease and their families, physicians, dietitians, and other health

care providers for the advancement of education, research, and advocacy for individuals with celiac

disease.

  • Advocate with parents to school personnel about appropriate educational and therapeutic strategies

including: physical, occupational, and speech therapy; nursing; and adaptive and assistive technology.