Nursing Capstone

“Barriers to Palliative Care Related to Physicians/ Nurse Practitioners not ordering it”

1. Abstract. Provide a concise (120 word or less) abstract summarizing the paper. Content should include purpose, methods, results (review/analysis of literature and implications for practice), and conclusions.
2. Introduction. The body of the paper begins with presentation of the specific phenomenon/topic under investigation. This section should address why exploration of this topic is important and the potential implications of such exploration. What is the problem? What question are you posing? A purpose statement and rationale should be delineated. 
3. Methods. Identify approach to literature review (keywords, databases). How many and what categories of papers did you locate? What is strength of evidence (level, consistency, currency)?
4. Review of literature. Provide an integrative review of pertinent empirical and theoretical literature. What are the key points to be made? How would you summarize the findings? What conclusions can be drawn? Assess gaps or limitations in current knowledge.
5. Implications for Practice. Formulate specific nursing implications as a result of completion of this exploration. Discuss implications within the context of the literature and the nursing area of study. How might this exploration influence clinical reasoning or patient/nurse management skills? What is the relevance to primary care? What is the relevance to nursing management? To your future practice?
6. Conclusions. Evaluate achievement of the purpose of the paper. Did the literature review answer your question and address the problem? Discuss the contribution of this paper to the advancement of nursing knowledge or practice.
7. References. (This section does not count towards the paper page length). At least 20 references are required. Only the following peer-reviewed references are allowed: 1) primary research reports; 2) evidence-based practice guidelines and algorithms; 3) systematic reviews and meta-analyses; and 4) professional websites with supportive references. One or two general review articles to introduce the problem from peer-reviewed journals are acceptable. Your literature is to be synthesized and integrated through-out the paper. The literature review is NOT to be a series of paragraphs, each summarizing one publication. The literature is to be used to support the points you are making. The following are NOT acceptable references: Wikipedia, websites without identified authors, websites with “.com,” textbooks or encyclopedias (online or offline), patient education brochures or website that were meant for consumer information. Government sites are acceptable only if material is targeting professionals, are authored, and include references. Reports MUST be from last 5 yr. If critical for your paper, you may go back 10 yr & note significance of this work. No more than two sources can be more than 5 yr old.

Project Plan Guideline: This is a 2 page summary of the paper. See example below this. 


-what are you proposing to investigate?

-identify problem

-pose question

– outline purpose

-why is this topic important/what is rationale? (e.g., need for change in practice, emerging health concern, major issue with morbidity or mortality)

-how project could potentially contribute to nursing knowledge and practice (brief)

Review/Analysis of Literature

-what approach did you take to review literature?

-how many papers did you locate? What categories (EBP guideline, primary research, etc.)?

-what is their quality? How strong is the evidence? Are the reports current and valid? 

-what are gap/limitations in knowledge?

-what are the main points to be made?

-how would you summarize the literature? What conclusions does it allow you to draw?

Implications for Practice
-what are the implications?

-what relevance do the stated problem and the EBP review have to primary care?

-how will this information influence your future practice?

Conclusions -did literature answer your question? Address the problem?

-how will it advance nursing knowledge or practice?

Project Plan for Capstone (EXAMPLE) (2 pages after the whole paper is completed)

Problem: Subclinical hypothyroidism is mild thyroid failure and usually progresses to overt hypothyroidism. It is a fairly common clinical problem with a prevalence rate of 4.3 to 9.5% in the U.S. population of according the NHANES III and Colorado study. Subclinical hyperthyroidism can be mild (TSH of 4.5-9 mIU/L) or severe (TSH> 10mIU/L). Screening and management for the disease is controversial as clinical recommendations differ between professional organizations and expert opinions.

Question: What reference points should be used to treat subclinical hypothyroidism and what management strategies should be used to prevent cardiovascular and neuropsychiatric sequellae? 

Purpose: (Rationale): Several cardiovascular risk factors have been identified in some patients with subclinical hypothyroidism and include hypercholesterolemia, atherosclerosis, hyperlipidemia, and cognitive symptoms such as depression and memory loss. Subclinical hypothyroidism often progresses to overt hypothyroidism. The progression from subclinical to overt hypothyroidism is subtle and untreated hypothyroidism can lead to irreversible cardiovascular and neuropsychiatric symptoms.

Review/Analysis of Literature

After defining subclinical hypothyroidism an area of interest, pertinent articles were identified by searching CINAHL, OVID NURSING, MEDLINE, National Guideline Clearing House, the Cochrane Database, and the National Health Services Database (UK). Key search terms were hypothyroidism, thyroid deficiency, thyroid insufficiency, underactive thyroid, subclinical hypothyroidism, euthyroid, thyroid peroxidase antibodies, Hashimoto’s thyroiditis. Other key words used were screening, diagnostics, therapy, treatment, management, consequences, sequelae, hyperlipidemia, hypercholesteremia, cardiovascular, and cognitive. Research articles produced from 2009 to January 2014 were reviewed. Two older research studies from 2007 and 2008 were also reviewed. Twenty-six articles were identified as pertinent to the project and assessed for strength of evidence. Eight of the articles are Level I, four are level II nine are level IV, and five are level V. 

Main Points: Subclinical hypothyroidism (SCH) is defined as serum thyroid stimulation hormone (TSH) concentration > 4.05 mIU/L with free T4 between 0.89-1.79 ng/dL. The prevalence of SCH is more common in women and increases with age. SCH has been shown to be associated with several health problems such as 

hyperlipidemia, cardiac dysfunction, cognitive function and progression to overt hypothyroidism. The most common cause for SCH is autoimmune thyroiditis or Hashimoto’s disease. Eighty percent of those diagnosed with SCH have anti-thyroid peroxidase antibodies (TPOAb). TPOAb laboratory testing along with TSH, T3, T4 was found in the literature to be a recommendation in the evaluation and monitoring of the SCH patient.

Several studies have shown conflicting results in evaluating and treating SCH and currently there is no consensus on how to manage the disease. Clinical guidelines of professional societies indicate that the disease must be managed on an individual case basis including empirically treating symptomatic patients. Many descriptive studies point out that the sequelae of prolonged untreated SCH may impact an individual’s quality of life. More research is needed to determine if treating SCH prevents hyperlipidemia and other cardiovascular problems and whether early treatment prevents progression to overt hypothyroidism

Implications for Practice

Primary care clinicians equipped with an understanding of the clinical course of SCH and management options based on evidence-based practice will be able to monitor and manage the SCH patient to achieve optimal treatment outcomes. 

Conclusion: The literature has answers the question as to which reference points should be used to treat subclinical hypothyroidism, however management strategies to prevent cardiovascular and neuropsychiatric sequelae need further investigation. Answers to these questions inform the advanced practice nurse on evaluation and management of this common disease to prevent progression to overt hypothyroidism and irreversible problems.


Aghili, F., Khamseh, M.E. Malek, J., Hadian, A., Baradaran, H.R., Najafi, L., Emami, Z. (2012). Changes in subtests of Wechsler memory scale and cognitive function in subjects with subclinical hypothyroidism following treatment with levothyroxine. Archives of Medical Science 2012, 8(6):2007 1096-1101. doi:10.5114/aom2012.32423

Baris, G., Collet, T., Virgini, V., Bauer, D.C., Gussekloo, J., Cappola, A.R., Nanchen, D., den Elzen, W.P.J., Balmer, P., Luben, R.N., Iocoviello, M., Triggiani, V. , Cornuz, J., Newman, A.B., Khaw, K., Judema, J.W., Westendorp, F.G.J., Vittinghoff, E., Aujesky, D., Rodondi, N. (2012). Subclinical thyroid dysfunction and the risk of heart failure events: an individual participant data analysis from six prospective cohorts. Circulation, 126 (9): .doi:10.1161/CIRCULATIONAHA.112.096024.

Biondi, B. (2012). Natural history, diagnosis and management of subclinical thyroid dysfunction. Best Practice & Research Clinical Endocrinology & Metabolism, 26 (2012), 431-446. Downloaded

Brenta, G., Vaisman, M., Sgarbi, J.A., Bergoglio, L.M., Carvalho de Andrada, C., Bravo, P.P., Orlandi, A.M. & Graf, H. (2013). Clinical Practice Guidelines for the Management of Hypothyroidism: Task Force on Hypothyroidism of the Latin American Thyroid Society (LATS). Arquivos Brasilieros de Endocrinologia and Metabologia 2013;57 (4):265-298. 

Chakera, A.J., Pearce, S.H.S. & Vaidya, B. (2012). Treatment for primary hypothyroidism: current approaches and future possibilities. Drug Design, Development and Therapy, (6), p. 1-11.

Cooper, D. S. & Biondi, B. (2012). Subclinical thyroid disease. The Lancet, 379, 1142-1154. Downloaded from:

Ertugrul, O., Ahmet, U., Asim, E., Gulcin, H.E., Vurak A., Murat, A., Sezai, U.S., Biter, H.I., Hakan, D.M. (2011). Prevalence of subclinical hypothyroidism among patients with acute myocardial infarction. International Scholary Research Network: ISRN Endocrinology, 2011. doi: 10:5402/2011/810251

Fernandes, R.M.S., Alvarenga, N.B., da Silva, T.I., & da Rocha, F.F. (2011). Cognitive dysfunction in patients with subclinical hypothyroidism. Arquivos Brasilieros de Endocrinologia and Metabologia 2011, 55(3):

Garber, J.R., Cobin, R.H., Gharib, H., Hennessey, J.V., Klein, I., Mechanick, J.I., Pessah-Pollack, R., Singer,P.A., Woeber, K.A. (2012). Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and The American Thyroid Association,18 (6), 989-1028.

Gencer, B., Collet, T., Virgini, V., Bauer, D.C., Gussekloo, J., Cappola, A.R., Nanchen, D., den Elzen, W.P.J., Balmer, P., Luben, R.N., Iocoviello, M., Triggiani, V. , Cornuz, J., Newman, A.B., Khaw, K., Judema, J.W., Westendorp, F.G.J., Vittinghoff, E., Aujesky, D., Rodondi, N. (2012). Subclinical thyroid dysfunction and the risk of heart failure events: an individual participant data analysis from six prospective cohorts. Circulation, 126 (9): .doi:10.1161/CIRCULATIONAHA.112.096024.

Ichiki, T. (2010). Thyroid hormone and atherosclerosis. Vascular Pharmacology, 52 (2010): 151-156. doi: 10.1016/j.vph.2009.09.004

Martins, R.M., Fonseca, R.H.A., Duarte, M.M.T., Reuters, V. S., Ferreira, M.M., Almeida, C., Buescu, A. , Dos Santos Teiseira, P.F., Vaisman, M. (2011). Impact of subclinical hypothyroidism treatment in systolic and diastolic cardiac function. Arquivos Brasilieros de Endocrinologia and Metabologia, 55 (7): 460-467. 

Nagasaki, T., Yamada, I.M., Shirakawa, K., Nagata, Y., Kumeda, Y., Hiura, Y., Tahara, H., Ishimura, E., Nishizawa, Y. (2009). Decrease of brachial-ankle pulse wave velocity in female subclinical hypothyroid patients during normalization of thyroid function: a double-blind, placebo-controlled study. European Journal of Endocrinology/European Federation of Endocrine Societies, 160(3): 409-15. Doi:10.1530/EJE-08-074d2

Pearce, S.H.S., Brabant, G., Duntas, L.H., Monzani, F., Peeters, R.B., Razvi, S. & Wemeau J.L. (2013). 2013 ETA Guideline: Management of Subclinical Hypothyroidism. European Thyroid Journal, 2, 215-228. DOI: 10:1159/000356507

Razvi, S., Ingoe, L., Keeka, G., Oates, C., McMillan, C. & Weaver, J.U. (2007). The beneficial effect of L-thyroxine on cardiovascular risk factors, endothelial function, and quality of life in subclinical hypothyroidism: randomized, crossover trial. The Journal of Endocrinology and Metabolism, 92(5): 1715-1723. doi: 10.1210/jc.2006 -1869

Rizos, C.V., Elisaf, M.S. & Liberopoulos, E.N. (2011). Effects of thyroid dysfunction on lipid profile. The Open Cardiovascular Medicine Journal, 2011, 5, 76084

Santi, A., Duarte, M.M.F.F., de Menezes, C.C. & Loro, V.L. (2012). Association of Lipids with Oxidative Stress Biomarkers in Subclinical Hypothyroidism. International Journal of Endocrinology, 2012, 1-7. DOI:10.1155/2012/856359

Selmer, C., Olesen, J.B., Hansen, M.L., Lindhardsen, J., Olsen, A.S., Madsen, J.C., Faber, J., Hansen, P.R., Pedersen, O.D., Torp-Pedersen, C. & Gislason, G.H. (2012). The spectrum of thyroid disease and risk of new onset atrial fibrillation: a large population cohort study. BMJ 2012, 345 (e7895). Doi:10.1136/bmj.e7895

Sgarbi, J.A., Teixeira, P.F.S., Maciel, L.M.Z., Mazeto, G.M.F.S., Vaisman, M., Montenegro, J., Ward, L.S. (2013). The Brazilian consensus for the clinical approach and treatment of subclinical hypothyroidism in adults: recommendations of the thyroid Department of the Brazilian Society of Endocrinology and Metabolism. Arquivos Brasilieros de Endocrinologia and Metabologia 2013;57 (3):166-183.

Shakoor, S.K.A., Aldibbiat, A., Ingoe, L.E., Campbell, S.C., Sibal, L., Shaw, J., Home, P.D., Razvi, S. & Weaver, J.U. (2009). Endothelial progenitor cells in subclinical hypothyroidism: the effect of thyroid hormone replacement. Journal of Endocrinology and Metabolism, 95(1): 319-322. doi: 10.1210/jc.2009-1421

Singh, S., Duggal, J., Molnar J., Maldonado, F., Barsano, C. & Arora, R. (2008). Impact of subclinical thyroid disorders on coronary heart disease, cardiovascular and all-cause mortality: A meta-analysis. International Journal of Cardiology, 125: 41-48.

Tian, L. , Gao, C. Liu, J. & Zhang, X. (2010). Increased carotid arterial stiffness in subclinical hypothyroidism. Journal of Internal Medicine, 21, 560-563. doi: 

Tseng, F., Wen-Yuan, L. Cheng-Chieh, L., Long-Teng, L. Tsai-Chung, L. Pei-Kun, S. & Kuo-Chin, H. (2012). Subclinical hypothyroidism is associated with increased risk for all-cause and cardiovascular mortality in adults. Journal of the American College of Cardiology, 60 (8), 730-737. Downloaded from:

Velkoska, N.K., Bosevski, M., Dimitrovski, C. & Krstevska, B. (2011). Subclinical hypothyroidism and risk to carotid atherosclerosis. . Arquivos Brasilieros de Endocrinologia and Metabologia, 55 (7):475-480.

Villar H.C.C.E., Saconato H., Valente, O. & Atallah, A.N. (2009). Thyroid Hormone Replacement for Subclinical Hypothyroidism (Review). The Cochrane Collaboration, The Cochrane Library (1), 1-59. Downloaded from: https://www.thecochranelibrary

Yurtdas, M., Gen, R., Ozcan, T & Aydin, M.K. (2012). Assessment of the elasticity properties of the ascending aorta in patients with subclinical hypothyroidism by tissue Doppler imaging. Arquivos Brasilieros de Endocrinologia and Metabologia 2013;57 (2): 132-138.


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