Primary care: The art and science of advanced practice nursing (6th ed.).

This is the standard text for NP students and practicing advanced practice nurses who need one volume spanning primary care across the lifespan. It matters because it does what few textbooks attempt: it anchors every clinical guideline in a caring framework, so protocols never lose the person. If you want the science without losing the soul of nursing, this is your reference.

1. 1Chapter 1

   The Circle of Caring: nursing process, rebuilt for primary care

   Two nurse educators look at the nursing process — assess, diagnose, plan, implement, evaluate — and see a gap. Primary care demands something more responsive: patients arrive with undifferentiated complaints, social complexity, and no admission note to guide you. So Dunphy and Winland-Brown redraw the circle. Their model keeps the discipline of the nursing process but bends it around what primary care actually asks of a clinician. It becomes the organizing spine of the entire book — every chapter that follows hangs on this frame, and the art and science of nursing are explicitly woven together rather than split apart.

   The idea

   Most clinical models are borrowed from medicine and retrofitted for nursing. This one runs the other direction: it takes nursing's own process and stretches it to fit primary care's realities, where the presenting problem is rarely the whole problem. The surprise is how much of advanced practice depends on that framing — you can memorize guidelines, but without a model that holds the whole person, you're just protocol-checking. The Circle of Caring is the book's argument that art and science aren't rivals; they're the same circle.

   Try this: This week, pick one patient visit and consciously run the full Circle of Caring — not just the assessment and plan, but the social and caring dimensions you'd normally skip.

2. 2Chapter 2

   1965: a nurse and a physician invent the nurse practitioner

   Children in the mid-1960s are waiting too long for care. There aren't enough primary care physicians to go around, and pediatric visits pile up unmet. At the University of Colorado, a nurse named Loretta Ford and a physician named Henry Silver decide the shortage won't fix itself. In 1965, they launch the first nurse practitioner program, creating the pediatric nurse practitioner role — nurses trained to deliver primary care to children directly. It's a workaround that becomes a profession. Every NP practicing today traces their role to that single program, built by two people who saw a gap and refused to wait for the system to close it.

   The idea

   The nurse practitioner role wasn't born from ambition or turf — it was born from a shortage. That origin matters: the profession's legitimacy has always rested on meeting a real access need, not on replacing anyone. Ford and Silver's collaboration is also the point — a nurse and a physician built it together. When debates flare about NP scope of practice, remember the role began as a partnership answering a problem medicine alone couldn't solve.

   Try this: If you're an NP student, write down why you entered the field — then compare it to the access gap Ford and Silver saw in 1965.

3. 3Chapter 2

   Caring as the philosophical core, not the garnish

   A student flips past the clinical chapters to one titled simply 'Caring and the Advanced Practice Nurse.' The question underneath: with all this science to master, why spend a chapter on caring? The answer the chapter builds: caring isn't a soft add-on to advanced practice — it's the core concept of nursing itself. Jean Watson's Theory of Human Caring is presented as the philosophical foundation for advanced practice nursing, giving the clinician a framework for what all those guidelines are ultimately for. The chapter sits early in the book deliberately, before a single protocol appears.

   The idea

   Textbooks usually front-load science and bolt on 'humanistic' chapters as decoration. This one inverts the order: caring comes first, as the foundation everything else stands on. Watson's theory gives advanced practice a philosophical spine — the idea that the relationship itself is part of the treatment. That's what separates an NP who follows guidelines from one who practices nursing at an advanced level.

   Try this: Read one Watson caring concept and apply it to your next patient interaction — notice what changes in how you frame the encounter.

4. 4Chapter 3

   Screening gets specific: colorectal cancer at 45

   A patient in their mid-forties sits across from you, healthy, no complaints, wondering what they actually need. Chapter 3 on health promotion gives you the answer sheet: the U.S. Preventive Services Task Force recommendations, including the shift to start colorectal cancer screening at age 45. That number moved down from where it used to be, and the chapter makes sure you know it. Health promotion isn't a vague wellness lecture here — it's a concrete, evidence-graded set of actions you take with every apparently healthy patient who walks in.

   The idea

   The hardest part of primary care is that the most important work happens with people who feel fine. Screening recommendations are how evidence becomes action in those moments, and the age thresholds shift as data accumulates — 45 for colorectal cancer is the current line. The skill isn't memorizing one number; it's building a habit of checking current USPSTF guidance rather than practicing from what you learned years ago.

   Try this: Check your last ten patients aged 45–50: how many are current on colorectal cancer screening per the current USPSTF recommendation?

5. 5Chapters 3 and 25

   The 5 A's: a framework for actually changing behavior

   You've told a patient to quit smoking, exercise more, eat better. They nod. Nothing changes. The book reaches for a structure: the 5 A's, a framework for behavioral counseling interventions. The framework is referenced in the book, though the exact wording varies between citations; the shared core is that a 5 A's framework is used for counseling. The point isn't the acronym; it's that behavior change needs a sequence, not a lecture. Ask first, advise clearly, assess readiness, assist with a plan, arrange the next contact.

   The idea

   Advice fails because it's a single event; behavior change is a process with distinct steps. The 5 A's turn a vague exhortation into a clinical intervention with a beginning, middle, and follow-through. What surprises people is how much rides on the first and last A — asking before advising, and arranging follow-up after. Skip those and the middle three collapse into the lecture that never worked.

   Try this: At your next counseling moment, force yourself through all five steps — especially 'arrange' — and book the follow-up before the patient leaves.

6. 6Chapters 11 and 13

   ABCDE: the alphabet that catches melanoma

   A dark spot on a patient's back. Is it nothing, or is it the thing you can't miss? The book hands you a mnemonic: ABCDE. Asymmetry. Border irregularity. Color variation. Diameter greater than 6 millimeters. Evolving. Five features, run in order, that separate a suspicious pigmented lesion from one you can watch. It's the kind of tool that fits on a card and changes what you do in the exam room — because melanoma found early is a different disease than melanoma found late.

   The idea

   Screening tools earn their place by being usable under time pressure, and ABCDE is the classic example: five checks, no equipment, immediate triage. The 'E' — evolving — is the one clinicians most often underweight, because change over time requires a history, not just a look. The lesson for practice: a lesion that fails any letter gets attention, and 'getting bigger or changing' counts even when the rest looks benign.

   Try this: Do a full-body skin check with ABCDE on your next physical exam patient — and photograph anything that hits two letters.

7. 7Chapters 14 and 15

   Hypertension at 130/80: the line that redefined millions

   The 2017 ACC guideline is cited in the book. Blood pressure of 130/80 mmHg or higher — a reading that used to be 'prehypertension' — is now hypertension. The guideline states its goal plainly: 'The goal of treatment is to reduce blood pressure to <130/80 mmHg in most adults, particularly those with a 10-year atherosclerotic cardiovascular disease risk of ≥10%.' Overnight, a vast band of patients who thought they were fine became candidates for treatment. The book walks you through the categories so you can classify, risk-stratify, and act.

   The idea

   Diagnostic thresholds are clinical decisions disguised as numbers, and moving one from 140/90 to 130/80 reclassifies an enormous population. The guideline's genius is pairing the lower threshold with risk stratification — the 10-year cardiovascular risk of 10% or more — so intensity of treatment follows risk, not just the reading. For primary care, that means every blood pressure check is also a risk calculation.

   Try this: For every hypertensive patient this week, calculate their 10-year ASCVD risk before deciding how aggressively to target <130/80.

8. 8Chapters 14 and 16

   Metformin first, HbA1c under 7: the diabetes baseline

   A new type 2 diabetes diagnosis lands in your schedule. Where do you start? The book quotes the American Diabetes Association (2022) Standards of Medical Care: 'Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes.' The target for most nonpregnant adults is an HbA1c below 7% — but the Standards add a wrinkle: more stringent targets, like below 6.5%, make sense for younger patients with short disease duration. One diagnosis, one drug, one number — and then the individualization begins.

   The idea

   Guidelines give you a default, and the art is knowing when the default bends. Metformin-first is the standard because it works, it's tolerated, and it's cheap — but the HbA1c target is where patient factors enter. A 35-year-old newly diagnosed gets a tighter target than an 80-year-old with years of disease. The ADA's framing teaches the deeper skill: start with the standard, then individualize deliberately, not accidentally.

   Try this: For each of your type 2 diabetes patients this week, write down why their HbA1c target is — or isn't — <7%.

9. 9Chapters 18 and 20

   Staging kidney disease: GFR categories and the 10–20% slide

   A creatinine comes back slightly off. Is this kidney disease, or a lab quirk? The book explains the use of equations for estimating glomerular filtration rate (eGFR). Then KDIGO's 2012 guideline gives the map: chronic kidney disease classified by GFR category, G1 through G5, and albuminuria category, A1 through A3. The stakes are concrete: risk of progression is highest in patients with G3aA3 or worse, and progression to end-stage renal disease runs 10–20% over 5 years in that group. Two letters and a number tell you who's on the fast track.

   The idea

   Kidney disease is silent until it isn't, which is why classification matters more here than in almost any other chronic disease. The G-and-A grid does something clever: it combines two independent axes — filtration and protein leak — because either alone understates risk. A patient with G3aA3 isn't 'moderate CKD'; they're on a 5-year clock toward dialysis. That reframing changes how aggressively you manage blood pressure, medications, and referrals.

   Try this: Reclassify every CKD patient on your panel by both GFR and albuminuria category — flag anyone at G3aA3 or worse for intensified follow-up.

10. 10Chapters 19 and 26

    Low back pain: what to try before the opioid

    A patient doubles over with acute back pain, asking for something strong. The book arms you with two documents. The American College of Physicians (ACP) guideline for acute, subacute, and chronic low back pain is referenced. And the CDC's 2016 opioid guideline draws the line: nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. The sequence matters — the strong stuff isn't first, and for chronic pain it isn't even second.

    The idea

    Low back pain is where the opioid era collided with evidence, and the guidelines that emerged are a course correction. The ACP's staging and the CDC's preference ordering share a logic: reserve the riskiest tools for after the safer ones fail, and for chronic pain, the safer ones come first by default. Practicing this way isn't soft on pain — it's honest about what the trajectory of back pain actually is.

    Try this: Before your next chronic pain visit, list the nonpharmacologic and nonopioid options you'll offer first — and document why.

11. 11Chapters 20 and 12

    ABCD2 and the 4.5-hour window after a TIA

    A patient's arm went numb for twenty minutes this morning. It resolved. Do you send them home? The ABCD2 score is reviewed for risk stratification after a TIA. And if the worst happens — a full ischemic stroke — the AHA guidelines set the clock: tPA given within 4.5 hours of onset. Two tools, one message: cerebrovascular events are timed emergencies, and the primary care clinician is often the first person holding the stopwatch.

    The idea

    Transient symptoms are the most dangerous kind, because both patient and clinician want to believe them. ABCD2 converts that relief into arithmetic — age, blood pressure, clinical features, duration, diabetes — so disposition follows risk rather than reassurance. The 4.5-hour tPA window then defines the whole system downstream: the score decides who gets worked up fast, and the clock decides what treatment is still possible.

    Try this: Memorize the ABCD2 components tonight; use it on the next TIA call to decide same-day workup versus ED transfer.

12. 12Chapters 21 and 30

    U=U and the US MEC: contraception and HIV, guideline-driven

    Two conversations, one framework. A patient wants to know which contraception is safe given her medical history — the CDC's United States Medical Eligibility Criteria for Contraceptive Use gives the answer, condition by condition. Across the room, a patient with HIV asks what treatment means for his future. U.S. Department of Health and Human Services (2022) guidelines recommend antiretroviral therapy be initiated for all individuals with HIV regardless of CD4 count, with the goal of achieving and maintaining an undetectable viral load ('U=U'). Undetectable equals untransmittable. Both conversations end with evidence, not opinion.

    The idea

    These two guidelines share a philosophy: replace clinical folklore with graded, condition-specific evidence. The US MEC turns 'is this safe for her?' from a hunch into a category, and 'U=U' turns HIV counseling from fear into fact — treatment as prevention, backed by the goal of viral suppression for every patient. Primary care is where both conversations happen first, which makes knowing the current criteria non-negotiable.

    Try this: Bookmark the current CDC US MEC and HHS HIV guidelines on your phone; check them before your next contraception or HIV counseling visit.

13. 13Chapters 22 and 40

    PSA, shared decisions, and the physician shortage math

    A 60-year-old man asks whether he needs the PSA test. The USPSTF recommendation on PSA screening is covered, emphasizing shared decision-making, laying out what screening can and can't promise so he decides with you, not for him. Then the book zooms out to the system around that exam room: the Association of American Medical Colleges' 2021 report projects a shortage of 17,800 to 48,000 primary care physicians by 2034. The man in front of you is one patient; the shortage is the reason advanced practice nurses exist at scale.

    The idea

    PSA screening is the textbook case of a decision that belongs to the patient — the evidence doesn't dictate, it informs. Pair that with the AAMC shortage projection and you see the book's quiet argument: as physician supply tightens toward 2034, the clinician who can do shared decision-making well becomes more valuable, not less. Advanced practice nursing isn't a stopgap; it's the answer the shortage math demands.

    Try this: At your next PSA discussion, bring a decision aid and let the patient state his priorities before you state a recommendation.

14. 14Chapters 23 and 34

    Two ends of the lifespan: DDST-II and the Comprehensive Geriatric Assessment

    Monday morning: a toddler who isn't talking like her cousins. Friday afternoon: an 84-year-old whose family wonders if she can still live alone. The book gives you a tool for each. The Denver Developmental Screening Test II (DDST-II) is cited as a tool for developmental surveillance. For the older adult, the Comprehensive Geriatric Assessment (CGA) is cited to evaluate functional status, cognition, and social support. Same week, same clinician, two completely different assessments.

    The idea

    Primary care spans cradle to grave, and the assessments at each end look nothing alike — but they share a principle: measure function, not just disease. The DDST-II catches developmental delay early, when intervention matters most; the CGA catches the losses that don't show up in a problem list — can she cook, who checks on her, is her memory holding. Both tools exist because the important answers aren't in the chart.

    Try this: Add one functional question — 'who helps you at home?' — to every visit with a patient over 75 this week.

15. 15Chapters 24, 7, and 34

    Beers Criteria: the prescriptions that hurt older adults

    An 80-year-old with heart failure and chronic kidney disease carries a medication list that reads like a pharmacy. The Beers Criteria from the American Geriatrics Society (2019) states that NSAIDs are to be avoided in patients with chronic kidney disease or heart failure, and benzodiazepines should be avoided due to risk of falls and delirium. Two drug classes, both common, both routinely prescribed to the patients they harm most. The criteria exist because 'we've always given her ibuprofen' is how injuries happen.

    The idea

    Polypharmacy is where good intentions produce bad outcomes, and the Beers Criteria is the field's institutional memory of those outcomes. The logic behind the named examples is worth internalizing: NSAIDs strain kidneys and hearts that are already struggling, and benzodiazepines turn into falls and delirium in brains that can't clear them. Deprescribing is a skill, and a published criteria list is where it starts.

    Try this: Audit one older adult's medication list against the 2019 Beers Criteria this week — flag every NSAID and benzodiazepine and make a deprescribing plan.

16. 16Chapters 25 and 35

    Palliative care early: the Temel study and the consensus statement

    The old model: palliative care arrives at the end, after everything else has failed. The National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care dismantle that: 'Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided along with curative treatment.' The Temel et al. (2010) study found that early palliative care in advanced cancer improves quality of life and may prolong survival. Patients who got comfort care sooner didn't just die better; they may have lived longer.

    The idea

    The Temel finding inverted a decade of assumptions: adding palliative care early didn't subtract from treatment, it may have added life. That's why the consensus statement's 'any age, any stage' language matters — it reframes palliative care as a parallel track, not a terminal one. For primary care, the practical shift is referral timing: the question isn't whether the patient is dying, it's whether they're seriously ill.

    Try this: Refer one seriously ill patient to palliative care this month who isn't hospice-eligible — early, alongside active treatment.

Nurse practitioner students preparing for certification and practicing APRNs who want one current, lifespan-spanning primary care reference. Also valuable for physicians and PAs who want the nursing-perspective framework behind the same guidelines.

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