Ambulatory Exam 1

Ambulatory Care

Healthcare outside of the acute care setting (outpatient care)

Broader term for healthcare, encompassing unique communities and populations and the public health sector

Differences between pop health and ambulatory care

Pop health focuses on:

health promotion and disease prevention, not treating the ill

the aggregate, not the individual

tracking epidemiological data

policy development

Population in Population Health

a group of individuals within a defined geographic area or a group by other shared characteristics (like ethnicity, age, employment status, etc.)

Community in Community Health

refers to a group of people with shared geography and/or other characteristics, but tends to be more local, whereas population health has a broader scope

Screening

testing a group at a specific point in time

Surveillance

broader analysis, continuous data collection

Upstream prevention

Interventions that aim to treat the cause of a health problem

Primary and specialty services

care outside of the hospital, like PCP, outpatient surgery, specialist medical treatment, etc

Health disparities

differences in health outcomes among groups

Social determinants of health

The conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources at global, national, and local levels

What does an ambulatory care nurse focus on?

- Upstream Prevention

- Primary and specialty services

- Health disparities

- Social determinants of health

- Patient education

- Patient engagement & activation

- Effective provider-patient communications

- Transitions of care

- Long-term care planning

- Attention to nurse-sensitive indicators

Main goal of ambulatory care

Individual controls treatment plan, client self-determination

Difference in treatment plan for ambulatory vs acute care

Ambulatory: Individual controls treatment plan

Acute: Healthcare team controls treatment plan

Difference in timing of care for ambulatory vs acute care

Ambulatory: Time of care varies: singular, episodic or may be seen intermittently over a period of years

Acute: Individual seen in a specified time period – admission to discharge

Difference in focus of care for ambulatory vs acute care

Ambulatory: Focus is on total healthcare picture

Acute: Focus is on a specific issue – cause for hospitalization

Difference in individual control for ambulatory vs acute care

Ambulatory: Care is initiated by the individual

Acute: Care may be out of the individual’s control

Difference in nursing observation for ambulatory vs acute care

Ambulatory: Nurse must rely on intermittent observations and the willingness and/or ability of the individual or caregivers to provide information

Acute: Nurse has direct and continuous observation of the individual

Difference in nursing skills for ambulatory vs acute care

Ambulatory: Broad range of nursing responsibilities

Acute: Specific responsibilities

Assessment-Based Approach for Ambulatory Care

•Identify client strengths and assets rather than just deficits

•Assess readiness to learn and motivation for change

•Evaluate current support systems and resources

•Determine barriers to independence (physical, financial, social, cultural)

Education and Skill Building for Ambulatory Care

•Health literacy development - teach clients to understand their conditions, medications, and treatment plans

•Self-care skills training - medication management, wound care, blood glucose monitoring, etc.

•Problem-solving skills - help clients learn to identify problems and generate solutions

•Decision-making support - guide clients through weighing options rather than making decisions for them

Resource Connection and Advocacy for Ambulatory Care

•Link clients to community resources - food banks, transportation services, support groups, financial assistance

•Navigate healthcare systems - teach clients how to schedule appointments, communicate with providers, understand insurance

•Advocate for accessible services - work to remove barriers in the healthcare system

•Connect with peer support - facilitate relationships with others who have similar experiences

Empowerment Strategies for Ambulatory Care

•Use collaborative goal-setting - involve clients in identifying their own priorities

•Encourage self-advocacy - teach clients to speak up for their needs

•Build on cultural strengths - incorporate traditional healing practices and family structures

•Promote gradual responsibility transfer - slowly shift tasks from nurse to client as competence grows

Environmental Modifications for Ambulatory Care

•Home safety assessments - identify and address fall risks, medication storage issues

•Assistive technology - help clients access and learn to use devices that promote independence

•Community accessibility - advocate for ramps, public transportation, accessible facilities

Home safety check can include...

- Assess need for client home modifications

- Apply knowledge of client pathophysiology to home safety interventions

- Educate client on safety issues

- Encourage client to use protective equipment when using devices that can cause injury

- Evaluate client environment for fire and environmental hazards

What does insurance or governmental support usually cover?

•As expected, depends on your level of coverage, but generally, all should cover some provider-prescribed, skilled, intermittent or episodic care outside of the hospital

•Medicaid tends to offer more benefits for nonmedical personal care

Medicare

federal health insurance for persons 65+ (note: also available for those <65yo with ALS or ESRD)

Medicaid

state-run (but joint federal- & state-funded) program to help cover medical costs for persons with lower income

Medicare Part A

helps cover inpatient care in hospitals, and skilled nursing facilities.

Also pays for some home health care and hospice care and inpatient care in a religious non-medical health care institution

Medicare Part B

helps cover medically necessary doctors' services, outpatient care, home health services, durable medical equipment, mental health services, limited outpatient prescription drugs, and other medical services.

Also covers many preventative services

Centers for Disease Control and Prevention (CDC)

Founded in 1946 with first goal to prevent Malaria spread in US, expanded to all communicable disease; focus on disease surveillance overall

World Health Organization (WHO)

Founded in 1948, following WWII to create global cooperation on health issues; first focus was on TB and malaria, plus women & children's health, nutrition and sanitation

The Red Cross defines disaster as

“a sudden calamitous event that seriously disrupts the functioning of a community or society and causes human, material and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources"

Emergency Management

The managerial function charged with creating the framework within which communities reduce vulnerability to threats/hazards and cope with disasters

usually managed by state government or tribal government

Disaster Preparedness

usually managed by federal government

mass casualty incident

an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short time

Natural Disaster

great destruction or loss of life caused by natural forces rather than by human actions

•hurricanes

•Wildfires

•Earthquakes

•Tornados

•Tsunami

•Heat/cold exremes

•Volcano

•Landslides/Avalanche

•Floods/monsoons

•Drought

Man-made Disasters

Disasters resulting from human actions or negligence.

Mass shooting

Nuclear

Gas leak/explosions

War, coups

Pollution

Chemical spills

Transportation

Terrorism

Cyber attack

Shootings

Fire/Arson

Infrastructure collapse

Beyond loss of life, illness, and injury, disaster lead to:

- disruption in services like hospital care

- environmental imbalances (mold, cholera, etc)

- Psychological, emotional, social wellbeing

- Food shortages (crops, displacement, work)

- Population movement

Mitigation

Risk reduction

Ex: improving infrastructure, coordinated public warning systems

Preparedness

planning & training for potential disasters

Ex: detailed and written emergency plan with training and recourses, practice simulation

Responce

activities that address the short-term, direct effects of an incident. This is the immediate action phase during and after a disaste

Ex: evacuations, immediate health needs, life-sustaining services like hydration, search/rescue, emergency services like backup power

#1 Goal of emergency management

Decrease loose of life

#2: decrease property loss

Why is it beneficial for President to declare disaster vs emergency

$$ and resources

Tribal and Territorial Governments

Puerto Rice

Guam

American Samoa

US Virgin Islands

Northern Mariana Island

Tribal Regions

Nursing Role in Mitigation

Community Education

Advocacy

Vulnerability Assessment

Community Education For Nursing Role in Mitigation

Nurses educate the public on topics such as creating family disaster plans, assembling emergency kits, and understanding local hazards.

* This one overlaps with preparedness*

Advocacy For Nursing Role in Mitigation

Nurses advocate for policy changes that promote community resilience, such as improved building codes and environmental protections.

Vulnerability Assessment For Nursing Role in Mitigation

Nurses help identify vulnerable populations within a community who may be at higher risk during a disaster, such as older adults, children, and those with chronic illnesses and limited mobility

Nursing Role in Preparedness

Developing Emergency Management Plans

Training and Drills

Resource Management

Developing emergency management plans (EMP) Nursing Role

•Nurses participate in the development of disaster plans for healthcare facilities and communities. (Sometimes called operational plans)

•For healthcare facilities, a robust EMP is not just a best practice. It is a critical component of client safety and a requirement by regulatory bodies like The Joint Commission and the Centers for Medicare & Medicaid Services (CMS).

•An EMP is a detailed written plan that outlines specific roles, responsibilities, and procedures in the event of an emergency.

•There should be different plans for different emergencies or hazards.

Training and drills Nursing Role

Nurses actively participate in disaster drills and simulations to test EMPs and refine their skills.

Resource management Nursing Role

Nurses help ensure that adequate medical supplies, equipment, and personnel are available to respond to a disaster.

Nursing Role during Response

Leadership and Incident Command

Triage

Direct Client Care

Shelter Management

Leadership and incident command Nursing Role

Depending on the EMP, nursing leaders may be involved in incident command activities.

Triage Nursing Role

In mass casualty incidents, nurses are responsible for triaging clients, prioritizing care based on the severity of their injuries

Direct Client Care Nursing Role

Nurses provide essential medical care, including first aid, wound care, medication administration, and emotional support to victims.

Shelter Management Nursing Role

Nurses may work in temporary shelters, providing care to displaced individuals and families

Recovery

This final phase focuses on returning the community to a state of normalcy.

Nursing Role during Recovery

Long term care

mental health support

community rebuilding

Long Term Care nursing role

Nurses provide ongoing care for individuals with injuries or illnesses sustained during the disaster

Mental Health Support Nursing Role

Nurses play a crucial role in providing mental health support to both victims and fellow responders, helping them cope with the trauma of the event

Community Rebuilding Nursing Role

Nurses contribute to the rebuilding of healthcare infrastructure and the restoration of community health services.

RACE for Fires

rescue, alarm, confine, extinguish

PASS for fire extinguishers

Pull, Aim, Squeeze, Sweep

CUS

I am Concerned

I am Uncomfortable

This is a Safety issue

De-escalate

Whether you are arriving to scene as bystander or emergency response personnel, what is your first priority?

Safety

Cascading Events

Events that occur as a direct or indirect result of an initial event

Ex: earthquake leads to tsunami

_____ is the #1 cause of death from injury

bleeding

Manageable span of control: one supervisor to how many subordinates?

1 to 5

START and SALT

most common system used for mass casualties in the field

Triage

the medical screening of patients to determine their relative priority of need and the proper place of treatment

START Triage (Simple Triage and Rapid Treatment)

Primary use: Adult patients (typically ≥8 years)

Assessment criteria:

•Respiratory rate (breathing)

•Perfusion (circulation/pulse)

•Mental status (ability to follow commands)

Categories: Immediate (red), delayed (yellow), minor (green), deceased (black)

Time limit: Ideally 60 seconds or less per patient

SALT Triage

Primary use: All age groups, including pediatric patients

Process:

Sort: Global sorting of patients who can walk

Assess: Individual assessment using LSI and priority criteria (ABCs or ABCDs)

Lifesaving Interventions: Simple interventions like positioning airway, bleeding control

Treatment/Transport: Final prioritization for treatment and transport

Categories: Same color coding but more nuanced decision-making process

Prioitization

Airway, Breathing, Circulation, Dysfunction (neuro)

Red Triage Color

unstable, need immediate support to save their life

Yellow Triage Color

stable, but serious, likely need treatment but can be delayed ~ 30-60 minutes

Green Triage Color

stable, but wounded/ill, likely minor and can withstand waiting > 60 minutes for treatment; “walking wounded”

black triage color

deceased or expectant for death; injuries incompatible with life

SBAR

Situation

Background

Assessment

Recommendation

Mass Care and Emergency Assistance Includes

actions taken to protect evacuees and others from the effects of the event. Includes sheltering, food distribution, medical care, clothing, and other essential life support needs of those who have been displaced by a threat/hazard.

Health and Medical Services Provides

health and medical services in emergencies, including emergency medical, hospital, public health, environmental health, mental health, and mortuary services.

Hurricane Katrine Vulnerable Population

- elderly

- disabled

- low income

- children/families

Danger of Flood Waters

animals and insects

live wires

harmful bacteria

dangerous chemicals

sewage

sharp objects & debris

What is the epidemiology triad

Environment, agent, host

Susceptible host, what should we consider

immunity, age, genetics, co-morbidities, life style

Environmental factors, what should we consider

pollution, air, sanitation, water, geography (urban, rural, tropical, desert, etc), access to care, politics

Infectious agent. what should we consider

virus, bacteria, other, chemical, physical injury

Tests for TB

1. tuberculin skin test (TST or PPD)

2. IGRA Blood test

3. Sputum smear

4. Nucleic Acid Amplification

5. Chest X-ray or CT

Tuberculin Skin Test (TST)

Used to determine past or present tuberculosis infection present in the body. This is based on a positive skin reaction to the introduction of a purified protein derivative (PPD) of the tubercle bacilli, called tuberculin, into the skin.

IGRA Blood Test

for those vaccinated with BCG as a child it won't give false +

Sputum smear and culture

works if patient is actively coughing or in low income settings

Nursing Tips for Excellent Sputum Collection

1. Morning is best

2. Rinse mouth

3. have patient take deep breath, hold, out, try to initiate deep cough

4. Open container when about to spit

5. Spit about 5mL, or 1 tsp

6. Close container and date

TST Test Interpretation

≥5mm: HIV+, immunocompromised, recent exposire

≥10mm: high risk groups, immigrants from high-prevalence areas

≥15mm: low risk individuals

S/S of TB

unintentional weight loss

night sweats

loss of appetite

chest pain

couch lasting more then 3 weeks

fatigue

fever

coughing up blood

TB First-Line Meds

Rifampin

Isoniazid

Pyrazinamide

Ethambutol

TB first line med side effects

Isoniazide: hepatotoxicity, peripheral neuropathy (take vit B6)

Rifampin: orange discoloration of body fluids, hepatotoxicity

Ethambutol: optic neuritis

Phrazinamide: Hepatotoxicity, hyperuricemia

TB Infection controll protocols

airborne precautions until non-contagious

negative pressure room

N95 respirator

Latent TB

25% of the world has been exposed to TB

10% of those get active TB

Airborne Precautions

standard precautions + mask, negative pressure, clean hands

Droplet precautions

Standard + mask, googles, wash hands