Ambulatory Exam #3

Triggers that can elicit an asthma attack

• Respiratory tract infections

• Exercise

• Drugs (ASA and morphine)

• Emotional upset

• Bronchial irritants (cigarette smoke)

Triggers for exacerbation of COPD

• Dust and chemicals

• Air pollution

• Tobacco smoke

• Infection

Risk factors for asthma

• Genetic predisposition

• Slightly more common in male children and female adults

• Preterm delivery

• Maternal smoking

• Childhood allergic rhinitis

• Respiratory infections early in life (RSV & bronchiolitis)

• Bronchial irritants

Risk factors for COPD

• Smoking

• Biomass fuel cooking

• Bronchial irritants

Short term treatments for asthma

• SABA such as albuterol may be first – quick onset, less expensive.

• Anticholinergic and short-acting Beta-2 agonist (SABA) – more effective than either alone

Improves quality of life, but doesn’t increase life expectancy

Long term treatments for asthma

• Inhaled corticosteroids- ICS (mometasone)

• Inhaled long-acting β2-agonists - LABA (salmeterol)

• Combination inhaled medications ICS +SABA (Symbicort)

Primordial Prevention

relates to prevention on a societal or legal/legislative level

primary prevention interventions for COPD and asthma

• Education about risks of smoking

• Educate about risk factors

• Avoiding possible triggers

secondary prevention interventions for COPD and asthma

• Recognize occupational risks– industry and agriculture, tertiary sector

• Lung cancer screenings

• Pulmonary function tests

tertiary prevention interventions for COPD

• Eliminate exposure to inhaled toxins

• Vaccination for respiratory diseases 

• Stop smoking

• Antibiotics

• Surgery

tertiary prevention interventions for asthma

• Recognize early symptoms and triggers

• Always have rescue inhaler

• Long term medication treatments 

• Vaccination for respiratory diseases

What are the diagnostic tests that confirm the presence of COPD and asthma?

• USPSTF Recommendations: Lung Cancer Screening (Grade B)

• Pulmonary function tests: can use to determine severity and track disease progression

Lung Cancer Screening guidelines

• Annual, for 50-80 y/o with 20 pack-year smoking history

• Discontinue once haven’t smoked in 15 years

Pulmonary function test details

• Forced vital capacity (FVC): amount of air breathed out forcefully and quickly after breathing in as much as you can.

• Forced expiratory volume: amount of air breathed out during the first, second, and third seconds of the FVC test. FEV1 (during the 1st second) is used in calculating below.

• FEV1/FVC ratio: ratio between the FEV1 and FVC

For tertiary prevention, what are the nursing actions to avoid or reduce exacerbations of COPD and asthma?

• Educate about, identify, and avoid triggers

• Pharmacological treatments (ex: rescue inhaler, corticosteroids, antibiotics)

  • Make sure they understand how to use it

• Vaccinate against respiratory diseases

• Recognize early symptoms and triggers

• O2, home O2

What are the risk factors for CAD?

Modifiable: 

• HTN

• Diabetes

• High cholesterol

• Smoking

• Obesity

• Stress

• Physical inactivity

• Unhealthy diet

• Excessive alcohol

• Sleep apnea

Non-modifiable:

• Age

• Family history

• Gender: women less risk until after menopause

• Race: related to higher incidence of HTN

CAD diagnostic tests

• EKG

• Labs

• Echocardiogram

• stress test– treadmill/exercise, pharmacologic, six-minute walk test

• Cardiac catheterization

• Coronary calcium score

What is the action of cholesterol in heart disease? Understand the different lipids – which one is desirable?

• HDL: “good,” high density lipids- transports cholesterol from cells to liver; want it to be high (healthy fats, exercise), can remove excess cholesterol or any buildups 

• LDL: Lousy /bad/low density lipids- transports cholesterol from liver to cell; want to be low

• Triglycerides: most common type of fat in the body

In heart disease: LDL builds up to form plaque, atherosclerosis

Statins: use and side effects

• used to reduce cholesterol

• Monitor liver function

• Rhabdomyolysis (not common) but some have muscle symptoms

ACE Inhibitors side effects

• ACE-I cough and Hypotension adverse effects

Beta blockers side effects

Bradycardia and Hypotension adverse effects

Nitrates interaction

Dangers with Viagra-type drugs

What does tertiary prevention in a post-MI patient look like? How do you prevent the complications of dysrhythmia, heart failure, a second MI?

• Lifestyle: HTN, DM, nutrition, sodium limits

• Increase exercise

• Consider implantable cardioverter/defibrillator

• Vaccinations

• Medications (ACEI, beta blockers, loop diuretics, SGLT-2 inhibitors)

• Monitor weight and other symptoms, track HR and look for dysrhythmias 

For the patient with heart failure, what should the patient and nurse monitor to avoid exacerbation of fluid buildup?

• Weight

• Abnormal lung sounds (rales)

• Shortness of breath

• Increased coughing

• Ankle edema

• Ascites 

• Neck vein distension 

• S3 gallop in heart sounds and tachycardia 

• BNP labs

How would the RN recognize signs and symptoms of HF exacerbation?

• Swelling in legs or stomach

• Shortness of breath, dizziness that is new

• Increased coughing

• Poor appetite

• Changes in heart beat or rate

• Cardiomegaly

Occupational: over time, what has been the main change in the perspective of employers toward employee health?

• shift from focusing on just occupational injuries to occupational diseases as well

• Working population is getting older as time goes on

Occupational health: employer interventions

• Occupational Health Clinics

  • Education

  • Disease prevention (secondary and tertiary strategies)

  • Health and wellness planning

  • Assessment and referrals

• Broadening the population to more than full time

• A wider group of stakeholders: insurance buy-in

• Health and well-being strategies

• Activity and health tracking

Home health: What is the role of the RN “on their turf”?

• Assessment (health and home safety)

• Medication delivery and IVs

• Patient/Family Teaching

• Coordination of Care and Service

• Assist with ADLs

• Vitals, wound care, response to medication

In assessing a patient in the home, what findings would be of concern to the RN?

• Fall risks: rugs, poor lighting, loose wires

• Less controlled environment

• Safety of nurses: animals in home

• Cleanliness/sanitation

Legal considerations of palliative/hospice care

Pronouncing death– rules vary by state, physician may or may not have to be present

Benefits of of palliative/hospice care

• 24-hour RN support

•  Medical supplies/equipment

•  Medications

•  In home clinical and personal care

•  Multidisciplinary team

•  100% care/meds paid by Medicare

•  Respite care for caregivers

•  Bereavement support

Myths/misunderstandings of of palliative/hospice care

• You must agree to a DNR

• You will die within 6 months

• You can’t change your mind and try curative therapy

• You can’t undergo palliative chemo or radiation

• You must stop dialysis

• Hospice hastens death

• Hospice supports physician aid in dying

Characteristics of palliative care

• Paid by insurance or self

• Any stage in disease

• Includes curative treatment

• Typically in hospital

Characteristics of hospice care

• Paid by medicare, medicaid, or insurance

• Prognosis of 6 months or less 

• Excludes curative treatment

What are the current challenges for school nurses? What student health issues are they expected to address?

• Chronic illness: diabetes, asthma, epilepsy

• Increasing awareness of allergies

• Learning, mental health, or behavioral challenges

• Physical challenges (obesity and mobility issues)

• Legal and societal challenges (abuse, vaccination)

Review the nursing expectations and responsibilities in infusion and dialysis.

• Assessment, monitor for complications

  • Phlebitis, infiltration, infection

• Coordination of support services and resources

• Collaborate with other healthcare professionals

• Manage vascular access devices (VADs)

What are the implications of home dialysis for elderly patients?

• Negative perceptions and bias from healthcare workers about eligibility of older adults for home dialysis

• Concerns with burden of treatment

• Complications could be more prevalent 

• Caregiver stress and burnout

refugee definition

someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion

immigrant definition

someone who makes a conscious decision to leave his or her home and move to a foreign country with the intention of settling there

migrant definition

A person who voluntarily leaves his/her country of origin to seek residence in another country

people seeking asylum definition

someone whose request for sanctuary has yet to be processed; they have suffered persecution or fear that they will suffer persecution due to: Race, Religion, Nationality, Membership in a particular social group, Political opinion

healthcare options for refugees in US

• Refugee Medical Assistance (RMA)

  • for 8 months

• Could be eligible for Affordable Care Act after 8 months

What are nursing considerations for both physical and mental health issues related to care of those leaving countries with challenging conditions?

• lack of knowledge about services

• availability of services, transportation, hours of service

• discrimination

• language and cultural barriers

• inability to afford care

• lack of documentation

What are the guaranteed rights and healthcare issues for inmates in federal prisons?

• guaranteed a right to health care by the 1976 U.S. Supreme Court decision Estelle v. Gamble

  • type and quality vary

• clinic visits, continuity visits for chronic conditions

• infirmaries available

What are the challenges specific to incarcerated women, especially related to pregnancy and delivery?

• 6-10% are pregnant

• high risk for poor maternal and infant health

• high rate of co-morbid conditions

What are the healthcare challenges specific to those without stable housing?

• lack of space in treatment facilities

• inability to pay

• lack of transportation

• non-supportive attitudes in healthcare personnel, stigma

• lack of coordinated services

• safety

• weather, crime

What challenges also would be specific to medications and adherence for unhoused people?

• cost

• timing

• food

• refrigeration/storage