i give up

Epidemiology of Obesity

• ~43% of adults in US are obese

• 1/10 children become obese from 2-5 years old

Obesity rates are highest in:

• South and Midwest

• in Blacks, Hispanics

primary obesity

• excess caloric intake for body’s metabolic demands

• food low in calories and fits person’s lifestyle works best

weight loss stopped?

• ask if there is a change in diet and exercise

secondary obesity

• congenital disease

• endocrine disorders

• CNS lesions and disorders

Drugs for secondary obesity

• corticosteroids

• antipsychotics

Family Hx of obesity is indicative of?

increased chance for developing obesity

major site for regulating appetite

hypothalamus

• neuropeptide Y

  • powerful appetite stimulant

• hormones and peptides made in gut and adipocyte cells affect hypothalamus

lack of physical exercise can lead to:

• increased time spent:

  • gaming

  • surfing internet

  • watching TV

lack of access to affordable food and nutritious foods can lead to:

stretching food dollars by buying less expensive, poor nutrition quality foods

for young adults, tell them how losing weight will:

make them feel better

health risks associated with obesity

• increased mortality, primary with increased visceral fat

• reduced quality of life

• most conditions can improve with weight loss

android obesity pts at greater risk:

• increased LDLs

• High triglycerides

• decreased HLDs

HTN in obesity may occur related to:

• increased circulating volume

• abnormal vasoconstriction

• increased inflammation

sleep apnea

• snoring

• hypoventilation

obesity hypoventilation syndrome

• reduced chest wall compliance

• increased work of breathing

• decreased total lung capacity

• weight loss can improve lung function

osteoarthritis

• stress and cartilage deterioration in weight-bearing joints

  • knees

  • hips

• obesity triggers inflammatory mediators

• higher incidence of hyperuricemia and gout

for obese, ask:

what was the reason that started weight gain

Obese pt health Hx

• explore genetic and endocrine factors

• objective

  • lab tests of liver and thyroid function, fasting glucose and lipid panel

  • height, weight, waist circumference, BMI

• comorbid diseases related to obesity

  • HTN, sleep apnea, DM

Obese pt assessment:

• BMI

• waist circumference

• waist-to-hip ratio (WHR)

• body shape

waist circumference

• visceral fat with android obesity have increased risk for CVD, metabolic syndrome

  • men greater than 40” waist

  • women greater than 35” waist

apple-shaped body

• fat located primarily in abdominal area

• android obesity

pear-shaped body

• fat located primarily in upper legs

• gynoid obesity

clinical problems for pt w/ obesity may include:

• altered blood glucose level

• musculoskeletal problem

• risk for disease

overall goals for obese pts

• modify eating patterns

• take part in a regular exercise

• achieve and maintain weight loss to a specific level

• minimize or prevent health problems related to obesity

Obesity is one of most challenging health problems

• treatment begins w/ pts understanding their weight Hx and deciding on a plan that is best for them

barriers to counselling about obesity include:

• time constraints

• not wanting to cause embarrassment

• lack of reimbursement for weight loss services

Use motivational interviewing

• help pt understand why they want to lose weight

• help them gain confidence in their abilities

any diet can work if:

• it reduces caloric intake compared to expenditure

  • bulk to prevent constipation

• includes a variety of healthy foods

  • fruits and vegetables

  • sufficient protein

• pt will adhere to it

food portion must be carefully determined:

• w/n diet guidelines

• can be weighed

• determine portion size

diets low on carbs:

can lead to raid weight loss but are difficult to maintain

aim for at least:

• 150min weekly of moderate exercise

• 75min weekly for vigorous exercise

Obesity - Gerontologic Considerations

• can worsen age-related problems

  • urinary incontinence

  • hypoventilation

  • decreased quality of life

metabolic syndrome

• group of metabolic risk factors that increase a person’s chance of developing CVD, CVA, and DM

  • prevalence is 50% in those 60 years of age and older

  • number of persons aged to 20 to 39 years in metabolic syndrome steadily increasing

• pts are at higher risk for heart disease, CVA, DM, renal disease, polycystic ovary syndrome

metabolic syndrome; if 3 or more of the following conditions

• waist circumference

  • >= 40” (men)

  • >= 35'“ (women)

• active treatment for

  • triglycerides > 150mg/dL

  • HDL cholesterol

    • < 40 (men)

    • < 50 (women)

  • BP >= 130/85

  • Fasting glucose >= 100 mg/dL

metabolic syndrome etiology and patho

• insulin resistance related to excess visceral fat

• increased prevalence of CAD

  • HTN

  • increased risk for clotting

  • abnormal cholesterol levels

metabolic syndrome clinical manifestations

• impaired fasting glucose

• HTN

• abnormal cholesterol levels

• obesity

metabolic syndrome nursing/interprofessional management

• healthy lifestyle is cornerstone of treatment

• other interventions focus on controlling risk factors

  • reduce LDL cholesterol

  • lower blood pressure

  • reduce glucose levels

Tuberculosis (TB) - Basic Information

• airborne transmission

• Requires:

  • negative-pressure room

  • N95 respirator

• Isolation is priority.

TB - Key Assessment Findings

• Persistent cough

• hemoptysis

• night sweats

• weight loss

• fatigue

• low-grade fever

TB - Common Issues

reported:

• Hacking cough

• weight loss

• night sweats

• positive PPD

If TB question asks first action:

prevent spread to others first.

TB precautions

Airborne precautions

• not droplet/contact

Asthma - Basic Information

• causes:

  • bronchospasm

  • inflammation

  • mucus production

• Severe attacks may progress to respiratory failure

Asthma - Key Assessment Findings

• Wheezing

• chest tightness

• accessory muscle use

• tachypnea

Asthma - Common Issues

• Suddenly no wheezing

• difficulty speaking

• confused

• decreased breath sounds

Asthma - Silent chest means?

emergency.

Asthma - If wheezing disappears with poor air movement?

patient is worsening, not improving

Asthma Emergency

• A silent chest with little or no wheezing

  • severe airway obstruction

  • possible respiratory failure

COPD - Sleepy after oxygen?

Think CO₂ retention

COPD - Basic Information

• COPD includes:

  • chronic bronchitis

  • emphysema

• Some pts retain CO₂

• Excess oxygen may worsen hypercapnia

COPD - Key Assessment Findings

• Barrel chest

• chronic cough

• sputum

• pursed-lip breathing

• diminished breath sounds

COPD - Common Issues

• Drowsy after oxygen

• confused

• decreased respirations

COPD - If oxygen therapy causes mental status change:

suspect CO₂ retention

COPD Priority assessment

respiratory assessment

COPD pt on O2, indication of CO2 retention:

• Drowsiness

• decreased respirations

• confusion

ABGs - Basic Information

• normal range

  • pH

    • 7.35–7.45

  • PaCO2

    • 35–45

  • HCO3

    • 22–26

• High CO₂ = respiratory cause

ABGs - Key Assessment Findings

• pH changes

• altered breathing pattern

• confusion

• lethargy

ABGs - Common Issues

pH low + CO₂ high

ABG values

• First check pH, then CO₂

• Low pH + high CO₂

  • = Respiratory Acidosis

A low pH with high carbon dioxide usually indicates:

respiratory acidosis caused by hypoventilation

PNA - Basic Information

• Infection causes:

  • alveolar inflammation

  • impaired gas exchange

• Hypoxia is a major complication

PNA - Key Assessment Findings

• Fever

• productive cough

• crackles

• dyspnea

• pleuritic pain

PNA - Common Issues

• Sudden confusion

• restless

• older

• adult becomes weak

PNA - Confusion in respiratory pt?

think hypoxia first

• Check oxygen saturation before other interventions.

PNA Complication:

• Sudden confusion in pt w/ PNA may be hypoxia

  • so check O2 sat first

MI - Chest pain + sweating + radiation?

• treat like MI until proven otherwise

• diagnose ischemia first:

  • obtain an EKG

Pain >20–30 min + Nitro not helping?

indicative of MI

MI - Basic Information

• occurs when coronary blood flow is blocked, causing:

  • myocardial ischemia

  • cell death

• time = muscle

• Door-to-ECG w/n 10min

MI - Key Assessment Findings

• Chest pressure

• crushing pain

• diaphoresis

• nausea

• dyspnea

• anxiety

• pale cool skin

MI - Common Issues

• Chest pressure radiating to jaw/left arm

• sweating

• Sx not relieved by rest

Sx suggest MI?

• priority is rapid cardiac assessment

  • 12-lead ECG + O2 + perfusion

Myocardial Infarction vs Angina:

• Chest pain lasting longer than 15 to 30 minutes

  • not relieved by rest or nitroglycerin may indicate an MI

Troponin / MI Diagnostics - Basic Information

• Troponin

  • most specific cardiac biomarker for myocardial damage

  • rises w/n hours after infarction

Troponin / MI Diagnostics - Key Assessment Findings

Chest pain + elevated cardiac enzymes

Troponin / MI Diagnostics - Common Issues

• Cardiac enzymes

• myocardial injury

  • troponin

Stable Angina vs MI - Basic Information

• Stable angina usually improves w/ rest or NTG

• MI pain is prolonged and persistent

• Most likely MI lasting long and not relieved by rest and NTG

Stable Angina vs MI - Key Assessment Findings

• Chest pressure

• activity intolerance

• pain pattern

Stable Angina vs MI - Common Issues

• Pain lasted >20–30 min

• not relieved by NTG

Right-Sided Heart Failure - Basic Information

• Right = Rest of body (JVD, edema)

• Right-sided HF causes systemic venous congestion

• Blood backs up into body circulation

Right-Sided Heart Failure - Key Assessment Findings

• JVD

• peripheral edema

• hepatomegaly

• ascites weight gain

Right-Sided Heart Failure - Common Issues

• "Swollen legs

• neck vein distention

• abdominal fullness”

Question shows edema + JVD?

think right-sided HF

Left-Sided Heart Failure - Basic Information

• Left = Lungs (crackles, dyspnea)

• Left-sided HF causes pulmonary congestion

• Blood backs into lungs

Left-Sided Heart Failure - Key Assessment Findings

• Crackles

• orthopnea

• dyspnea

• pink frothy sputum

• fatigue

Left-Sided Heart Failure - Common Issues

• "SOB in supine

• crackles

• night coughs”

Lung Sx?

left-sided HF

Heart Failure Home Management - Basic Information

• Weight gain = fluid gain

• Fluid retention is a major complication

• Daily weights help detect worsening early

Heart Failure Home Management - Key Assessment Findings

• Weight gain

• edema

• fatigue

• decreased exercise tolerance

Heart Failure Home Management - Common Issues

• "2–3 lb gain overnight

• swollen ankles"

The most important HF self-monitoring intervention

daily weight same time every morning.

Peripheral Arterial Disease (PAD) - Basic Information

• Pain with walking = arteries blocked

• Rest relieves arterial pain

• PAD occurs when arteries narrow from atherosclerosis, reducing blood flow to the legs.

• Pain usually occurs during activity because muscles need more oxygen

Peripheral Arterial Disease (PAD) - Key Assessment Findings

• Cool extremities

• weak/absent pulses

• shiny skin

• hair loss

• thick toenails

• delayed cap refill

Peripheral Arterial Disease (PAD) - Common Issues

• “Leg pain while walking

• pain relieved by rest

• cold feet”

Pain with activity that improves with rest?

PAD + intermittent claudication

• Think ischemia

Acute Arterial Occlusion - Basic Information

• Sudden arterial blockage is a limb-threatening emergency

• Tissue can die w/o rapid intervention

Acute Arterial Occlusion - Key Assessment Findings

• 6 P’s = emergency

  • pain (sudden severe)

  • pallor

  • pulselessness

  • Poikilothermia (cold limb)

  • Paresthesia (numbness)

  • paralysis

Acute Arterial Occlusion - Common Issues

• "Sudden pale leg

• no pulse

• severe pain"

Pulses suddenly disappear?

• vascular emergency

  • Notify provider immediately

Chronic Venous Insufficiency (PVD/CVI) - Basic Information

• Veins cannot return blood effectively causing blood pooling and edema