Ambulatory Exam 1

Acute Care

Inpatient, hospital-based care focused on short-term, high-intensity interventions.

Ambulatory Care

Outpatient, non-hospital setting where patients receive care and return to independent living.

Acute Nurse

A nurse responsible for continuous monitoring and frequent interventions in a hospital setting.

Ambulatory Nurse

A nurse who relies on intermittent observations and focuses on patient education and self-management.

Goals of Acute Care

Stabilization, safe discharge, prevention of immediate complications, and meeting measurable clinical outcomes.

Goals of Ambulatory Care

Client independence and self-determination, with a focus on long-term health management and prevention.

Public Health Nursing

Nursing that focuses on the aggregate population for prevention, surveillance, health promotion, and policy.

Population in Population Health

A defined group with shared characteristics, such as geographic, demographic, or risk factors.

Population vs Community

Population is broader and data-driven, while community is smaller/local with personal connections.

Medicare

Federal health insurance for people aged 65 and older, and for some under 65 with ALS or ESRD.

Medicare A

Covers hospital/inpatient care, skilled nursing facilities, and hospice services.

Medicare B

Covers outpatient services, physician visits, durable medical equipment, and home health.

Medicaid

State-based health insurance for low-income individuals, covering hospital and outpatient services.

Screening

A point-in-time assessment of a specific group to detect undiagnosed diseases.

Surveillance

Continuous, systematic monitoring over time to track health trends.

Key Difference between Screening and Surveillance

Screening is a snapshot of current prevalence, while surveillance tracks changes over time.

Role of the Home Care Nurse

Provides care to patients in their homes, focusing on health management and support.

Examples of Acute Care Settings

ICU, med-surg, ED.

Examples of Ambulatory Care Settings

Clinics, home health, schools, telehealth, public health.

Examples of Medicare A

70-year-old admitted with pneumonia.

Examples of Medicare B

72-year-old receiving weekly home health nursing visits.

Examples of Medicaid

Low-income child at community health clinic.

Examples of Screening

TB skin test on students this fall.

Examples of Surveillance

NYC Health Department monthly MRSA case reporting.

RN (skilled nursing)

Wound care, IV therapy, med teaching, assessment, chronic disease management. Stays 45-60 minutes, clinical focus.

Nurse aide

Assists with ADLs (feeding, bathing, toileting). Longer shifts (4-8 hrs).

Skilled vs ADL support

Distinguish 'skilled' = RN clinical judgment vs ADL support (aide).

Benefit of home care

Longer education, patient comfort/logistics, real world assessment.

Need for home care

New medication.

Safety concerns of home care

Trusting nurse, new people in your environment.

Safety risks

Firearms, pets, clutter, fall hazards.

Nurse safety

Agencies use GPS check-ins, policies for leaving unsafe homes, not just 'push-button for police' (professor highlighted bias concerns with that approach).

Medication adherence

Confusion when generics change (pills different colors/shapes).

Family dynamics

Sometimes conflict between patient/family and nurse.

Empowerment

Helping patient set/manage own health goals.

Community Assessment Goal

Systemically identify health needs & assets in a defined population.

Community Assessment Process

Collect primary data (interviews, windshield surveys, focus groups). Collect secondary data (census, epidemiological stats, disease registries, vital statistics, population demographics). Analyze → prioritize issues → plan interventions.

Challenges in Community Assessment

Limited resources, capturing representative data, translating findings into realistic nursing interventions.

Windshield Survey

Assess a community: public transportation, housing, roads, sidewalks, businesses, meeting places, food options, people, healthcare options, services, look for own ethnocentrism: tendency for individuals to interpret social norms based on one's own culture.

Emergency

Local, manageable with available resources.

Disaster

Overwhelms local resources, requires outside aid (state/federal), exceeds the community or society's ability to cope using its own resources.

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.

4 Phases of Disaster Management

Mitigation, Preparedness, Response, Recovery.

Mitigation

Prevent/reduce impact (levees, immunizations, improving infrastructure, coordinated public warning system with pre-scripted messages).

Preparedness

Planning, drills, stockpiling supplies (detailed and written emergency plan with training and resources).

Response

Active disaster care (triage, treatment, shelter) - addresses the short term direct effects of an incident.

Recovery

Long-term rebuilding, mental health support.

Vulnerable Populations in Disaster

Elderly, children, disabled, chronically ill, homeless, immigrants/language barriers, pregnant.

Health & Safety Hazards of Disasters

Physical injuries, infection outbreaks, contaminated water/food, mental health issues (PTSD, stress), flood water can hide dangerous sickness: animals, insects, dangerous chemicals, live wires, sewage, harmful bacteria, sharp objects and debris.

Mass Casualty Triage

START method used for mass casualties.

Immediate (red)

Life-threatening but treatable, unstable, immediate support. Examples include active hemorrhage, cardiac arrest, active CPR.

Delayed (yellow)

Serious, can wait, stable, need care in 30-60 minutes. Example includes moderate burns.

Minor (green)

Walking wounded, can withstand waiting >60 minutes for treatment.

Expectant (black)

Unlikely to survive, deceased.

SALT

Sort, Assess: individual assessment using life saving interventions and priority criteria (ABCs), treatment/transport: final prioritization for treatment and transport.

Fire Protocols

RACE: for fires.

RACE

Rescue patients and self, Alarm, Contain, Extinguish/evacuate.

PASS

For fire extinguishers: Pull the pin out, Aim the nozzle at fire, Squeeze handle, Sweep the spray from side to side.

Epidemiology Triad

Host: Susceptible host: immune, age, lifestyle, genetics, comorbidities; Agent: Infectious agents: virus, bacteria; Environment: pollution, occupational hazard, chemicals, politics, access to care, rural/urban, food source.

Example of Epidemiology Triad

TB outbreak → host = immunocompromised, agent = Mycobacterium TB, environment = crowded shelter.

Tuberculosis (TB) Testing

PPD (Mantoux): induration >10mm = positive in general population. Check in 2-3 days.

Positive Induration

Positive Induration >= 5mm = Immunocompromised pts; >=10mm = people in high congregate settings or those with diabetes, cancer; >=15 mm = people with no known risk factors for TB.

Interferon gamma release assay (IGRA)

Blood test preferred over PPD if had BCG vaccine, with logistical benefit of 1 day results.

Active vs Latent TB

Active = coughing up blood, night sweats, cough lasting more than 3 weeks, weight loss, contagious; Latent = no symptoms, not contagious, still needs treatment.

Isoniazid Prophylactic Therapy

If test positive, do isoniazid prophylactic therapy for 6-9 months.

Tuberculosis (TB) Treatment

RIPE or combo pill Rifafour: Rifampin, Isoniazid, Pyrazinamide, Ethambutol.

Rifampin

Orange discoloration of body fluids (Expected), hepatotoxicity.

Isoniazid

Hepatotoxicity, peripheral neuropathy (need to take neuroprotective pyridoxine, vitamin B6).

Pyrazinamide

Hepatotoxicity, hyperuricemia.

Ethambutol

Optic neuritis (vision changes).

Public Health for TB

Mandatory reporting, contact tracing, isolation.

Precautions

Airborne: TB, measles, COVID (N95, negative pressure room, clean hands); Droplet: Flu, pertussis (surgical mask within 6 ft, eye protection, clean hands); Contact: MRSA, C. diff (clean hands, gown, gloves, wash with soap and water on exit); Neutropenic: Reverse isolation for immunocompromised, strict hand washing before patient care, no sick visitors or personnel, no plants or fresh fruit/vegetables; Standard precautions: Hand, PPE, equipment, environment, linens, needles, resuscitation, placement, respiratory.

HIV Testing

ELISA, Western blot, rapid antibody.

Window period

Infection present but test negative (2-8 weeks).

PEP

Post-exposure prophylaxis that must be started within 72 hours of exposure.

Common PEP regimen

Truvada and Dolutegravir.

PrEP

Daily prophylaxis for high-risk individuals using Truvada (Tenofovir, Emtrictabine), Descovy, Apretude.

ART

Antiretroviral therapy for HIV treatment.

CD4 count

A lab test that measures the number of CD4 cells in the blood.

Viral load

Blood test reporting number of copies of HIV RNA per mL in blood (undetectable viral load: < 200 copies/ml).

U=U campaign

Undetectable = untransmittable.

Tenofovir, lamivudine, dolutegravir

#1 regimen in the world for HIV treatment.

Zidovudine

Can prevent fetal transmission of HIV.

Efavirenz

Notorious for causing nightmares.

Nucleoside and non-nucleoside reverse transcriptase inhibitors

Classes of antiretroviral medications.

Integrase inhibitors

Class of antiretroviral medications that includes Dolutegravir, known for faster viral replication and reduced side effects.

Opportunistic infections

AIDS defining illnesses such as Pneumocystis pneumonia (PJP), Cytomegalovirus (CMV), and Encephalopathy.

Epidemic

Sudden increase in a specific region.

Pandemic

Global spread, exponential growth (e.g., COVID).

Endemic

Ongoing baseline presence of a disease in a specific region (e.g., malaria in Africa).

Herpes Zoster (Shingles)

Characterized by painful unilateral rash along dermatome and blisters.

Shingrix

Vaccine recommended for individuals aged ≥50 years.

Lice

Characterized by intense and persistent scalp itching, visible nits, and a tickling sensation.

Permethrin shampoo

Treatment for lice.

Nits

Lice eggs.

Plasmodium falciparum

Most dangerous malaria parasite, requires mosquito host to survive and reproduce.

Transmission of malaria

Occurs through Anopheles mosquitos via the bloodstream.

Diagnosis of malaria

Blood smear and rapid antigen test.

Cerebral malaria

Most serious form of malaria characterized by infected red blood cells accumulating in capillaries.

Artemisinin-based combination (ACT)

Main treatment for malaria.