Ambulatory Exam 2

Name the 5 SDOH

Education Access/Quality

Economic Stability

Healthcare Access/Quality

Social + Community Context

Neighborhood + Build Environment

Education Access/Quality Assessment Aspects

education background and learning preferences

Health literacy

Identify language, audio, visual barriers

Check digital literacy and access to tech

Economic Stability Assessment Aspects

financial concerts, employment, access to food, ability to pay for food

Healthcare Access/Quality Assessment Aspects

insurance, coverage, location of clinical, points of care, care than meets cultural needs, transportation to clinics

Remember that having insurance isn't the whole picture

Social + Community Context Assessment Aspects

Looking for community cohesion and engagement and civic participation

Cultural practices of community; do they experience discrimination and racism

What do social support networks look like? For adults and adolescents alike.

Neighborhood + Build Environment Assessment Aspects

Housing quality and safety (homicide rate)

Environmental exposures from air and water

Space space of physical activity

Check for issues related to crime and violence

intersectionality

the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.

Higher SES predicts ____ health and lower SES predicts _____ health

Higher SES predicts better health and lower SES predicts poorer health

From the Healthy People 2030 “Leading Health Indicators”, indicate the 5 that have gotten worse.

Drug overdose Deaths

Homicides

House food insecurity and hunger

4th Grade students who reading skills are ≥ proficient achievement for grade level

Tobacco use among adolescents

interventions related to health information to improve health literacy

You can test reading level in Word, best to have non-med person review

Use: teach-back method

Include not just language, but cultural photos, food recs

Consider visual aids, spacing & large font

assessment related to health information to improve health literacy

The language, is it simplified, at a 5/6th grade reading level, without medical jargon?

Does the patient understand the teaching?

Culture and language of target population

Overall look of written info

High Food Security

no reported indications of food-access problems or limitations

Marginal Food Security:

one or two reported indications—typically of anxiety over food sufficiency or shortage of food in the house. Little or no indication of changes in diets or food intake

Low Food Security:

reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake.

Very Low Food Security

reports of multiple indications of disrupted eating patterns and reduced food intake.

Food Desert

An area in a developed country where healthy food is difficult to obtain

Urban: >1 mile from stores

Rural: >10 miles from stores

Medicare Eligibility

65yo or certain conditions

Medicare Part A is

hospital insurance

Medicare Part B is

medical insurance, you do pay a monthly premium

Medicaid

A federal and state assistance program that pays for health care services for people who cannot afford them.

~22K/yr for 1

~45K/yr fam of 4

What age range has unintentional injuries as #1 cause of death

1-44 y/o

#3 for males overall

#6 for females overall

Homicide is top 5 cause of death for what age range

1-44 y/o

Interventions to decrease tobacco use among adolescents

Tobacco 21: raising the age to buy tobacco products to 21

Excise Tax: put a high tax on tobacco products

Enforce smoke-free zones

Education at schools and for parents

Med: bupropion (Zyban, Wellbutrin)

names of common medications or substances that lead to overdose deaths

Fentanyl (#1)

Simulants

Benzos

Antidepressants

Max dose per 24 hour of aceteminophen

4g (4000mg)

Explain the role of the nurse care coordinator

Coordinates care plans and communication between patients and the healthcare team.

Ensures smooth care transitions and continuity of care.

Advocates for patient-centered, safe, and effective care.

Health Issues Likely Related to Environmental Pollution

Environmental health issues are tied to specific contaminants in the air, water, soil, or built environment.

The cause is usually more localized, chemical, or industrial.

Ex: Traffic exhaust, Lead in pipes or paint, pesticide exposure

Health Issues Likely Related to Climate Change

Climate change refers to changes in temperature patterns, extreme weather events, and shifts in ecosystems over time.

Health effects arise from heat stress, altered disease patterns, and disruptions to living conditions.

Ex: Increased frequency of heat waves, Changing rainfall patterns, Hurricanes, floods, droughts, Wildfire expansion

Lead poisoning sources

-lead-based paints

-drinking water via lead pipes

-lead-contaminated soil/air

-pottery glazes

-folk remedies

lead poisoning important numbers

no safe levels, but 5 ug/dL is the number taken seriously

45 ug/dL = medication intervetion

Lead Poisoning Effects

it is a neurotoxin that can lead to developmental delays, behavioral issues, and lower IQ in children and make personality changes in adults

Lead Poisoning treatment

Low Exposure: high vitamin C, iron and calcium

- Leafy greens!

Blood Levels above 45 ug/dL: Chelation therapy

Chelation therapy

synthetic agent administered via IV, binds to lead (or mercury) and then compound pulled out of the body through urine

What to be careful about Chelation therapy

Careful with people with kidney issues!

Serving size allow for seafood

Serving = 4oz (for ppl 11 and up)

Best choices for seafood

2-3 serves per week are ok! (kids = 2 serves, preg = 1 serving)

Catfish, cod, crab, lobster, oyster, salmon, sardine, scallop, shrimp, tilapia, tuna (canned light)

Seafish to avoid

highest mercury levels

Shark, swordfish, orange roughly, marlin, king mackerel

particulate matter (PM)

Solid or liquid particles suspended in air; also known as particles and particulates.

The smaller it is the deeper it is able to get into alveoli => more dangerous

- 2.5

Nursing Edu to reduce particulate matter exposure

Reduce wood bruins stove use

Don't use air fresheners

Open windows/use vent when cooking

Use air purifier with HEPA filter

Vacuum/dust regularly

Reduce humidity to decrease mold/mildew

Test for radon

People at most risk for cold-related illness

Diabetes pt: less sensation and inadequate blood vessels

Homeless: exposure

People who drink: vasodilation causes a feeling of warmth and increased body heat loss b/c of blood to surface of skin

Treatment for cold related illness

Iloprost => causes vasodilation

Frostbite External body signs

skin is cool, waxy, pt feels numb, pain, burning or pricky,

Getting worse = no pain

Frostbite Temp

core body WNL

Cold skin

Frostbite signs of getting worse

waxy/shiny blisters, can progress to gangrene, risk of infection

Hypothermia External Body Signs

shivering

if shivering stopped = SEVERE, near death, won't feel pain

Hypothermia Temp

≤95 F (35 C)

Hypothermia signs of worsening condition

increased confusion, irregular HR, skin is blue, can become unresponsive

Hypothermia treatment

Warm IV fluids

Bear hugger

Warm drinks

Cover/Wrap head

Plastic warp around body (if outside) to prevent evaporation heat loss

Prevent BP drop

Heat Exhaustion S/Sx

Skin: pale, moist

Temp: >100.4F/34C

GI: N/V/D

Pain: Muscle cramps, HA

HR: WNL

Energy: Fatigue, weak

Neuro: anxious

Heat Exhaustion Treatment (Nursing)

Remove excess clothing

place cool clothes on skin and fan

give sports drink with sugar and salt

Heat Stroke S/Sx

Skin: warm, dry

Temp: >104F/40C

GI: N/V/anorexia

Pain: HA

HR: elevated

Energy: fatigue, lethargy, stupor

Neuro: confused, agitated, seizures

Heat Stroke Nursing interventions

Same as exhaustion, but caution with drinking

Also needs ice bags on groin and armpits

Call 911, emergency

Monitor vitals

how to decrease the production of medical waste

Use reusable equipment when appropriate

Open supplies only when needed

Educate staff on waste segregation

Encourage proper recycling of packaging materials

Choose digital charting

Advocate for multi-dose vials instead of single-use

Encourage refillable sanitizing stations

Promote patient and staff education on sustainability practices

Air Quality Index (AQI)

air quality index measures safety of outside air

AQI 0-50

good/green. little to no risk

AQI 51-100

Moderate

sensitive individuals should avoid outdoor activity

AQI 101-150

Unhealthy for sensitive groups

general public and sensitive individuals are at risk of irritation/resp problems

AQI 151-200

Unhealthy

increased likelihood of adverse effects and aggregation to heart and lungs among general public

AQI 201-300

very unhealthy

general public will be noticeably affects

AQI 301+

Hazardous

general public at high risk of experiencing strong irritation and adverse health effect => stay inside

Edu:

suggestions on how to decrease exposure to microplastics

Avoiding non-stick cookware and plastic

Tupperware as heat increases leaching

Use foil instead of plastic wrap

Wear clothes made of natural fibers

Buy food products (like PB) stored in glass jars

Buy wooden or metal toys instead of plastic ones

Look for plastic-free cosmetics

Define hospital readmissions

Patient readmitted to any hospital within 30 days of discharge for same/related condition of original hospitalization (excludes any planned readmissions, like upcoming procedure)

Most Common Conditions that lead to re-admission

Cardiac: MI, HF, s/p CABG

Respiratory: COPD, pneumonia

Ortho: TKA or THA

How to prevent readmissions

Tied readmission rates to hospital funding

ED or Urgent Care: shortness of breath

ED

ED or Urgent Care: vomiting or diarrhea

Urgent care

ED or Urgent Care: couch, cold, glue, sore throat

urgent care

ED or Urgent Care: broke bone

ED

ED or Urgent Care: serious burns/cuts

ED

ED or Urgent Care: change in consciousness/mental status/seizure

ED

ED or Urgent Care: possible CVA

ED

ED or Urgent Care: possible MI/Chest pain

ED

ED or Urgent Care: Rash w/o fever

urgent care

Education for heart failure at home & in the community

Nutrition counseling esp fluids and sodium (HF <2L and 2g)

Exercise training/counseling

Weight management

Manage BP and HR and Cholesterol

Manage co-morbidities (diabetes, stop smoking)

Emotional wellbeing and psychosocial support

HF weight management edu

Daily weights to monitor fluid retention

Same time every day, AM best

Cardiac rehab is for:

HF, s/p MI, angina, and s/p cardiac surgery like stents, CABG, valve repair or heart transplants; sometimes congenital

Cardiac rehab is NOT for:

High risk for arrhythmias, decompensation of HH, unstable angina

Normal BP ranges

S <120

D<80

Elevated BP ranges

S: 120-129

D: <80

Stage 1 HTN BP ranges

S: 130-139

D: 80-89

Stage 2 HTN BP ranges

S: 140+

D: 90+

Stage 3 HTN BP ranges

S: 180+

D: 120+

Taking at home BP patient Edu

1) prepare by not: exercising, eating, drinking caffeine before

2) go to bathroom before, find a quiet place to sit, relax for 5 minutes

3) uncover your upper arm

4) rest you arm on the table at the level of the heart

5) feet uncrossed and flat on floor

6) sit straight in chair, stay calm and related, don't talk or watch TV

Healthy Cholesterol levels

Total: under 200

LDL: under 100

HDL: over 60

At Risk Cholesterol levels

Total: 200-239

LDL: 100-159

HDL: 40-59 (M), 50-59 (F)

dangerous cholesterol levels

Total: >240

LDL: >160

HDL: <40 (M), <50 (F)

Low density lipoprotein

the transport vehicle of cholesterol from liver, through blood to cells of the body, but leads to deposits on the walls of the arteries; so aim for < 100

High density lipoprotein

the transport vehicle of cholesterol from the cells and blood back to the liver for storage; aim for 60-80

Hemoglobin A1C

A test that measures the level of hemoglobin A1c in the blood as a means of determining the average blood sugar concentrations for the preceding two to three months.

Hemoglobin A1C levels

Normal: <5.7%

Prediabetes: 5.7-6.5%

Diabetes: ≥6.5%

Fasting Plasma Glucose

also known as fasting blood sugar test. measures circulating glucose level in a patient who has fasted at least 8 hours

How is fasting plasma glucose test done

No food or drink for 8-12 hours before test.

Done from normal venous blood draw.

2 tests recommend to officially diagnose

Fasting Plasma Glucose levels

Normal: <100 mg/dL

Prediabetes: 100-126

Diabetes: ≥126

Quad cane

heavier and a bit harder to life but more stable

Single point cane

easier mobility, less stable

Edu on using a cane safely

- The cane should be held on the stronger side (right side for left-sided weakness)

- The proper sequence is: cane forward, weak leg forward (together with cane), then strong leg forward

- When going UP stairs: "Up with the good" - the strong leg leads. Then bring the weaker leg and cane up together

- When going DOWN stairs: "Down with the bad" - the cane and weak leg go first. Then bring the stronger leg down

- 15-30 deg angle @ elbow

- Head of cane at hip level (or greater trochanter)

- TEACHBACK!

education on how to care for home oxygen: Safety

Intensifies combustion

No smoking

10 feet distance from open flames (no fires, gas stoves, candles, etc)

Careful with flammable oil and alcohol based substances like petroleum jelly or hand sanitizer (use water based substances)

Change nasal cannula every 2 weeks or so

Respiratory S/Sx: When to call provider today Sometime

Trouble breathing while doing things

Feeling like there is not enough air in the room

Meds do not feel like they are healing as usual

Not sure what meds to take

Feel like they need to increase O2 from from normal to breath

Starting to feel uncomfortable

Respiratory S/Sx: When to call provider NOW

Confused or sleepy feeling

Can't get enough air

Face and fingers/toe turning blue

Meds not helping at all

Not sure what to do

Oxygen does not feel like it is helping

Very uncomfortable

Anxious or afraid

Describe safe handling of chemotherapy at home

best practice is to use gloves or pour the pill into a pill cup and swallow from there.

no crushing pills and no handling by caregivers unless they are wearing gloves

no handling at all for those who are pregnant.

If you do touch the medication, wash your hands thoroughly with soap and water.

Drug metabolites remain in bodily fluids—for up to 72 hours after the last dose.

Even if not required, partners may wish to consider barrier protection during sex due to risks related to infection, pregnancy, and exposure to the chemotherapy medication.