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Dr Elizabeth Forster

Primary Health Care: a basic level of health care that includes programs directed at the promotion of health, early diagnosis of disease or disability, and prevention of the disease. Principles are based on: 1.Equity, 2.Social Justice, 3.Empowerment. Strategy of primary health: Build – on Alma-At principles, Ensure universal access, Consider population issues, Create adequate conditions for effective provisions of health care to vulnerable groups, Organise integrated care – preventive, acute and chronic care, Strive to improve performance. Activities: Education, Promotion, Provision of water and sanitation, maternal and child health care, Immunisation, Prevention of endemics, Appropriate Tx. Chronic illness self-management requirements: Clear understanding of illness & outcomes sought, Active engagement in own disease management processes, Self- management skills, Self-efficacy (ability to successfully learn and perform behaviour), Health literacy. Managing chronic illness: Understanding of disease and Tx, Monitoring S/S – detecting changes – treatments, Seek help, Prevention and management of crisis. Associated factors with chronic illnesses: Hereditary, Lifestyle, Environmental factors associated with development. Public health interventions: Taxation: tobacco, alcohol, unhealthy foods, Limitations on additives: salt, Monitoring of BP and cholesterol- drug Mx, Gastric banding, Skin cancer campaigns. Perioperative nursing: Changing trends in surgery: Increased use of technology and availability of it, Laser and laparoscopic interventions – decrease hospitalisation and cost burdens, Anaesthetics, Economic trends – perioperative visiting and day surgeries, Ethical issues: blood transfusions, transplant and autonomy for clients i.e. life support. Peri-operative nurse assessment: mental/physiological status, range of motion/mobility- including corrective devices and pain issues, sensory impairments or language barrier, cultural differences, religious/spiritual needs, cardiovascular and respiratory status (vital signs, airway patent, maintain oxygen saturation), nutritional status (N.P.O.), medications and allergies (obtain from patient's history). Pre-operative risk factors: Age, Smoking, Alcohol, Nutritional status, Weight, Pre-existing health problems, Medications, Cancer or treatment, Heart/respiratory failure, Obesity, Pregnancy, Severe infection, Immobolity. Physiological assessment: Head to toe / Systematic approach – BASELINE VALUES, Hx, acute/ chronic issues, resp, cardio, integ, musco, nutrit, and elimination, Allergies, Past surgical complications, Herbs and vitamins. Psychological assessment: Situational changes, Concerns with the unknown, Concerns with body image, Past experiences, Knowledge deficit, Emotions: Anxiety, fear. Diagnostic screening/ assessment: Blood tests, Electrolytes, BGL, Liver function, Urea & Creatinine, ABG, Urinalysis, X-rays, ECG, Pulmonary function tests. Cardiovascular disease: any abnormal condition characterised by dysfunction of the heart and blood vessels. Risk factors: Family history Genetics, Age, Sex, Smoking, Alcohol, Diet, Lifestyle, Level of activity, Weight, Pre-existing health conditions, Ethnicity: Indigenous, Maori, Pacific Islander. Heart failure: the heart cannot pump enough blood to meet the metabolic requirements of body tissues. Causes: Dysfunction of: Lungs, kidneys and liver, ACS, MI ((heart attack) is the irreversible necrosis of heart muscle secondary to prolonged ischemia), Anaemia, HTN, Pulmonary disease, Renal disease. Assessment: Past health history, Medications, Health perception, Nutritional/metabolic status, Elimination, Activity/exercise, Sleep/rest, Cognitive/perceptual. Complications: 1.Kidney damage or failure. Heart failure can reduce the blood flow to kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment. 2.Heart valve problems. The valves of heart, which keep blood flowing in the proper direction through heart, can become damaged from the blood and fluid build-up from heart failure. 3.Liver damage. Heart failure can lead to a build-up of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for liver to function properly. 4.Heart attack and stroke. Because blood flow through the heart is slower in heart failure than in a normal heart, it's more likely you'll develop blood clots, which can increase risk of having a heart attack or stroke. Management: 1.Pharmacological: ACE inhibitor (Dilates peripheral blood vessels, Reduces BP, Angiotensin II receptor antagonists are an alternative), Diuretics, Beta-adrenergic blockers (Decrease HR, conductivity, contractility and O2 demand, Selective and non-selective beta blockers), Fish oil, Cardiac glycoside (Principally used AF and HF, Increase force of contraction, Slows heart rate), Vasodilator therapy (Arteriolar- reduce afterload, augment CO, Venous- reduce preload, lower ventricular filling pressure, reduce pulmonary congestion (eg. Nitrates- nitroglycerin)), Iron supplements. 2.Non pharmacological: Treat underlying cause, Alleviate the symptoms & improve QOL, Decrease disease progression, prolong survival, Improve activity tolerance, Reduce hospital readmission(Reduce workload of heart, Increase force of myocardial contractility, Reduce venous congestion, Improve oxygenation and maintain respiratory status, Decrease sodium and water retention, Assess and treat iron deficiency). Coronary bypass surgery (CABG) or angioplasty with or without stenting may help improve blood flow to the damaged or weakened heart muscle, Heart valve surgery may be done if changes in a heart valve are causing your heart failure, A pacemaker can help treat slow heart rates or help both sides of your heart contract at the same time, A defibrillator sends an electrical pulse to stop life-threatening abnormal heart rhythms. Acute coronary syndrome: ACS is a broad spectrum of clinical presentations, spanning STEMI (heart attack) through an accelerated pattern of angina without evidence of myonecrosis/infarction (muscle death). Causes: ACS is most often a complication of plaque (atherosclerosis) build-up in the arteries in heart. These plaques, made up of fatty deposits, cause the arteries to narrow and make it more difficult for blood to flow through them. Complications: Angina – Non-STEMI and STEMI (Ischaemic related pain), MI, Cardiac death. Management: Reperfusion therapy (Aspirin, PCI, Fibrolysis: prevents blood clots from getting bigger), Antithrombolytic therapy, Oxygen therapy, Diet, Exercise, Smoking, Depression, Education. PCI Percutaneous coronary intervention (PCI) is one of the two coronary revascularisation techniques currently used in the treatment of ischaemic heart disease, the other being coronary artery bypass grafting (CABG).PCI involves non-surgical widening of the coronary artery, using a balloon catheter to dilate the artery from within. A metallic stent is usually placed in the artery after dilatation. Antiplatelet agents are also used. Stents may be either bare metal or drug-eluting. Indications: Acute ST-elevation myocardial infarction (STEMI), Non–ST-elevation acute coronary syndrome (NSTE-ACS), Stable angina, Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope), Asymptomatic or mildly symptomatic patient with objective evidence of a moderate-sized to large area of viable myocardium or moderate to severe ischemia on noninvasive testing. Complications: Restenosis of the stent, Stent thrombosis, Hemorrhage, Perforation, Damage to kidneys- contrast dye, Death, Stroke, Allergic reaction. HTN: disorder characterized by high bp- over three consecutive accounts. Arterial walls become thickened, inelastic and resistant to blood flow and the LV becomes distended and hypertrophied as a result of its efforts to maintain normal circulation against increased resistance. Causes: 1.Primary: elevated blood pressure without identified cause and accounts-Contributing factors: Increase SNS activity, over production of Na retaining hormones and vasoconstrictors, increased sodium intake, body weight, diabetes, alcohol. 2.Secondary: Secondary hypertension can be caused by conditions that affect your kidneys, arteries, heart or endocrine system. Complications: Angina, MI, LV hypertrophy- can lead to CCF. Management: Medication (Calcium channel blockers: Block the movement of extracellular calcium into the cells, causing vasodilation and decreased heart rate, contractility and SVR)(Low-dose thiazide diuretic: Inhibit NaCl reabsorption in the distal convoluted tubule; increase the excretion of Na and Cl), Manage associated conditions, Lifestyle modification (Diet- low sodium, saturated fats, Exercise), Monitor BP, ACE inhibitors, Angiotensin receptor blockers. Angina: 1.Stable: (exertive), due to activity or exercise, painful episodes predictable- (Nitrates, Oxygen if hypoxic or in shock, Beta blockers, Calcium channel blockers), 2.Vasospastic: caused by coronary artery spasm, episodes of pain: waking, resting or sleep, 3.Unstable: Pre-infarction- acute coronary insufficiency, unpredictable, chest pain prolonged and severe. Causes: Coronary Artery Disease- Cholesterol plaque, Coronary Artery Spasm. Complications: Stroke, Heart attack, Depression. Management: Ongoing monitoring (Vital signs, Level of consciousness, ECG rhythm changes, Pain and medication, Monitor for complications-Cardiac arrhythmias, Acute MI, Cardiac arrest), Pharmacological management of CHD(Antiplatelet (aspirin), Anticoagulation (warfarin), ACEI/ARA, Beta-blockers, Statins (lipid lowering), Nitrates (Gtn), Insulin/oral hypoglycaemics), Non-pharmacological management (Rest, Reassurance, Education- lifestyle advice, Regular monitoring- consider cardiac rehabilitation, Assess for depression, level of social support). AAA:An aneurysm (developed in the abdomen) occurs when a segment of the vessel becomes weakened. The pressure of the blood flowing through the vessel creates a bulge at the weak spot. Causes: Emphysema, Genetic factors, High bp, High cholesterol (atherosclerosis), Male gender, Obesity, Smoking. Complications: Infection pseudoaneurysm, Death, Rupture of repair site – internal bleeding. Management: 1.In a traditional (open) repair, a large cut is made in your abdomen. The abnormal vessel is replaced with a graft made of man- made material, such as Dacron. 2.The other approach is called endovascular stent grafting. This procedure can be done without making a large cut in your abdomen, so you may get well faster. If you have certain other medical problems, this may be a safer approach. Endovascular repair is rarely done for a leaking or bleeding aneurysm. 3.Ultrasounds every 6 months tracking the development of the aneurysm, 4.Exercise and diet, 5.Medications: Statins. Respiratory conditions: Asthma: Asthma is a disorder that causes the airways of the lungs to swell and narrow, leading to wheezing, shortness of breath, chest tightness, and coughing. Asthma attacks may last for a few minutes to several hours, patient may be asymptomatic between attacks with normal or near-normal pulmonary function. Causes: Allergy triggers (house dust mites, pollens, animal fur, moulds), Irritating substances breathed in the air (Cigarette smoke), Viral infections (colds and flu), Weather (cold air, change in temperature), Work-related triggers (wood dust, chemicals, metal salts), Some food additives, Certain medications (eg. Aspirin, some blood pressure drugs), Exercise. Assessment: Wheeze is suggestive but not diagnostic of asthma, The absence of physical signs does not exclude a diagnosis of asthma, Crackles on chest auscultation indicate an alternate or concurrent diagnosis, History or signs of allergic rhinitis, Chest x-ray not routinely done but can show hyperinflation & will confirm or rule out other problems if uncertain presentation. Diagnosing asthma in children:based on a history of recurrent or persistent wheeze in the absence of any other apparent cause, can be confirmed by a clinical response to an inhaled bronchodilator, in children aged >7yrs use spirometry to confirm the diagnosis of asthma, when cough is the predominant symptom of suspected asthma careful assessment is needed to avoid making an incorrect diagnosis of asthma, Exercise-induced dyspnoea is not always due to asthma, even in children with a confirmed diagnosis of asthma. Complications: 1.Free air or gas within the pleural cavity (pneumothorax) can develop during severe asthma attacks, especially if the individual requires mechanical ventilation. 2.A severe asthma attack that does not respond to treatment can lead to prolonged contraction (bronchospasm) of smooth muscles (status asthmaticus) and may be followed by respiratory failure and death. 3.patients who have chronic pulmonary disease in addition to asthma will often have more severe and debilitating episodes of asthma. 4.Long-term oral steroid use by asthmatics can lead to blood chemistry disturbances, cataracts, osteoporosis, immunosuppression, and adrenal suppression. Over-treatment of asthma with bronchodilators may precipitate cardiac arrhythmia. Management: 1.Pharmacological management- Bronchodilator meds, Anti-inflammatory meds, Long-acting beta2 agonist (symptom controller) meds usually prescribed in combination with an inhaled corticosteroid (ICS) preventer. Combination medications consist of and ICS and a symptom controller in a single inhaler device, 2.Education to improve asthma control-Allergen avoidance/control, Use of a written asthma action plan, Smoking cessation, diet and exercise (including specific management of exercise-induced asthma if required), 3.Correct inhaler technique-Reasons may include (Co-morbidities, Inadequate coordination of inspiration and inhaler, Inability to achieve a high enough inspiratory flow rate, Inability to achieve a firm seal around mouthpiece), Technique can be improved by education and ask question “Can you show me how to us your inhaler?” COPD: A lung disease which is characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. Chronic bronchitis is an inflammation of the lining of your bronchial tubes, which carryair to and from your lungs. Emphysema occurs when the air sacs (alveoli) at the end of the smallest air passages (bronchioles) in the lungs are gradually destroyed. Classification: Emphysema and chronic bronchitis Causes: Lung irritants-active and passive smoking, Air pollution, Chemical fumes, Dust, Genetics, Pre-existing. Complications: 1.Respiratory infections-People with COPD are more susceptible to colds, the flu and pneumonia. Any respiratory infection can make it much more difficult to breathe and produce further damage to the lung tissue. An annual flu vaccination and regular vaccination against pneumococcal pneumonia help prevent some infections. 2.Acute respiratory failure- Patients who ignore exacerbations or discontinue bronchodilator treatment are at risk for acute respiratory failure, 3.Peptic ulcer-The incidence of peptic ulcer disease is increased in people with COPD. The reason for this occurrence is partly explained by hypersecretion of gastric acid resulting from increased arterial carbon dioxide and decreased arterial oxygen tension. This occurs only in patients who chronically retain carbon dioxide. 4.Depression/Anxiety-Patient can feel helpless with low self-esteem and be unable to vent their emotions for fear of compromising their breathing. Anxiety can complicate respiratory compromise and mayprecipitate dyspnoea and hyperventilation. 5.High blood pressure-COPD may cause high blood pressure in the arteries that bring blood to lungs (pulmonaryhypertension). Treatment: Assessment (spirometry), High caloric diet, Bronchodilators, CPAP machine if needed, Steroids, Vaccines, Pulmonary rehab, Transplant, Exercise as tolerated, Psychological support, Education (meds, exercise, nutrition, chronic lung disease and management, patient outcomes and feedback). Cystic fibrosis: (a lethal genetic autosomal recessive diseasea mong caucasian children, adolescents, young adults) Cystic fibrosis is a result of a defective gene that codes for the Cystic fibrosis transmembrane conductance regulator CFTR protein, which is responsible for regulating the flow of chlorine in and out of a cell. Assessment: Diagnosis is usually made within 10days of birth using Guthrie test and confirmed using sweat test. It is characterised by altered function of the exocrine glands involving primarily the lungs, pancreas and sweat glands. It is not curable at present but life expectancy has increased with advances in treatment & medication. Gastrointestinal changes-1.Thick mucus blocks pancreatic ducts, 2.Cysts formed in pancreas replaced by fibrous tissue, 3.These prevent the secretion of pancreatic enzymes- Trypsinogen, lipase & amylase do not reach the intestine to digest ingested nutrients- malabsorption of fats and proteins, and fat soluble vitamins. 4.These changes can caus
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