Types of prevention
primary- car restraints, bicycle helmets, immunizations
secondary- prevent for those with RF-pap, mammo
tertiary-mgmt of established disease- meds, lifestyle
Primary
Preventing the health problem, most cost effective form of healthcare **IMMUNIZATIONS, ensuring adequate illumination at home (preventing falls)
Secondary
Detecting disease in early asymptomatic stages, screenings
-Early cause finding of asymptomatic disease via the use of a screening test
Ex. highly abnormal mammo not final word
Tertiary
Minimizing negative disease induced outcomes, potentially viewed as a failure of primary prevention
Ex- rehab, PT, OT
Who should not receive influenza vaccine
4 mon old born at 32 weeks gestation
receive flu- 6 mon and older
can give during pregnancy/lactation
give children 2x- 4 months apart
MMR
preggers can’t receive (no varicella, or zoster, smallpox, flu mist, rotavirus), but lactation OK!
its live but weakened
give again to those born after 1957
Give to 6-11 month who are travelling outside US
May treat and have an innocent flat pink rash
2 doses ( at 12-15 mon and 4-6 years)
Tetanus
can get from soil, a depth of the wound is important
Preggers- get a tdap in her thirst trimester to pass onto the unborn child (pertusis is a bad outcome!), family members need to be up to date- can cause lockjaw
T-dap- 1 at 11-64 and then booster every 10
dTap-five doses
Pertussis- uncontrollable cough, vomitting, fatigue, dx: nasopharyngeal culture and PCR testing
tx: Azithromycin
No pap smear
prior to 21 or in elderly
Benadryl
older, cross BBB, can cause sedation, urinary retention (bad for BPH)
herpes zoster
stronger chickenpox vaccine-zoster vaccine
post-herpetic neuralgia- persists after 1 month
Herpes keratitis is damage to the corneal epithelium caused by the herpes virus, commonly shingles. The patient usually has acute onset of eye pain, photophobia, and blurred vision in the affected eye.
primary open angle glaucoma
peripheral vision loss, elevated intraocular pressure, deep-cupping of optic disc, tx with beta-adrenergic antag (Timolol), alpha agonists, prostaglandin analogues
Glaucoma screening test- Tonometry
Normative aging
Need for increased illumination
Macular degeneration
central vision loss, common cause of new onset blindness in elderly
More females
Screening tests- Amsler grid test
Meniere’s disease (idio) vs. Meniere’s syndrome (secondary)
dizziness, tinnitius, nystagmus, vertigo RF: ototoxic drugs, tx: benzos for rest and corticosteroids for anti-inflam
oral cancer
ulcerated lesion with indurated margins, most common SCC, RF: HPV 16, screening at dental visits
beta lacatams with allergic reactions
penecillins, cephalosporins, carbapenems
rashes with Epstein Barr
Otitis externa
Caused by fungus- Candidia or Aspergillus/P. aeruginosa
hallmark is pain on palpating tragus
Tx–> fluoroquinolone
AOM
S.penumoniae (gram pos)-40-50%, tx with amox/cephalo, macrolides, resistance protein binding sites
H.influenza (gram neg)- can produce beta-lactamase
M.catarrhalis (gram neg)- also produces beta-lactamase, can get better without antibiotic
Need abnormal ear drum (bulging TM) + pain (otalgia)/rubbing/tugging ear
tx- Acetaminophen and otic drops help with ST
Watchful waiting- 6 months or older, with non-severe illness, unilateral, fever <102.2, otalgia <48
<6 months-begin antibiotic!! if allergy-Cefdinir], RF: pacifier use for 10 months, feedings in the supine, smoke exposure, day care,
<2- 10 days
2-6 yrs- 7 days
6 yrs- 5 days
1st line- Amox 90 BID, Amox clav BID
With PCN allergy- **Cefdinir (Cephlosporins)
Group A strep
(GABHS)
Streptococcus pyogenes, risk for rheumatic fever and Glomerulo., peritonsillar abscess,
tx- amox then try macrolide if doesnt’t improve
GOLD STANDARD IS THROAT CULTURE
indoor allergen
dust mites (perennial), pets, cockroaches, mold spores
Acute Bacterial rhinosinusitis
S.penumoniae**, RF-viral infection, allergies, tobacco use, 1st line is Augmentin, penicillin allergy-Cefdinir
2nd line- if not better…Clindamycin and Cefixime
Mono
30-50 days ago was infected before sxs, give prednisone not amox (rash), at least 50% present with spleen enlargement, wait 1 month to go back to sports
Anterior and posterior cervical lymph
Pharyngitis with exudate
right and left upper quadrant abdominal tendernes
Hepatomegaly in 10% of cases
Splenomegaly in 50% of cases
Asthma flare
FEV1/Peak expiratory flow rate- drops early (even before patient notices) and good indication of severity of asthma
S3
systolic dysfunction or early diastolic, common in HF (dyspnea, crackles, tachycardia- 3 adject/s3),
marker of ventricular overload- best heard with bell
S4
diastolic dysfunction, common in poorly-controlled hypertension, recurrent myocardial ischemia, unstable angina
Systolic Murmurs
Mitral (rad to axilla) Mitral Benign is- negative hx
Regurgitation Valve lower grade
Physiologic Prolapse no radiation
Aortic (rad to neck) PMI WNL
Stenosis (harsh) softens w. position change
Systolic
Diastolic Murmurs
Mitral
Stenosis (Rumble)
Atrial
Regurg (blowing)
Diastolic
Aortic stenosis
young man, exercise tolerance, harsh systolic murmur, softer when changing position, radiation to the neck (assume it came out of AORTIC VALVE)
LVH, congenital defect
RF- rheumatic fever, older adults-calcification
Calcific aortic stenosis
82 y/o woman, dizzy walking up a flight of stairs, harsh systolic murmur radiation to neck,
Mitral Regurgitation
62 y/o male with HTN, HF, PMI displaced (big LV), accentuated when rolled to the side, louder with hand grip, holosystolic, blowing murmur
Mitral Valve Prolapse
27 y/o woman, runner, oral contraceptive, funnel chest/pectus excavatum, mid-late systolic murmur which moves forward upon position change
HONKING (heard best at apex)
Marfan’s syndrome, scoliosis
Tx: obtaining an echo is a prudent next step
Encourage aerobic activity
16 y/o male basketball player, which finding on a cardiac exam would warrant immediate eval
LOUD S4- problem!
S4 is the sound of diastolic dysfunction
Murmur gets louder with position change (from sitting to standing)
—-> HCM
Murmurs (mitral regurgitation)
common in LVH (also PMI shifts
would see dyspnea upon exertion)
RF: rheumatic heart disease, endocarditis, calcific annulus
sports- depends on degree of LVH
Asthmastic
1st test- FEV or PEFV because its the earliest sign/drops early so best estimation of severity compared to Oxygen sat/ABGs (which drop late)
Leadership role
A process by which a person influences a group of individuals to achieve a common goal
Ex. Collaborating with the regional public health department on a initiative to combat obesity through a community-based exercise program (Keyword-collaborating)
Support for NP practice
Focus on output–> NP practice outcomes
Research design
Ranking- highest to lowest
Meta-analysis/Systematic Reviews, RCTs, cohort studies, case-control series, case series/reports, expert opinions
Research Utilization:
Identify the problem
Assess published research
Design the innovation
Evaluate the situation
Decide whether to use the innovation
Utilization review
the process of evaluating the appropriateness of inpatient hospitalization.
Proof of the medical necessity for the patient’s hospitalization is done mainly through chart reviews and is part of the utilization review process.
A claim can be denied under this process if the reviewer and the payer do not agree with the decision for hospitalization.
Payment could be denied to the healthcare facility if utilization review does not deem the treatment necessary.
Avoid accidental burn injuries in home
home hot water set at no more than 120 (takes 5 mins in length to cause 3rd degree burn)
second degree burns- moist, red skin with peeling borders
third degree- you debrided
Community/herd immnity
Describes the state in which a sufficient proportion of a pop is immune through vaccination or prior illness- even individuals that aren’t vaccinated (infants, immunocompromised) are offered some protection because everyone
Active Immunity
In response to an antigen, presence of an antibody produced in the host (waiting to protect you, 1 month from getting the dose, but LIFELONG=BETTER)
Passive Immunity
Immunity conferred by an antibody produced in another host, acquired naturally by an infant from mother (onset is within hours of getting dose but time limited only 6-9 months)
Treatment of analphylaxis
Immediately administer EPI then administer Benadryl then call 911
Pneumonia vaccine
Not contra in immunosupressed, does not protect against most pneumonia-causing pathogens (just s.pneumococcal), *can give during antimicrobial therapy
Flumist
Only for 2-49 and not in presence of airway disease
Immune globulin (passive)
concentration solution of antibodies derived from pooled donated blood product (SAFE!)
Gardasil
Quadrivalent vaccine- 6, 11, 16, 18
6 and 11-wart virus
16 and 18- malignancy virus
Males- get 9-26, get three dose series
Hep B vaccine
previously unvaccinated adults with DM should be vaccinated immediately upon diagnosis (because can be in group type settings/lancets/equipment not cleaned)
PPD and MMR
IF MMR vaccine is given on the previous day or earlier, the PPD TST should be delayed for at least one month (false positive)
Elderly with RF
Given PPSV23 (Pneumovax) 1 year ago, should be given a dose of PCV13 (Prevnar) today- gives an additional boost
Live virus
MMR, Varicella, FluMist, Zoster
Contra-Pregnancy, Immuno/HIV only less than 200,
Rotavirus- oral vaccine given to infants
Restating
“You said that you got angry when your boyfriend came home last last night” keyword- YOU
OPen ended questions
What’s on your mind
Clarification
I don’t think i see the connection. Can you explain that to me again?
Alcohol Abuse Lab results ***
AST/ALT- 3x ULN 83/50 (normal 0-31)
MCV- 105 (normal 80-96)
Hypertriglyceridemia- TG= 325 (normal <150)
Transtheoretical Model of Change
Precontemplation- not interested, minimizes problem
Contemplation- considering
Preparation- changes in behavior
Action-
Maintenance/relaspse
Ask/Advise/Assess/Assist/Arrange
Cancer
New Cases- Female breast Male prostate
Deaths- M=lung, prostate, colon, pancreas
F=lung, breast, colon, pancreas
Endometrial cancer- unexpected post-menopausal bleeding (represents 50% of all gyno ca)