Chronic Disease Management Flashcards
- INR and warfarin
International normalised ratio –
- Normal INR is 1, those on warfarin should aim for 2–3 (2.5 as an ideal).
- People with an INR higher than the normal range who are not taking warfarin may have a medical condition.
Warfarin –
- Vitamin K antagonist (blocks vitamin K epoxide reductase) leading to decrease in factors 2, 7, 9 and 10.
- Regular blood tests, take at same time every day, do not double dose to catch up.
History taking for INR and warfarin
Intro –
- I understand you are… and I can see from your results that your INR is…
- Check patients understanding of INR and warfarin;
= Warfarin is an anticoagulant and that means its job is to stop the blood from clotting too easily.
- Explain what INR is and the risks of it being high/low;
= Provides information about someone’s bloods tendency to clot.
= The higher the INR, the longer it takes the blood to clot and so the increased bleeding risk. The lower the INR, the thicker the blood so increased clotting risk.
- Explain why they are on warfarin.
= Commonly used to treat blood clots (DVT/PE/prevent stroke in AF).
Compliance = needs to be taken every day at the same time and you should not double dose
INR and Warfarin: Presenting complaint of Px
Ask how they are feeling?
- Any recent infections/illnesses?
- Any diarrhoea/vomiting?
= Bloody/dark stool or vomit.
High INR symptoms
- Any high INR symptoms?
= Headache, severe stomach ache.
= Increased bruising.
= Prolonged bleeding after minor cuts/menstrual bleeding/gum bleeding.
= Blood in urine.
Low INR symptoms
- Any low INR symptoms?
= Sudden weakness/numbness/tingling in any limb, visual changes, inability to speak (stroke symptoms).
= New pain, swelling, redness, heat in body parts or new SOB or chest pain (DVT/PE symptoms).
INR and warfarin: Patient medical history
Liver failure (lack of clotting factors).
- Bleeding disorders (haemophilia, factor 7 deficiency)
INR and warfarin: Drug history
- Do you know how many times you are meant to be taking the warfarin?
- How and when do you take it? Have you missed any doses? If so, did you double dose?
= Taking too much anticoagulant medication can cause increased INR. - Are you finding this okay or are you struggling to keep up with the dose – if so, why?
- Any other medications;
= Aspirin, NSAIDs, herbal medication (St John’s wart), OCP/HRT, omeprazole, prednisolone, rifampicin
Social History
- Any diet changes?
Foods containing vitamin K are green fruit/veg like broccoli, kale, celery, cucumber, green beans, green apples/grapes, pears, avocado
Not necessary to cut out these veg but keep consistent if on Warfarin
Binge drinking alcohol can INCREASE INR
Smoking can INCREASE INR
INR Warfarin advice
Decreasing the risk of bleeding:
- Avoid activities that cause bleeding or bruising
- Brush/shave gently
- Tell dentist and any other HCP that you take anticoags
Treating elevated INR
- Vitamin K
- Blood components may be given during a transfusion to help stop bleeding
- If there’s no clear reason then warfarin dose can be decreased and INR rechecked
Treating low INR
LMWH, warfarin
Compression stockings if immobile
- HbA1c
Normal = 42 mmol/L or <6.0%
Pre-diabetes = 42 - 47 mmol/L or 6 - 6.4%
Diabetes > 48 mmol/L or 6.5%
Benefits of lowering Hba1c:
- reduces risk of: retinopathy, neuropathy, diabetic nephropathy
- less likely to suffer from: cataracts, heart failure, amputation
History for HbA1c
I understand you are… and I can see from your results that your HbA1c is…
- Check when the patient was diagnosed, if it’s T1/T2 and their understanding of their diabetes and HbA1c;
= HbA1c shows us the average blood glucose level over the previous 2–3
months as the sugar sticks to cells in our blood.
- How well do you think your diabetes is being managed?
- Explain benefits of lowering HbA1c;
= Reduces the risk of retinopathy (eye problems), neuropathy (losing
sensation in your feet/hands) and diabetic nephropathy (kidney issues).
= Less likely to suffer from cataracts, heart failure and amputation.
Presenting complaint of HbA1c
How are you feeling?
Any recent infections/illnesses?
= D+V/illnesses can affect the amount of insulin required
Any hospital admissions for DKA/hypos?
Any symptoms of diabetes?
- Polyuria, polydipsia, weight loss, vision changes, tingling in feet, impotence (ED)
Past medical history of HbA1c
Any CVD/cerebrovascular/renal/visual complications
Any co-morbidities
HbA1c can be falsely raised in:
- Kidney disease
- Chronic excessive alcohol intake
- Vitamin B12 def
HbA1c can be falsely decreased in:
- Acute/Chronic blood loss
- Sickle cell disease
- Thalassaemia
Drug history of HbA1c
What diabetic medications do you take?
How/when are you taking the medication?
Any side effects?
Are you finding it okay or are you struggling to keep up with the dose? If so - why
Injecting correctly (site rotation), monitoring glucose levels?
Any other medications/changes?
Social History
Activities of Daily living:
- How is your mood/sleep?
- Are home circumstances okay?
- Do you feel like your disease is affecting your ADLs
Diet:
- Adhering to dietary restrictions
- Been on a recent diet/tried to lose weight?
- Exercise
- Smoking + alcohol
Advice for lowering HbA1c
Dietary modifications;
- Awareness of snacking and sugary foods/carbs affecting the blood sugar
level.
- Physical activity;
- Regular exercise can help stop blood sugar levels rising.
- Check with doctor first because some diabetes medicines can lead to hypoglycaemia if you exercise too much.
Take extra care when ill;
- “Sick day rules” check blood sugar more regularly (4h), keep taking diabetes medications even if you don’t feel like eating, contact diabetes team, check ketones.
Monitor blood sugar level –
- So you can spot an increase early and take steps to prevent it.
- Support available;
- GP, diabetes nurses, online resources, training courses.
- Peak flow/spirometry
Peak flow
- Take your peak flow before using the preventer inhaler
- Always use the same peak flow meter
Spirometry
- Measures functional lung volumes
Obstructive lung disease
- Causes:
= Reversible (asthma) and irreversible (COPD)
= Bronchiectasis
= Inhaled foreign body, tumour
- Takes a long time to exhale (wheeze) so not much breathed out at 1 second but volumes not bad overall
= FEV1<FVC
= FEV1/FVC < 0.7 with FEV1<80% predicted
Restrictive lung disease
- Usually diseases of the interstitium affecting chest wall movement and elasticity;
= Scoliosis, kyphosis, ankylosing spondylitis.
= Neuromuscular diseases like Guillain-Barré syndrome, myasthenia gravis.
= Pulmonary fibrosis, sarcoidosis, asbestosis.
- Due to restriction, lung volumes are small and most of breath is out in the first:
second.
= FEV1/FVC > 80% because of the FVC being proportionally lower.
History taking for Spirometry
I understand you are… and I can see from your results that your peak
flow/spirometry is…
- Check patients understanding of peak flow/spirometry and their condition –
= Peak flow test measures how fast you can breathe out so you can see how
well your lungs are working.
= Spirometry measures lung function, specifically the amount (volume) and
the speed (flow) of air that can be inhaled/exhaled.
Presenting complaint
- How are they feeling?
- Any recent illnesses/infections?
- Any SOB?
- Is there any particular time you notice your condition worsens (winter etc).
- Enquire about red flags;
= Wheeze is getting worse.
= Affecting ADL.
= Waking up at night with symptoms (SOB, cough).
= Using reliever inhaler more than usual.
Drug history
- How well do you think your condition is being controlled?
- What medications do you take? Which inhalers do you use and how often?
- Do you take any other medications (if on steroids then severe).
- Any beta-blockers.
- Check inhaler technique and check inhaler use has been assessed by the nurse.
Social History
Any (new) pets?
- Recent travel anywhere?
o Particularly to places that are polluted.
- Housing situation (damp)?
- Hayfever
- Smoking? Alcohol? Impact of condition on life.
Exacerbations and Advice
- Stop smoking.
- Avoid precipitants.
- Vaccination (flu).
- Exercise.
- Eating.
- Support.
Exacerbations
Is there any particular time you notice that your asthma is worse e.g. is it worse during the winter months?
Any pets/any new pets?
Recent travel anywhere? (Your would want to be weary of places which are particularly polluted).
Housing - (there may be damp)?
Hayfever
