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Phase 2B OSCES > Chronic Disease Management > Flashcards

Chronic Disease Management Flashcards

1
Q
  1. INR and warfarin
A

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.

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2
Q

History taking for INR and warfarin

A

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

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3
Q

INR and Warfarin: Presenting complaint of Px

A

Ask how they are feeling?
- Any recent infections/illnesses?
- Any diarrhoea/vomiting?
= Bloody/dark stool or vomit.

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4
Q

High INR symptoms

A
  • Any high INR symptoms?
    = Headache, severe stomach ache.
    = Increased bruising.
    = Prolonged bleeding after minor cuts/menstrual bleeding/gum bleeding.
    = Blood in urine.
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5
Q

Low INR symptoms

A
  • 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).
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6
Q

INR and warfarin: Patient medical history

A

Liver failure (lack of clotting factors).
- Bleeding disorders (haemophilia, factor 7 deficiency)

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7
Q

INR and warfarin: Drug history

A
  • 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
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8
Q

Social History

A
  • 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
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9
Q

INR Warfarin advice

A

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

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10
Q

Treating elevated INR

A
  • 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
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11
Q

Treating low INR

A

LMWH, warfarin
Compression stockings if immobile

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12
Q
  1. HbA1c
A

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

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13
Q

History for HbA1c

A

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.

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14
Q

Presenting complaint of HbA1c

A

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)

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15
Q

Past medical history of HbA1c

A

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

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16
Q

Drug history of HbA1c

A

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?

17
Q

Social History

A

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

18
Q

Advice for lowering HbA1c

A

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.

19
Q
  1. Peak flow/spirometry
A

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.

20
Q

History taking for Spirometry

A

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.

21
Q

Presenting complaint

A
  • 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.
22
Q

Drug history

A
  • 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.
23
Q

Social History

A

Any (new) pets?
- Recent travel anywhere?
o Particularly to places that are polluted.
- Housing situation (damp)?
- Hayfever
- Smoking? Alcohol? Impact of condition on life.

24
Q

Exacerbations and Advice

A
  • 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

25
Q
  1. Inflammatory Markers (CRP/ESR)
A

CRP:
- Non-specific marker.
- Substance produced by the liver and increases in the presence of inflammation.
- Acute marker.
Routinely measured in assessment of disease activity of autoimmune/inflammatory conditions –
- Rheumatology (RA, JIA, seronegative arthritis like ankylosing spondylitis, reactive
arthritis and psoriatic arthritis), Crohn’s disease, Vasculitis, polyarteritis nodosa, Pancreatitis.

Assistance with diagnosis and monitoring infection:
- Infective endocarditis, Abscess post-op infection, Response to Abx.

Differentiation between inflammatory conditions –
- SLE vs. RA.
- Crohn’s vs. UC.

Causes for raised CRP –
- Burns, trauma, Infections (pneumonia, TB), Chronic inflammatory diseases (SLE, vasculitis, RA), MI, IBD, cancers.

ESR:
- Increased fibrinogen means RBCs stick together and so fall faster.
- Raised ESR = rate of fall quicker.
- ESR rises and falls slowly.
Causes for raised ESR –
- Malignancy (Malignant lymphoma, Carcinomas of colon/breast), Haematological (Multiple myeloma, Anaemia of acute/chronic disease combined with iron deficiency anaemia), Connective tissue disorders (SLE, RA, Polymyalgia rheumatica and temporal arteritis), Infections (TB, acute hepatitis, bacterial).

26
Q

History taking for ESR/CRP

A
  • I understand you are… and I can see from your results that your CRP/ESR is…
  • Check patients understanding of CRP/ESR and their condition
    = It’s a marker of inflammation which tells us that there could be a flare up in
    your condition or new infection detected.
27
Q

Presenting complaint

A
  • How are they feeling?
  • Any recent illnesses/infections?
28
Q

Drug history

A

How well do you think your condition is being controlled
What medication do you take? How often?
Any issues taking your medication?
Do you take any other medications?

29
Q

Social history

A

Recent travel anywhere?
Smoking?
Alcohol?
Impact of condition on life

30
Q

Advice

A

Stop smoking
Advice on disease management if they’re non-compliant

31
Q
  1. LFTs
A

Albumin –
- Low;
= Can be a sign of malnutrition (Crohn’s/UC, coeliac).
= Kidney disease, liver disease (hepatitis, cirrhosis).
- High;
= Severe infections/dehydration, chronic inflammatory diseases, hepatitis.

Globulins –
- Total proteins.

Bilirubin –
- High conjugated = liver/bile duct disease.
- High unconjugated = Gilbert’s or haemolytic anaemia.

Liver enzymes increase in –
- Chronic high alcohol excess.
- Obesity (especially in men).
- Smoking (in women).
- Drug reaction.

ALP –
- Bile duct obstruction stimulates ALP synthesis;
= Increase in obstructive liver disease.
= Non-hepatic origin like increased osteoblastic activity in Paget’s, osteomalacia, vitamin D deficiency.

GGT –
- Liver disease markers of drugs/alcohol (increases)

AST or ALT –
- Liver disease markers of drugs, toxins, viral (increases).

GGT + ALP –
- Biliary problems.

AST + ALT –
- Hepatic problems.

GGT + ALP risen > AST + ALT –
- Obstructive jaundice.

32
Q

History taking

A

I understand you are… and I can see from your results that your LFTs are…
- Check patients understanding of LFTs and their condition –
= Explain the relevant increased result.

33
Q

Patient history

A

How are they feeling?
Any recent illnesses/infections?

34
Q

Patient medical history

A

Gallstones in the past
Crohns/UC
Surgery in past if malabsorption mat have had some bowel removed

35
Q

Drug history

A

How well do you think your condition is being controlled?
What mediation do you take? How often?
Any issues taking your medication?
Do you take any other medications.

36
Q

Social history

A
  • Recent travel anywhere?
  • Smoking?
  • Alcohol?
  • Recreational drugs/toxins?
  • Diet.
  • Impact of condition on life.
37
Q

Advice

A
  • Stop smoking/alcohol/drugs.
  • Diet advice.
  • Advice on disease management if they’re non-compliant.

Phase 2B OSCES (2 decks)

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