Exam 1 Flashcards
3 levels of preventative care (primary, secondary, tertiary
Maintaining patient confidentiality
•Limits, check state requirements
- EMR
- HIPAA
Example of guy at soup kitchen with homicidal thoughts – sometimes it’s not easy to figure out what action you need to take
Definition of primary care
- Medical diagnosis and treatment (acute, subacute, and chronic)
- Psychological diagnosis and treatment
- Support patients of all backgrounds in all stages of illness
- Communication of information about prevention, diagnosis, prognosis, and possible treatment options
- Prevention and care of acute and chronic disease and disability through risk assessment, health education, early disease detection, preventive treatment, behavioral change
- HOLISTIC, COMPREHENSIVE
scope of job functions of primary care APRN
NONPF(National Association of Nurse Practitioner Faculties):
NP Competency Domains
1 Management of Patient Health/Illness Status
7 Culturally-Sensitive Care
NP Competency Domain #1 Management of Patient Health/Illness Status
- Providing health promotion/disease prevention services
- Providing health protection interventions
- Providing anticipatory guidance
- Providing counseling
- Promoting healthy environments
- Incorporating community needs, strengths, and resources into practice
- Applying principles of epidemiology and demography into practice
- Demonstrating critical thinking and diagnostic reasoning skills into clinical decision making
- Obtaining a health history from patient
- Performing a physical exam
- Differentiating between normal and abnormal findings
- Employing screening and diagnostic strategies
- Analyzing data to determine health status
- Formulations and developing differential diagnoses
- Initiating therapeutic interventions
- Managing health/illness status over time
- Prescribing medication
- Counseling patient on the use of complementary/alternative therapies
- Evaluation of outcomes of care
- Communicating effectively
- Providing for continuity of care
NP Competency Domain 2 The Nurse Practitioner-Patient Relationship
- Attending to patient’s response to changes in health status and care
- Creating a climate of mutual trust
- Providing comfort and emotional support
- Applying principles for behavioral change
- Preserving the patient’s control over decision making
- Negotiating a mutually acceptable plan of care
- Maintaining confidentiality and privacy
- Respecting the patient’s inherent worth and dignity
- Using self-reflection to further a therapeutic relationship
- Maintaining professional boundaries
NP Competency Domain #3 The Teaching-Coaching Function
- Assessing the patient’s educational needs
- Creating an effective learning environment
- Designing a personalized plan for learning
- Providing health education
- Coaching the patient for behavioral changes
- Evaluating the outcomes of patient education
NP Competency Domain #4 Professional Role
- Demonstrating evidence-based approaches to care
- Delivering safe care
- Functioning in a variety of roles
- Communicating personal strengths and professional limits
- Advocating for the advanced practice role of the nurse
- Marketing the nurse practitioner role
- Participating as a member of health care teams
- Collaborating/Consulting with other health care providers
- Advocating for patients
- Acting ethically
- Incorporating current technology
- Evaluating implications of health policy
- Participating in policy making activities
- Providing leadership
- Accepting personal responsibility for professional development
NP Competency Domain #5 Managing and Negotiating Health Care Delivery Systems
- Incorporating access, cost, efficacy, and quality when making care decisions
- Demonstrating current knowledge of health care system financing as it affects delivery of care
- Analyzing organizational structure, functions, and resources to affect delivery of care
- Practicing within scope of practice
- Applying business strategies
- Evaluating the impact of health care delivery systems on care
- Participating in all aspects of community health programs
- Advocating for policies that positively affect health care
- Negotiating legislative change to influence health care delivery systems
NP Competency Domain #6 Monitoring and Ensuring the Quality of Health Care Practice
- Monitoring quality of care
- Assuming accountability for practice
- Engaging in continuous quality improvement
NP Competency Domain #7 Culturally Sensitive Care
- Preventing personal biases from interfering with the delivery of quality care
- Providing culturally sensitive care
- Assisting patients of diverse cultures to access quality care
- Incorporating cultural preferences, values, health beliefs, and behaviors into the management plan
- Assisting patients and families to meet their spiritual needs
- Incorporating patient’s spiritual beliefs in care
Screening Test: factors that assist in decision making process for ordered screening tests
- Characteristic of the disease and its Rx
- Significant impact on health and longevity
- Treatment available and effective
- Treatment more effective early
- Characteristics of the test
- Acceptable risk & inconvenience
- Characteristics of population
- Accessibility to testing and therapy
- Willingness to be tested
Grades of recommendations: strong evidence for = A
Differential diagnosis-definition
distinguishing between two or more diseases with similar symptoms by systematically comparing their signs and symptoms
Hints:
- Consider the duration of symptoms (i.e. cough for 3 months has different differential dx than cough for 1 week)
- Consider the statistical likelihood of a given problem in your patient (i.e. think about age, sex, race, habitus, lifestyle….a 40 year old male with abd pain probably doesn’t have a uterine cyst)
- Don’t overlook potentially treatable conditions, OR potentially life-threatening conditions
- Think about zebras
- Might need another evaluation from a different provider or a specialty consult
- Might need lab results, diagnostic tests…or you may never find out exact cause and you may just have a presumptive diagnosis. Don’t jump to conclusions – be careful about labeling someone with a disease they don’t have (i.e. dx of HTN is different from diagnosis of elevated blood pressure). Can use symptoms as diagnosis if you’re not sure
Example: a farmer with nausea, headache, and weakness could have virus, Lyme disease, food poisoning, hangover, heat exhaustion, medication reaction, pesticide poisoning, pregnancy
Diagnostic testing-why order them
To make a diagnosis
To identify subclinical disease
To help form a prognosis
To monitor therapy
Always ask: Will the test change the treatment plan?
Considerations:
Interpret in light of what is already known about patient
Tests are not perfect
Tests should provide additional information
Test results should influence patient care
Test should be cost effective
Sensitivity
Sensitivity is the probability that an individual with the disease will test positive (few false negatives)
SNout (rules out)
for this reason, SCREENING TESTS given to the general population need to have high sensitivity; ex: enzyme-linked immunosorbent assay (ELISA) is a high-sensitivity initial screening test for HIV/AIDS à performed x 2 and those who test positive are then given a diagnostic test
(TP/all who have the dz(TP+FN))
Specificity
Specificity is the probability that an individual without the disease will test negative (few false positives)
SPin (rules in)
DIAGNOSTIC TESTS (given to specific individuals identified as at risk by initial screening tests) need to have high specificity; ex: western blot test used to dx HIV/AIDS in individuals who tested positive on the ELISA
TN/all who do not have dz(TN + FP)
NNT
In clinical treatment regimens, the number of patients with a specified condition who must follow specified regimen for a prescribed period in order to prevent occurrence of specified complication(s) or adverse outcome(s) of the condition”
Inverse of the absolute risk reduction
Perfect NNT is 1
The higher the NNT, the less effective is the treatment
Should be understood within the CONTEXT provided (eg., prevention context)
e.g., drug saves 2% of people – so need to treat 50 to save 1.
Relative risk
Relative Risk (aka Risk Ratio)
Probability of an outcome for someone with the risk, relative to the outcome for someone without the risk
When RR = 1 → no association between risk & outcome
RR can only be calculated when population data available for all patients of interest (ex: in a cohort study); by contrast, if only sample data is available (ex: in a case-control study), then odds ratio (OR) is used to estimate relative risk
PPV
Positive predictive value (PPV)of a test represents the likelihood that a patient with a positive test has the disease. (disease present (a)/total population(a+b))
NPV
Negative predictive value (NPV) represents the likelihood that a patient who has a negative test is free of the disease. (disease absent (d)/total population(c+d))
False negative
the patient has the disease but the test is negative
EDD
Naegle’s Rule: LMP + 7 days – 3mths + 1 year
Only useful if LMP normal, cycles regular
Estimated Delivery Date
ETOH use and pregnancy
Not recommended
Potent teratogen. Can cause FAS characterized by growth restriction, facial abnormalities, and CNS dysfunction
Recommended weight gain in pregnancy: where does it come from?
Most: uterus and its contents, the breasts, and increases in blood volume and extravascular extracellular fluid
The rest: metabolic alterations that result in an increase in cellular water and deposition of new fat and protein—so-called maternal reserves.
Nausea and vomiting in pregnancy
especially first half - to about 14 to 16 weeks
Seldom complete relief, but can be minimized
- Eating small meals at more frequent intervals but stopping short of satiation
- ginger
- Mild symptoms: vitamin B6 given with doxylamine
- severe symptoms: phenothiazine or H1-receptor blocker antiemetics
Backache in pregnancy: relief measures
- squat rather than bend over when reaching down
- back support with a pillow when sitting down
- avoid high-heeled shoes
- Muscular spasm and tenderness (acute strain or fibrositis): analgesics, heat, and rest
*Severe back pain should not be attributed simply to pregnancy until a thorough orthopedic examination has been conducted
Hemorrhoids: relief measures for pregnant women
topically applied anesthetics, warm soaks, and stool-softening agents
Heartburn: relief measurs
upward displacement and compression of the stomach by the uterus, combined with relaxation of the lower esophageal sphincter
- Mild: more frequent but smaller meals and avoidance of bending over or lying flat
- Antacids: Aluminum hydroxide, magnesium trisilicate, or magnesium hydroxide alone or in combination
- (more aggressive tx possible)
OTC safe and unsafe in pregnancy
no aspirins, NSAIDs – premature closure of DA, newborn bleeding.
Tell them what they CAN have, e.g., Tylenol, Benadryl
Labs ordered during first prenatal visit
CBC: dilutional/Fe def anemia
VDRL
HBsAg (refer to GI)
HIV
Hgb electrophoreisis: esp AA, Asian, all
Rubella: no vacc*
Varicella: no vacc*
Blood type, Rh & Ab screen
1st trimester screening,Quad Screen
Urine culture
GC/CT
Pap (as indicated)
PPD (if at risk)
Ultrasound for dating/ nuchal fold (<13 +6 weeks
*immunosuppressed – vaccinate after birth
Prenatal Labs ordered 15-20 weeks
15-20 weeks: Quad screen/ AFP/ Integrated screen
Quad: trisomies, NTDs
AFP: NTDs
Integrated screen: trisomies, NTD
Stages of Pregnancy
First trimester (week 1-week 12) Second trimester (week 13-week 28) Third trimester (week 29-week 40)
Physical exam at first prenatal visit
ROS and focus on: Mouth-dental health (infection), Thyroid, lungs, breasts (hormonal changes can cause some breast cancers to grow more rapidly), lymph nodes, Heart, abdomen (includes FH (fundal height)/leopolds/FHTs); Pelvic: samples for Pap, GC./CT; bimanual exam for uterine sizing & pelvimetry; extremities for edema, varicosities (clotting factors increase, esp in 3rd T)
Exercise and pregnancy
horough clinical evaluation be conducted before recommending an exercise program. I
n the absence of contraindications, pregnant women should be encouraged to engage in regular, moderate-intensity physical activity 30 minutes or more a day.
Each activity should be reviewed individually for its potential risk.
Activities with a high risk of falling or abdominal trauma should be avoided.
Scuba diving should be avoided because the fetus is at an increased risk for decompression sickness.
UTI’s and pregnancy
assoc w/preterm or low birth weight infants
Get urine cultures: ketones, protein, nitrates – anatomical changes make preg women more at risk for UTI
Culture and treat empirically
Test of cure if treated for UTI
Recommended Tx: nitrofurantoin/Macrobid
Hgb electrophoresis results in pregnancy
at first prenatal visit if at risk: looking for sickle cell and thalassemia traits.
- Mgmt: 4 mg per day of folic acid
- standard of 1 mg of folate in prenatal vitamins inadequate
- increased risk of spontaneous abortion, stillbirth, and preterm labor. Therefore, ACOG recommends that serial ultrasonography and antepartum fetal testing be performed.
Periodontal disease and pregnancy
linked to preterm labor.
Treatment of existing periodontal dz improves dental health but does not prevent preterm labor
Dental caries not aggravated by preterm labor
Pregnancy is NOT a c/i to dental work, including radiographs
Murmurs & heart sounds during pregnancy
(1) an exaggerated splitting of the first heart sound with increased loudness of both components;
(2) a loud, easily heard third sound
(3) systolic murmur in 90 percent of pregnant women that was intensified during inspiration in some or expiration in others, and disappeared shortly after delivery.
(4) soft diastolic murmur was noted transiently in 20 percent, and continuous murmurs arising from the breast vasculature in 10 percent
Allergic Rhinitis: Signs & Symptoms
**Symptoms **
Nasal congestion
Sneezing
Rhinorrhea (clear)
Itching
PND
Coughing
Sore throat
Eye puffiness
Signs
Pale, boggy nasal mucosa with clear secretions
Enlarged nasal turbinates
Dark discoloration beneath eyes
Mouth-breathing
Enlarged tonsils and adenoids
Erythema would suggest acute/infectious
Eustachian Tube Dysfunction (OME) s/s, PE
Fullness, hearing loss, may have history of recent or recurrent AOM
May see air fluid level or bubble behind TM, or may be retracted
Typically not erythematous. Often seen with allergic rhinitis
AOM vs OME (eustachian tube dysfunction)
Eustachian Tube Dysfunction (OME): management
Can try decongestants; often will spontaneously remit (drugs not usually work – just time)
avg of 40 days
AOM s/s
- May report pain or pressure in one or both ears
- May not report ear symptoms but generalized symptom of illness-fever, irritability, loss of appetite (children)
- Radiation:
- Inner or outer ear, jaw, mastoid, head
- Quality:
- Varies-severe pain followed by sudden relief may indicate ruptured TM
AOM PE
- TM red or opaque and frequently bulging (may be retracted)
- Malleus is obscured
- Yellow fluid or pus behind the TM
- TM may perforate with consequent otorrhea (had pain, suddenly relieved)
- pain w/pressure on mastoid process
itis Media – Classification
Acute OM - rapid onset of signs & sx, < 3 wk course
Subacute OM - 3 wks to 3 mos
Chronic OM - 3 mos or longer
Severe vs non-severe vs recurrent AOM
- *Severe AOM**—AOM with the presence of moderate to severe otalgia or fever equal to or higher than 39°C (102.2°F)
- *Nonsevere AOM**—AOM with the presence of mild otalgia and a temperature below 39°C
- *Recurrent AOM**—3 or more well documented and separate AOM episodes in the preceding 6 months or 4 or more episodes in the preceding 12 months with at least 1 episode in the past 6 months
AOM: causative organisms
usually Strep pneumoniae and Haemophilus influenzae.
Less often Group A beta‐hemolytic strep, Staph aureus, or Moraxella catarrhalis.
AOM: treatment
- Amoxicillin (Amoxil) 500mg BID x 5‐7 d (Amoxicillin/clavulanate [Augmentin] if severe 875mg PO q 12h x 10d
- If PCN allergic: cefdinir (Omnicef) 300mg PO BID or 600mf PO QD; cefpodoxime (Vantin) 200mg PO BID,. etc
refer if doesn’t clear after 3 rounds, Recurrent AOM, perforated TM with hearing loss and dizziness: ENT.
Tympanostomy tubes remain widely used in clinical practice for OME and recurrent OM
Bacterial sinusitis
Inflammation of the mucous membranes that line the paranasal sinuses and concommitant inflammation of nasal mucosa.
sinusitis: viral vs bacterial
Viruses are more common than bacteria
- Onset with persistent s/s compatible with sinusitis, lasting for >= 10 days without improvement (hurts when bend over
- Onset with severe s/s of high fever (>=102) and purulent nasal discharge or facial pain lasting for at least 3-4 days at beginning of illness
- Onset with worsening s/s characterized by new onset of fever, h/a, or increase in nasal discharge following a URI that lasted 5-6 days and were initially improving
summary: high fever, severe pain, rapid onset or long duration that won’t resolve
Bacterial sinusitis: management
Antibiotics for 5-7 days in adults and 10-14 days in children
First Line therapy:
- Augmentin (amoxicillin/clavulanate):
- Dosing: Children <12 weeks of age: 30mg/kg/day in 2 divided doses; Children >12 weeks of age 22.5-45mg/kg/day in 2 divided doses; Adults 500-875mg BID
- Check back in 7 days to see if better!
Second Line therapy or PCN allergic:
Children: Levaquin or Combo therapy Cleocin(clindamycin) + Suprax(cefixime) OR Vantin (cefpodoxime)
Adults: Doxycycline, Levaquin, Avelox (reserve L & A for failure tx. They’re the big guns so save them)
Other treatments:
Intranasal Saline Irrigation (NETI-POT)
Intranasal corticosteroids can be helpful
Decongestants/Antihistamines NOT recommended
Pap: management of inadequate sampling
a) The woman is HVP+ (age ≥ 30) colpo or repeat cytology (2-4 months) if repeat is negative, repeat co-testing at 1 year if repeat is abnormal manage per asccp if repeat unsatisfactory again do a colposcopy
b) The woman is HPV- (age ≥ 30) repeat cytology (2-4 months) if repeat is negative, repeat co-testing at 1 year if repeat is abnormal manage per asccp if repeat unsatisfactory again do a colpo
c) The woman has an unknown HPV status (any age) repeat cytology (2-4 months) if repeat is negative, repeat co-testing at 1 year if repeat is abnormal manage per asccp if repeat unsatisfactory again do a colpo
(LSIL)
Low-grade squamous intraepithelial lesion
Encompassing HPV/ mild dysplasia/ CINI
ASC-US
Atypical squamous cell of undetermined significance
most common
ASC-H
Atypical squamous cells cannot exclude high grade SIL
HSIL
High-grade squamous intraepithelial lesion
Encompassing moderate and severe dysplasia, Carcinoma In Situ (CIS), CIN2 and CIN3
Management of CIN1 preceded by ASC-US, ASC-H or LSIL
Adolescent w/CIN1
Management of Women Ages 21-24 years with either Atypical Squamous Cells of Undetermined Significance (ASC-US) or Low-grade Squamous Intraepithelial Lesion (LSIL)
Management of Women with Low-grade Squamous Intraepithelial Lesions (LSIL)
LSIL (low-grade squamous intraepithelial lesions):
a) HPV- among women ≥ 30 w co-testing: repeat co-testing in 1 year (best) or colpo
i. cytology and HPV negative repeat contesting in 3 years
ii. ascus or HPV+ colpo
b) no HPV test: colpo
c) HPV+: colpo
Management of Pregnant Women with Low-grade Squamous Intraepithelial Lesion (LSIL)
Guidelines for frequency of PAP/HPV testing
**<21: **Do not screen
**21 - 25: ** w/cytology (pap smear) every 3 years
**20-65: **W/cytology every 3 years or co-testing (cytology/HPV every 5 years)
**Post-hysterectomy w/removal of cervix & no hx of high grade precancer or cervical cancer: **Do no screen
Hx of CIN2 or above: continue annual for 20 years
HPV testing guidelines related to patients vaccinated for HPV
Same screening guidelines: we do not yet have enough info about vaccine
Predictive Values
PPV, NPV
**Predictive values are heavily influenced by DISEASE PREVALENCE à if the prevalence of a disease is high, PPV/NPV will be similar to sensitivity/specificity; however, if the prevalence of a disease is low, PPV decreases and NPV increases
Recommended weight gain: normal BMI
Women with optimal pre-pregnancy weight (BMI 18.5-24.9) should gain 25-35 lbs.
Usually, 3 - 6 lbs. are gained total in first trimester, and ½ to 1 lb / wk in the remainder.
If pt. does not show a 10-lb weight gain by midpregnancy, assess her nutritional status, unless she is obese.
Inadequate weight gain = risk for LBW, especially if mother was normal or underweight.
Recommended weight gain in pregnancy: underweight women
Underweight women (BMI <18.5) can gain up to 40 lbs.
Recommended weight gain in pregnancy: overweight women
Overweight women (BMI 25-29.9) should gain no more than 15 lbs.
Recommended weight gain in pregnancy: morbidly obese
Morbidly obese women (BMI >40) do not need to gain weight.
Pregnancy: what to do in case of weight loss or excess weight gain
When excess weight gain is noted, counsel pt. regarding nutrition & physical activity.
Rapid weight gain requires an assessment for fluid retention.
Don’t limit fluids! Don’t restrict salt unless pt. has HTN.
*Patients should be cautioned against weight loss during pregnancy.
Prenatal labs: 24-28 weeks
24-28 weeks: GCT(GestDiab), CBC, VDRL, HIV. For women who are RH negative Blood type and antibody screen for administration of Rhogam
Prenatal labs: 35 - 37 weeks
35-37 weeks: GBS, GC/CT screen
Prenatal labs: 38 weeks to deliver
38 weeks-delivery NST/BPP (biophysical profile) weekly
no AFI (amniotic fluid index, part of BPP) for obese women – risk for intrauterine fetal demise. Best cheapest way – feel 5-10 kicks in an hour
Murmurs in pregnancy: management
Any diastolic murmur and any systolic murmur that is loud (grade 3/6 or higher) or radiates to the carotids should be considered pathologic.
Careful evaluation for elevation of the jugular venous pulse, for peripheral cyanosis or clubbing, and for pulmonary crackles is needed in women with suspected cardiac disease.
If cardiac dz suspected: ECHO
Tests for allergic rhinitis
serum radioallergosorbent (RAST) test or multiple allergen skin testing
Bacterial Sinusitis: S/S
- Severe high fever >102 and purulent nasal discharge or facial pain for at least 3-4 days
- Onset for >10 days w/o improvement
- Onset with s/s characterized by new onset of fever, headache, or increase nasal discharge following a URI that lasted 5-6 days and were initially improving
- Facial pain
- Nasal obstruction
- Hyposmia or anosmia
- Halitosis
Dental pain
Cough
Ear pain
Sore throat
Periorbital swelling
Malaise
Increased pain w/coughing/bending over/sudden head movement
No response to decongestants
Paps for HIV+
For HIV+ women, CDC has best guidelines à increased amount of SIL in HIV;
HIV+ women should be given cytology every 6 months within 1st year after initial HIV+ diagnosis, and if both test normal screening thereafter.
HIV+ women with ASC-H, LSIL, or HSIL should have colposcopy
ASCUS on pap, mgmt
ASCUS (atypical squamous cells of undetermined significance):
a) HPV test or
b) repeat cyto in 1 year
c) both a & b.
Results of the repeat cytology:
negative: goes back to routine screening
another ascus: colpo
Results of the HVP test:
HPV+: colpo (managed the same as women with LISL)
HVP- : repeat cotest at 3 years
Manage colpos per asccp guidelines
Sinusitis: Bacterial- Antibiotic Management
Abx NOT recommended as single drug therapy:
Macrolides (azithromycin/clarithromycin)
2nd and 3rd generation Cephalosporins
Bactrim
HIGH RATES OF RESISTANCE WITH S. PNEUMONIAE AND H. INFLUENZA
