HEALTH SCREENING & DISEASE PREVENTION
There are 3 levels of health prevention:
- primary: preventing the disease entirely (immunizations, nutrition and fitness, dental cleaning, safety features eg. seatbelt)
- secondary: focusing on identifying the disease, treating it, and preventing the spread (condoms, isolation, etc.)
- tertiary: focus on treating the long-term consequences of chronic illnesses/disability for optimal quality of life (rehabilitation, prevention of ulcers, medication, etc.)
Screening guidelines for everyone:
- dental q 6 mos
- BP @ 20 y.o. should be 120/80, screen yearly, biannual if higher than 120/80.
- BMI annual. Remember, BMI= kilos/(m^2) or (730 x lbs)/(in^2)
- Cholesterol<200 q 5 years starting @ 20 y.o.
- Glucose 90-120, A1C (4-5) q 3 years starting @ 45 y.o.
- Colorectal:
annual fecal occult beginning @ 50
& sigmoidoscopy q 5 years
or colonoscopy q 10 years
or double contrast barium q 5 years
or CT colonography q 5 years
For women:
- breast exam q 3 years starting @ 20, then annual starting @ 40 y.o.
- pap q 3 years starting @ 21
- annual mammogram starting @ 40
There are some female reproductive diseases that do not have good options for screening, such as
- Ovarian cancer (risks include: first pregnancy after 30 y-o, family hx of ovarian, breast, colon cancer, hx of dysmenorrhea, use of hormone therapy/infertility medications, and age over 40 y-o.), which has vague symptoms like pain and pressure of the abdomen, pelvis, back, or legs, GI symptoms, fatigue, frequent urination, or vaginal bleeding. Treatment is surgery, chemo, radiation.
- Myomas (uterine fibroids) have very similar sign and symptoms of pelvic pain and pressure and hypermenorrhea. Treatment is surgery.
- Endometriosis also have lower abdominal pain and dysmenorrhea. It causes pain during sex, and back and rectal pain. Treatment is oral contraceptives or surgery.
- Endometrial cancer causes vaginal bleeding between menstrual cycles or after menopause, and the risk increases three-fold for women who are 21+ pounds overweight. Treatment is hysterectomy, radium, and x-ray therapy.
For men:
The Try Guys Get Prostate Exams
- testicular self screening--the ATI book doesn't even HAVE this in their review book. For shame! The ACS doesn't say much about when you should begin self-screening, but you should just know that testicular cancer is the most common cancer among males 15-34 y.o.
- prostate screening @ 50 y.o. but all the texts are fishy about the frequency and what type of test (DRE? PSA?) this because the American Cancer Society has this absolutely laughably vague article regarding prostate screening.*
CONTRACEPTIVES
So the basic principle of birth control is either tricking your body into thinking its pregnant (which prevents follicular development), or preventing the sperm from meeting the ova. Everything else is just variation. You have abstinence, sterilization, or rhythm method, or coitus interruptus, which all attempt to do the same thing, which is to prevent the sperm from meeting the egg.
Then you have hormonal treatments, whether in depot form (depot medroxyprogesterone acetate aka DepoVera, patch, pill, ring, or even IUD. Then you have spermicidal substances in various methods of delivery and blocking the path of sperm, such as cervical capping, diaphragm, condoms, and just pushing that spermicide into the vagina.
There's a lot of non-barrier, non-medication methods for birth control, but I'm only going to talk about the rhythm method (aka Billings or Creighton method) which is pretty cool, but does require persistence (women's cycle do fluctuate with just about any type of stress-illness, work, etc.) Basically the woman monitors cervical mucus changes when toileting (watery mucus=ovulation because sperm needs to be able to get through the cervical os). Also you record your menstruation, and basal temperature. A temperature spike means LH surge, which means ovulation and then you have 12-24 hours to get jiggy with it to make a baby. (Well, technically sperm is viable around 72 hours to 5 days, so you have a bigger window in terms of having sperm floating around for a while before you ovulate.) Btw, there's a plethora of fertility apps to help you track your cycle for whatever reason. I'm a fan of Kindara.
Hormone method
Progesterone and estrogen contraceptives:
Basically estrogen and progesterone hormones causes the hypothalamus and anterior pituitary to shut down from negative feedback. Contraindications for this include a history of thrombosis or being in a high risk for thrombosis at this time, estrogen receptor positive tumors, lactation that is less than 6 weeks postpartum, and liver tumor.
Progestin-only contraceptives:
Causes inhibition of ovulation, thickening the cervical mucus, thinning the endometrium, and altering the cilia in uterine tubes. The main thing to remember about progestin-only methods is that because they don't contain estrogen (estrogen suppresses lactation), they can be used during lactation. You also have to remember that it has to be taken at the same time every day, and directions for making up a missed dose will vary. If you miss 2 or more in a row, you should get back on but also use the Morning After pill.
Method of delivery
Oral contraceptives: Can come in progestin only or estradiol/progestin remember to take it at the same time every day, and that if you miss one pill to just take it as soon as possible, and if you miss 2 days, use a backup method for a week. Hormonal contraceptives decrease the efficacy of anticonvulsants, antifungals, antituberculosis, and anti HIV medications -- or rather, I should say, any medications with the suffix anti- in it will decrease the efficacy of contraceptives. SE: breast tenderness, bleeding, n/v. Avoid smoking.Ethinyl estradiol and norelgestromin/transdermal patch: comes in the estradiol/progestin combination and you wear it on the low abdomen, upper outer arm, buttock or chest (not breasts). Replace on the same day every week for 3 weeks, rotating sites, with one week without a patch for menstruation.
Levonorgestrel 1.5 mg or "Plan B": aka the morning after pill is made of estradiol/progestin combination and comes in a larger than normal dose of oral contraceptive that has to be taken within 72 hours of unprotected sex. The next pill should be taken 12 hours after the first pill. This should never be taken as a primary method of birth control.
Intrauterine device: Here's a video about IUDs. They have to be placed and removed by a doctor, and they are 99% effective if correctly placed. There are two types of IUDs: hormonal or copper. Both types cause inflammation of the uterine lining which triggers immune cell release that will kill sperm, but the hormone IUD also causes thickening of mucus in the cervix and thins the endometrial lining so it is less likely to receive a blastocyst. The hormone reservoir lasts 7 years. The copper IUD lasts 12 years. The string of the IUD is just there to reassure a woman that it is still in place. Since it causes inflammation, it's a bad idea to use this if you have a pelvic infection. You need to teach women to check for the IUD thread after their period to make sure that the IUD hasn't be expelled with the menstruation debris. Also, check for copper allergies. If a pregnancy does occur with the IUD in place the IUD needs to be removed immediately, and an U/S needs to be done to rule out placenta previa or ectopic pregnancy. Also check for septic shock as there is a high risk of infection with IUDs.
Progestin only depot aka Depo-Provera: given SQ or IM. It is given during the first 5 days of the menstrual cycle and then administered every 11-13 weeks. You have to use a backup form of birth control for 7 days after the first injection. Return to fertility occurs about a year after cessation, but may be delayed as long as 18 months after discontinuation. Side effects include osteoporosis, weight gain, increased thrombosis, irregular spotting, decreased libido, and breast changes.
Spermicidal Method with Mechanical Blocking
Method of delivery
Cervical cap: the "FemCap" is the only cervical cap available in the U.S. You can watch an instructional video here. It's made of silicone and comes in three sizes. You insert it with the taller brim dorsally, and the shorter brim anteriorly. You put spermicide on the inside bowl that will be put over the cervix, around the brim, and on the dome. Insert it with the bowl over your cervix (usually easiest in a sitting position like you would putting in a tampon--I would recommend a chair, though, not the toilet), and hold it for 10 seconds in place to create a seal 15 minutes before sexual arousal, and keep it there for at least 6 hours and no more than 48 hours at a time. To remove, dimple in the dome to break the seal and pull it out by the strap. Wash with water and soap, dry, and put it in the storage container. You should get a pap smear every 3 months with the cervical cap. You shouldn't use a FemCap if you are on your period, had an abortion within the last 6 weeks, gave birth less than 8-10 weeks ago, or if you have a uterine/cervix/vaginal infection or disease or an abnormal Pap smear. And of course, you have to have familiarity, and it does take time, effort, and skill to insert.
Cervical diaphragm: basically work the same way the FemCap does. It can be made of rubber or silicone, and basically, you put spermicide inside of the dome, insert, and cap the cervix. You need to have annual gynecological exams to assess the fit, especially after weight loss or gain of 10 lbs or more, births, or second trimester miscarriage, or after any abdominal or pelvic surgery. It can be inserted 6 hours before sex and removed 6-8 hours after sex. The main complaints is that it's difficult to insert, and that the cold diaphragm and cold gel can temporarily reduce the vaginal response if inserted immediately before intercourse. It isn't a good option for women with poor vaginal muscle tone or recurrent UTIs.
Condom: Check the expiration date, open (not with your teeth or you might tear the condom). Makes sure you're putting the right side of the condom on your penis. (Hint: a condom has a pointy bit, like a sombrero. Put the sombrero on your penis like you would wear a hat.)
 |
| http://www.womenshealthmag.com/sites/womenshealthmag.com/files/images/bc-center-condoms-art.jpg |
Here's a great website that was very practical about gay sex, but also just how to put on a condom.
Female condom: basically, keep the rim on the outside of the vagina, and stick the part that looks like a collapsible cylinder into your vagina. Boom. Done. And, I was talking to a friend who is a sex educator and podcaster about how female condoms are actually quite comfortable. Here are articles about the product history, and how female condoms are the next big thing for safe sex.
Spermicide: nonoxynol-9 (N-9) reduces mobility of sperm upon contact. It should be used no more than 1 hour before sexual intercourse, and inserted (a preloaded vaginal suppository, foam, or what have you) high up into the vaginal so that it contacts the cervix. It also has to be reapplied for every additional romp (ok, ok, "act of intercourse"). Using it with a diaphragm or cervical cap increases efficacy. Interestingly, results from studies show that the use of N-9 may increase transmission of HIV and cause lesions. And that there is no evidence that the addition of spermicides to male condoms decreases the risk of pregnancy, so it is suggested that women with high HIV or STI risk behaviors avoid the use of spermicidal products containing N-9, which include the lubricated condoms. (This was taken from the fifth edition of Perry, Hockenberry, Lowdermilk, and Wilson's "Maternal Child Nursing Care" page 125). However, for the purposes of preventing pregnancy, you should definitely use a barrier method with N-9.
Mic's "How does birth control work? Nobody seems to know."
Educator: Have you heard about IUDs?
Man: Maybe you can fish with it? For eggs?
^^ The reason why we need to have medically accurate sex education in schools.
SEXUALLY TRANSMITTED DISEASES
GCCT=gonorrhea and chlamydia both mandatory report
- gonorrhea short incubation of 3-8 days: clear or cloudy discharge, treated with ceftriaxone IM, and erythromycin ophthalmically with neonates (blindness).
- chlamydia aka "the silent disease" because s/s are absent or minor and the incubation is up to 1-3 weeks: yellow/green discharge. (The ATI book also says "gray vaginal discharge." Tell me, what's the difference between cloudy and gray? Nobody knows? Ok, then.) Treated with azithromycin, doxycycline, and erythromycin ophthalmically with neonates (blindness)
Both cause:
- vaginal bleeding, swollen testicles
- frequent and painful urination/dysuria
- diffuse/nonspecific abdominal pain
- causes infertility and sterility
- both cause complications of pelvic inflammatory disease
Both can be passed to neonate during childbirth, but gonorrhea can be passed in utero. Often results in PID.
Pelvic inflammatory disease: Only occurs in women. S/s chronic abdominal pain, green or yellow vaginal discharge with unpleasant odor and dysuria. Often accompanied by fever, chills, N/V. Can lead to ectopic pregnancy and lead to infertility.
Syphilis has 3 stages:
stage 1=sores (appears within 3 months of infection) lasting up to 6 weeks.
stage 2=rash on body & flu symptoms.
stage 3=neurological/cardiovascular complications
Trichomoniasis: in 3 days to 2 weeks after infection you will see COPIOUS FROTHY, MUCOPURULENT, MALODOROUS green yellow vaginal discharge, or white, watery penile discharge. All of this accompanies your run of the mill dysuria and irritation. Treatment is metronidazole.
Herpes: can be transmitted even with no visible lesions. C/S indicated if active lesions present the 2 weeks before delivery, but also can be transmitted in utero. Acyclovir is started 36 weeks gestation to prevent outbreak before delivery.
Painful blisters for up to 3 weeks with possible systemic aches, enlarged lymph nodes and fever. Recurrences are preceded with shooting/tingling pain for hours to days before blister eruption.
No cure, but the symptoms can be shortened by use of any of the -cyclovirs.
Human papillomavirus: Many strains. Some cause condylomas that look flesh-colored of gray swelling, or cluster together like cauliflower, others cause cervical cancer. May cause recurrent respiratory papillomatosis. Treatment is imiquimod and podophyllin, and surgery to remove large warts. The best treatment is HPV vaccines as early as 9 years old, but definitely recommended for 11-12 year old girls.
HIV: can lie dormant for years without symptoms. Acute retroviral syndrome are non-specific with fever, malaise, lymphadenopathy, skin rash, but usually occur within the first few weeks before antibody tests are even positive. Can be spread during childbirth or during breastfeeding. Often first spotted because of signs of immunosuppression due to depletion of CD4 lymphocytes (candidiasis, weight loss, diarrhea, flu-like malaise). Treatment of obstetrical clients include zidovudine, nevirapine, and C/S 2 38 weeks.
Just so you know (since this is always a test question regarding HIPAA vs mandatory reporting to the CDC) these are the STIs you typically have to report to the CDC:
- Chancroid
- Chlamydia trachomatis
- Gonorrhea
- Hepatitis B
- Hepatitis C
- Syphilis, including congenital syphilis
Infections that are concerning during Pregnancy and L&D:
GBS: NORMAL FLORA in vagina--NOT an STI. Culture @ 35-36 wk. Tx: IVPB PCN q 4 hr during labor.
Listeria (deli meats/hot dogs/soft cheeses/unpasturized/refrigerated or smoked seafood): bacteria found in soil, water, plants NOT an STI. Causes premature labor, miscarriage, stillbirth
TORCH:
Toxoplasmosis: NOT AN STI passed through cat feces and other animals, or garden soils. Causes blindness, brain damage.
Other: (syph, varicella, parvovarius)
Rubella: causes cardiac, eye and ear disability, intellectual disability, liver and spleen damage. Remember MMR vaccine for mom after birth, no pregnancy for 1 month after. Children get the MMR @ 1 year and 4 years.
Cytomegalovirus (no treatment or vaccine): spread through saliva--may cause permanent hearing loss, vision loss, mental disability, microcephaly, lack of coordination, seizures, death.
Herpes infections: tx: acyclovir @36 wks, C/s if lesions visible within 2 weeks of delivery
INFECTION CONTROL
Things to remember:
Avoid placing clients on contact precautions with patients who are immunocompromised, with open wounds, or have anticipated prolonged lengths of stay.
Standard precautions (HepB, HepC, HIV<--only spread through blood and sexual contact) standard precautions can also include gown, mask, and goggles should the need arise--in other words, standard precautions can be upgraded to contact precautions if risk of blood and body fluids is high. Like, you can wear a gown for someone who just has food poisoning. The thing about standard precautions is that you have to treat all blood and body fluids as if they were contaminated.
Contact precautions (MRSA, C. diff, Hep A&E, Herpes, Carbapenem-resistant enterobacteriaceae, rotavirus, salmonella, shigellosis, staphylococcus, VRE<--these are all diseases that have diarrhea): isolated preferred but may cohort with the same organism. Sterile gown, gloves and mask (when risk of splashing, spraying, coughing, spitting, etc. occurs). Client leaves room only for essential clinical reasons.
Droplet precautions (meningococcal, pneumonia, RSV, rubella<--these diseases all have respiratory secretions that can be spread through coughing or sneeze): isolation preferred but may cohort with the same organism. Door is kept closed.) Must wear a mask within 3 feet of the patient.
Airborne precautions (varicella zoster/herpes zoster, rubeola, tuberculosis): Requires individual negative pressure rooms.
Note: if these lists seem overwhelming to you, it's easier to simply memorize the droplet and airborne (there are fewer).
Surgical Asepsis: only dry items touch the field with 1 inch borders
EATING DISORDERS
Eating disorders are actually psychiatric disorders. With eating disorders, the patient and the family may feel intense shame and are sensitive to others' perceptions. You have to empathize with the patient's low self-esteem, unworthiness, and dysphoria, but be firm if the patient is dishonest, manipulative, or attempting to provoke you. Reacting in an accepting and nonjudgemental way, and helping the patient to construct alternative ways to view their own behavior and logic will help to build trust.
There are 3 main types of eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorders.
Anorexia nervosa:
The thing to remember about anorexia is that the word "anorexia" is misleading because in medicine, the technical definition means "loss of appetite" as one might with chemo, or when nearing death. A person with anorexia usually does have a n appetite. Most anorexia patients restrict caloric intake, but some patients with anorexia actually do binge and purge--just not in cycles. These patients often exhibit:
- obsession with food (talking about it all the time whether about how good it tastes or how they can't eat something, but want to eat something, about the terror of gaining weight, etc.)
- focused on food preparation and food handling (often pushing things around their plate to make it look like they're eating and eating for as long as everyone else at the table)
- extreme exercise
- self-induced vomiting, abuse of laxatives and diuretics (remember, electrolyte imbalance, especially hypokalemia)
- cognition and self-perception impairment/judging self-worth by weight
immediate nursing concerns and s/s are
- acknowledge the emotional and physical difficulty the patient is experiencing
- hypokalemia, hypocalcemia, hypophosphatemia, hyponatremia--hypo everythingemia (CBC including hypoalbuminemia leading to edema)-->acute renal failure from dehydration--> cardiac dysrhythmias
- muscle weakening, constipation
- decreased fat, decreased estrogen, decreased calcium intake--> low bone density, amenorrhea
- cold extremities-->lanugo
later nursing tasks are:
- daily weights in bra and panties only with NO ORAL INTAKE before weighing--do not negotiate the resulting weight or reweigh
- normalizing eating patterns
- allow the patient to express feelings, and be encouraging, but remain firm about eating a set amount
- preventing the patient from purging for 1 hour after eating, administer liquid supplements.
- monitor bathroom trips after visitation to ensure no access to laxatives or diuretics
- privileges are related to weight gain (sorry, not sorry)
Treatment is addressing the acute complications like electrolyte imbalance/cardiac dysrhythmias, severe malnutrition and dehydration) with TPN and IVF watching for refeeding syndrome. Set a realistic goal of 90% ideal body weight and 2-3lbs/week weight gain, and improving coping skills. Eating in milieu is the best for these patients. Also, treatment of extreme depression and watching for self-harm behavior. In the beginning you may actually have to restrict working out to promote weight gain. Supporting the family as well as the patient is key.
Yeah, I know, it's extreme, especially the whole stalking the patient to the bathroom and stuff, but seriously, these people are starving themselves to within an inch of their lives. You have to make sure that food and water is getting into them and staying in them.
Bulimia nervosa: The bulimia patient may seem physically or emotionally fine. They are often at or very close to ideal weight, but there are certain physical signs one might see:
- enlarged parotid glands, dental erosion, caries
- hx of impulsivity and compulsivity, feelings of powerlessness, chronic low self-esteem, social isolation
- family hx of chaos/lack of nurturing (eh...I'm not sold on this--I think what they're attempting to communicated is that these patients are good at hiding their bulimia from family members and so there isn't this kind of intervention support group that accompanies those with anorexia)
- gastric rupture, electrolyte and cardiac disturbances
Nursing care is similar to that of anorexia in observation of meals during and after to prevent puring and hiding of food. Generally, the bulimic patient are easier to work with in a cognitive-behavioral sense. Interrupting compulsions of binging and purging may allow anxieties to come to the surface and be examined. Also, SSRI's (setraline, citalopram) and TCA's (imipramine, amitriptyline) help with preventing binging. Fluoxetine and bupropion help prevent relapse, but bupropion does increase risk of seizures.
 |
| http://giphy.com/gifs/reactiongifs-mad-zach-galifianakis-12jnTh8Dp0cFJS |
Binge Eating Disorder: It's important to understand that at one point or another, all people with obesity have points when their eating is out of control, so it's important to take a full history to identify cycles of binging episodes. It's a societal belief that obesity is a personality flaw of lack of self control and lack of discipline. You need to check those feelings at the door.
Of course with obesity brought on by binge eating there is a risk for diabetes, hypertension, and heart disease. You don't normally have to treat binge eaters with hospitalization. Just use cognitive behavioral therapy. There are common side effects such as:
- heartburn
- dysphagia
- bloating
- abdominal pain
- diarrhea
- urgency
- constipation/anal blockage
The treatment for binge eaters is the same weight loss mechanisms as normal weight loss, in addition to cognitive-behavioral and interpersonal therapy. Much of the medicinal treatment will be geared towards relieving symptoms of dyspepsia listed above. Medications that might be able to prevent binge eating are lorcaserin (designed to help people feel full after eating smaller meals by activating serotonin 2 receptors), topiramate/phentermine (topiramate gives a feeling of fullness, reduced taste sensation, and faster calorie burn, and phenterminea norepinerphine agonist that increaes concentration of appetite-regulating hormone leptin). Topiramate/phentermine is a schedule IV controlled drug due to its amphetamine-like effects (phentermine). It is shown to have birth defects, and is contraindicated with other drugs/diseases that may cause high blood pressure (glaucoma, MAOI, thyroxine). The most common side effects are paresthesia, altered taste sensation, insomnia, constipation, and dry mouth.
The last category of eating disorder is feeding and elimination disorders like pica, rumination, and avoidant/restrictive, which should all be mentioned because they are most often found in infants and children.
ANGER ABUSE ASSAULT
The thing you have to remember about anger, abuse, and assault is that they are rarely just about anger. Many feelings precipitate anger. Think about what causes you to be angry--being thrown to the side or ignored or rejected, embarrassed or humiliated, feeling guilty, being tired, or just being vulnerable in general.
People stay in abusive relationships because of denial, but the word "denial" has a negative associations of stupidity linked to it. Denial often occurs because of hope, because of needing to be loved and wanted, and because of fear of having to start over... or fear or not being lovable... fear of losing your children, or your home, or the dream of being a family...
 |
| http://extension.missouri.edu/explore/images/gh6608.jpg |
As a nurse, know that predictors of looming violence are:
- stone silence, jaw clenching, rigid posture
- ETOH or drug abuse
- pacing/restlessness
- verbal abuse
- loud voice
- intense or avoidance of eye contact
These signs may pop up during the tension building phase, but the victim often accepts responsibility for triggering the predictors. During the tension building phase the nurse should deescalate the situation as much as possible by maintaining a calm demeanor, using simple, short sentences, and avoid verbal struggles. Maintain the client's self-esteem and dignity (especially if you're dealing with the victim, but also by maintaining the abuser's self-esteem and dignity you prevent a progression to anger), and use purposefully nonaggressive posture, and maintain a large personal space.
All the signs of anger and looming violence also hold true for patients who are suffering from mental illness. The applications of de-escalation also apply. You can also give anxiolytics, and antipsychotics (haloperidol and chlorpromazine). Restraints and seclusion are used as a last resort.
Abuse can be mental, verbal, emotional, physical, sexual, neglect and economic. Remember to conduct the interview in private, be direct, honest, and professional, be understanding and attentive, limit the number of personnel who examine the patient, and never leave the victim alone with the abuser. Flunitrazepam (a benzodiazepine) and gamma-hydroxybutyrate (produces relaxation, euphoria, and disinhibition) are date rape drugs. Remember with rape, that you need to conserve evidence, so bag each item of clothing individually, and, if the patient consents, perform a rape kit. You will also need to collect skin, nail, and hair samples. Rape Trauma Syndrome (a variant of PTSD) can last for weeks, and they include feelings of numbness, disbelief, fear, denial, flashbacks, and emotional lability.
No comments:
Post a Comment