Lecture 1: Primary Health Care Primary Care: a basic level of health care that includes programs directed at the

promotion of health, early diagnosis of disease or disability, and prevention of the disease. Principles are based on: 1. Equity 2. Social Justice 3. Empowerment Strategy of primary health: Build on Alma-At principles Ensure universal access Consider population issues Create adequate conditions for effective provisions of health care to vulnerable groups Organise integrated care preventive, acute and chronic care Strive to improve performance

Activities: Education Promotion Provision of water and sanitation, maternal and child health care Immunisation Prevention of endemics Appropriate Tx

Chronic illness self-management requirements: Clear understanding of illness & outcomes sought Active engagement in own disease management processes Self-management skills Self-efficacy (ability to successfully learn and perform behaviour) Health literacy

Managing chronic illness: Understanding of disease and Tx Monitoring S/S detecting changes treatments Seek help Prevention and management of crisis

Associated factors with chronic illnesses:

Hereditary Lifestyle Environmental factors associated with development

Public health interventions: Taxation: tobacco, alcohol, unhealthy foods Limitations on additives: salt Monitoring of BP and cholesterol- drug Mx Gastric banding Skin cancer campaigns

Health Care Levels in Australia: Primary (prior to disease) Secondary (early detection & Tx limiting disability) Tertiary (rehab, disability minimisation, empowerment) Neonatal care Critical care Emergency Neurological Chronic illness

Promotion Screening Education Ages Services

(Acute) Diagnostic Surgical Medical Radiographic

Lecture 2: Perioperative nursing Changing trends in surgery Increased use of technology and availability of it Laser and laparoscopic interventions decrease hospitalisation and cost burdens Anaesthetics Economic trends perioperative visiting and day surgeries Ethical issues: blood transfusions, transplant and autonomy for clients i.e. life support

Peri-operative nurse assessment mental/physiological status range of motion/mobility- including corrective devices and pain issues sensory impairments or language barrier cultural differences, religious/spiritual needs cardiovascular and respiratory status (vital signs, airway patent, maintain oxygen saturation) nutritional status (N.P.O.) medications and allergies (obtain from patient's history)

Pre-operative risk factors Age Smoking Alcohol Nutritional status Weight Pre-existing health problems Medications

Physiological assessment Head to toe / Systematic approach BASELINE VALUES Hx, acute/ chronic issues, resp, cardio, integ, musco, nutrit, and elimination Allergies Past surgical complications Herbs and vitamins

Psychological assessment Situational changes Concerns with the unknown

Concerns with body image Past experiences Knowledge deficit Emotions: Anxiety, fear

Diagnostic screening/ assessment Blood tests Electrolytes BGL Liver function Urea & Creatinine Arterial blood gases Urinalysis X-rays ECG Pulmonary function tests

Lecture 3: CVD health risks Cardiovascular disease: any abnormal condition characterised by dysfunction of the heart and blood vessels. Risk factors: Family history Genetics Age Sex Smoking Alcohol Diet Lifestyle Level of activity Weight Pre-existing health conditions Ethnicity: Indigenous, Maori, Pacific Islander

Heart failure: the heart cannot pump enough blood to meet the metabolic requirements of body tissues. Causes: Dysfunction of: Lungs, kidneys and liver ACS

MI ((heart attack) is the irreversible necrosis of heart muscle secondary to prolonged ischemia) Anaemia HTN Pulmonary disease Renal disease

Complications: Kidney damage or failure. Heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment. Heart valve problems. The valves of your heart, which keep blood flowing in the proper direction through your heart, can become damaged from the blood and fluid build-up from heart failure. Liver damage. Heart failure can lead to a build-up of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for your liver to function properly. Heart attack and stroke. Because blood flow through the heart is slower in heart failure than in a normal heart, it's more likely you'll develop blood clots, which can increase your risk of having a heart attack or stroke. Management: ACE inhibitors Beta-blockers Diet Exercise Coronary bypass surgery (CABG) or angioplasty with or without stenting may help improve blood flow to the damaged or weakened heart muscle. Heart valve surgery may be done if changes in a heart valve are causing your heart failure. A pacemaker can help treat slow heart rates or help both sides of your heart contract at the same time. A defibrillator sends an electrical pulse to stop life-threatening abnormal heart rhythms.

ACS (863): ACS is a broad spectrum of clinical presentations, spanning STEMI (heart attack) through an accelerated pattern of angina without evidence of myonecrosis1/infarction (muscle death). Causes: Acute coronary syndrome is most often a complication of plaque build-up in the arteries in your heart (coronary atherosclerosis) These plaques, made up of fatty deposits, cause the arteries to narrow and make it more difficult for blood to flow through them. Complications: Angina Non-STEMI and STEMI (Ischaemic related pain)

MI Cardiac death

Management: Reperfusion therapy o Aspirin o PCI o Fibrolysis: prevents blood clots from getting bigger Antithrombolytic therapy Oxygen therapy Diet Exercise Smoking Depression Education

PCI Percutaneous coronary intervention (PCI) is one of the two coronary revascularisation techniques currently used in the treatment of ischaemic heart disease, the other being coronary artery bypass grafting (CABG).[1] PCI involves non-surgical widening of the coronary artery, using a balloon catheter to dilate the artery from within. A metallic stent is usually placed in the artery after dilatation. Antiplatelet agents are also used. Stents may be either bare metal or drug-eluting. Indications:

Acute ST-elevation myocardial infarction (STEMI) NonST-elevation acute coronary syndrome (NSTE-ACS) Stable angina Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope) Asymptomatic or mildly symptomatic patient with objective evidence of a moderate-sized to large area of viable myocardium or moderate to severe ischemia on noninvasive testing

Complications: Restenosis of the stent Stent thrombosis Hemorrhage Perforation Damage to kidneys- contrast dye Death Stroke Allergic reaction

HTN: disorder characterized by high blood pressure- over three consecutive accounts. Arterial walls become thickened, inelastic and resistant to blood flow and the LV becomes distended and hypertrophied as a result of its efforts to maintain normal circulation against increased resistance.

Causes: Primary: elevated blood pressure without identified cause and accounts o Contributing factors: Increase SNS activity, over production of Na retaining hormones and vasoconstrictors, increased sodium intake, body weight, diabetes, alcohol Secondary: Secondary hypertension can be caused by conditions that affect your kidneys, arteries, heart or endocrine system.

Complications: Angina MI LV hypertrophy- can lead to CCF

Management: Angina 1. Stable: (exertive), due to activity or exercise, painful episodes predictable a. Nitrates b. Oxygen if hypoxic or in shock c. Beta blockers d. Calcium channel blockers 2. Vasospastic: caused by coronary artery spasm, episodes of pain: waking, resting or sleep 3. Unstable: Pre-infarction- acute coronary insufficiency, unpredictable, chest pain prolonged and severe Causes: Coronary Artery Disease- Cholesterol plaque Coronary Artery Spasm ACE inhibitors Angiotensin receptor blockers Calcium channel blockers Diet- low sodium, saturated fats Exercise

Complications Stroke Heart attack Depression

Management

Rest Medications (nitroglycerin, beta blockers, or calcium channel blockers), Percutaneous coronary intervention (stenting or transluminal coronary angioplasty (PTCA), or Coronary artery bypass graft surgery (CABG).

AAA: An aneurysm (developed in the abdomen) occurs when a segment of the vessel becomes
weakened. The pressure of the blood flowing through the vessel creates a bulge at the weak spot.

Causes:

Emphysema Genetic factors High blood pressure High cholesterol- atherosclerosis Male gender Obesity Smoking

Complications: Infection pseudoaneurysm Death Rupture of repair site internal bleeding

Management:

In a traditional (open) repair, a large cut is made in your abdomen. The abnormal vessel is replaced with a graft made of man-made material, such as Dacron. The other approach is called endovascular stent grafting. This procedure can be done without making a large cut in your abdomen, so you may get well faster. If you have certain other medical problems, this may be a safer approach. Endovascular repair is rarely done for a leaking or bleeding aneurysm. Ultrasounds every 6 months tracking the development of the aneurysm Exercise and diet Medications: Statins

Respiratory conditions Asthma: Asthma is a disorder that causes the airways of the lungs to swell and narrow, leading to wheezing, shortness of breath, chest tightness, and coughing. Causes:

Allergy triggers, e.g. house dust mites, pollens, pets and moulds Cigarette smoke Viral infections, e.g. colds and flu Weather, e.g. cold air, change in temperature, thunderstorms Work-related triggers, e.g. wood dust, chemicals, metal salts Some medicines

Complications: Free air or gas within the pleural cavity (pneumothorax) can develop during severe asthma attacks, especially if the individual requires mechanical ventilation. A severe asthma attack that does not respond to treatment can lead to prolonged contraction (bronchospasm) of smooth muscles (status asthmaticus) and may be followed by respiratory failure and death. Individuals who have chronic pulmonary disease in addition to asthma will often have more severe and debilitating episodes of asthma. Long-term oral steroid use by asthmatics can lead to blood chemistry disturbances, cataracts, osteoporosis, immunosuppression, and adrenal suppression. Over-treatment of asthma with bronchodilators may precipitate cardiac arrhythmia.

Management:

Aims of management: o Achieve and maintain control of asthma symptoms o Maintain normal activity levels, including exercise o Maintain pulmonary function as close to normal as possible o Prevent asthma exacerbations o Avoid adverse effects from asthma medications o Prevent asthma mortality Quick relief (also called reliever medications) Long-term control (also called controller medications) o Examples: Beta2-adrenergic agonist agents Anticholinergic Agent Anticholinergic agent combinations Corticosteroid, oral Long-acting beta2 agonists Beta2-Agonist/Corticosteroid Combinations 5-lipoxygenase Inhibitor Methylxanthines Mast cell stabilizers Monoclonal Antibody

Corticosteroid, Inhalant Leukotriene Receptor Antagonist

COPD: Emphysema and chronic bronchitis are the two most common conditions that make up COPD. Chronic bronchitis is an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs. Emphysema occurs when the air sacs (alveoli) at the end of the smallest air passages (bronchioles) in the lungs are gradually destroyed. Causes: Lung irritants i.e. tabacco smoke including secondhand smoke Air pollution Chemical fumes Dust Genetics Pre-existing

Complications: Respiratory infections. People with COPD are more susceptible to colds, the flu and pneumonia. Any respiratory infection can make it much more difficult to breathe and produce further damage to the lung tissue. An annual flu vaccination and regular vaccination against pneumococcal pneumonia help prevent some infections. High blood pressure. COPD may cause high blood pressure in the arteries that bring blood to your lungs (pulmonary hypertension). Heart problems. For reasons that aren't fully understood, COPD increases your risk of heart disease, including heart attack. Lung cancer. Smokers with chronic bronchitis have greater risk of developing lung cancer than do smokers who don't have chronic bronchitis. Depression. Difficulty breathing can keep you from doing activities that you enjoy. And dealing with serious illness can contribute to development of depression. Talk to your doctor if you feel sad or helpless or think that you may be experiencing depression. Treatment: High caloric diet Bronchodilators CPAP machine nocte Steroids

Vaccines Pulmonary rehab Transplant Exercise as tolerated Psychological support

Cystic fibrosis: (a lethal genetic autosomal recessive disease) Cystic fibrosis is a result of a defective gene that codes for the Cystic fibrosis transmembrane conductance regulator CFTR protein, which is responsible for regulating the flow of chlorine in and out of a cell. Complications: Respiratory failure Pulmonary insufficiency Malnourishment Lethargy Death Depression Parenteral feeding NG / PEG (over 24 hours most commonly overnight)

Management: Antibiotics High caloric diet compromised of shakes and Mineral and vitamin supplements Psychological support Hygiene regime Pancreatic enzymes Nebs Daily physio

Bronchitis: Bronchitis is an acute inflammation of the air passages within the lungs. It occurs when the trachea (windpipe) and the large and small bronchi (airways) within the lungs become inflamed because of infection or irritation. Causes: Several viruses cause bronchitis, including influenza A and B, commonly referred to as "the flu." A number of bacteria are also known to cause bronchitis, such as Mycoplasma pneumoniae, which causes so-called "walking pneumonia." Bronchitis also can occur when a person inhales irritating fumes or dust. Chemical solvents and smoke, including tobacco smoke, have been linked to acute bronchitis.

Complications:

dyspnea, sometimes severe,

respiratory failure, pneumonia, cor pulmonale (enlargement and weakness of right heart ventricle due to lung disease), pneumothorax (collection of air or gas in lung causing lung collapse), polycythemia (abnormally high concentration of red blood cells needed to carry oxygen), COPD (some NIH investigators consider chronic bronchitis a type of COPD), emphysema, chronic advancement of the disease, and high mortality (death) rate (COPD is the 4th leading cause of death in the United States).

Management: Anti-inflammatory drugs, Anti-microbial, Analgesia anti-pyretic, corticosteroids, anti-viral Cough suppressants Beta 2 antagonists- Salbutamol Nebs Fluids Diet

Pneumonia: Respiratory tract infection that can be either lobular or bronchiolar. Causes: It is primarily caused by either bacterial or viral pathogens. Management: Shock Hypovolaemic shock: characterised by a decrease intravascular volume cause by significant blood and/or fluid volume. Caused by burns, trauma, internal bleeding. Management, positioning- raising legs, IV fluids and meds to increase blood pressure (Medicines such as dopamine, dobutamine, epinephrine, and norepinephrine may be needed to increase blood pressure and the amount of blood pumped out of the heart (cardiac output)). i. Altered LOC ii. Decreased UO iii. Decreased cap refill iv. Increased RR and pulse v. SBP < 90mmHg Antibiotics for bacterial infections post culture and sensitivity examination Anti-viral medication for viral infections Education about deep breathing and coughing including the use of the triflow Nebulisers PRN to help moisten secretions Physiotherapy promote respiratory function Nutritional support Oxygen therapy Home support to help perform ADLS

Septic Shock: Any type of bacteria can cause septic shock. Fungi and (rarely) viruses may also cause the condition. Toxins released by the bacteria or fungi may cause tissue damage, and may lead to low blood pressure and poor organ function. Some researchers think that blood clots in small arteries cause the lack of blood flow and poor organ function. The body also produces a strong inflammatory response to the toxins. This inflammation may contribute to organ damage. Risk factors for septic shock include: Diabetes Diseases of the genitourinary system, biliary system, or intestinal system Diseases that weaken the immune system such as AIDS Indwelling catheters (those that remain in place for extended periods, especially intravenous lines and urinary catheters and plastic and metal stents used for drainage) Signs/ symptoms: High or very low temperature, chills Lightheadedness Low blood pressure, especially when standing Low or absent urine output Palpitations Rapid heart rate Restlessness, agitation, lethargy, or confusion Shortness of breath

Management:

Breathing machine (mechanical ventilation) Drugs to treat low blood pressure, infection, or blood clotting Fluids given directly into a vein (intravenously) Oxygen Surgery

Cardiogenic shock: Characterised by decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Caused by Myocarditis (MI-o-kar-DI-tis). This is inflammation of the heart muscle. Endocarditis (EN-do-kar-DI-tis). This is an infection of the inner lining of the heart chambers and valves. Life-threatening arrhythmias (ah-RITH-me-ahs). These are problems with the rate or rhythm of the heartbeat. Pericardial tamponade (per-ih-KAR-de-al tam-po-NADE). This is too much fluid or blood around the heart. The fluid squeezes the heart muscle so it can't pump properly. Signs/ symptoms: Confusion or lack of alertness Loss of consciousness A sudden and ongoing rapid heartbeat Sweating Pale skin

A weak pulse Rapid breathing Decreased or no urine output Cool hands and feet

Management:

Oxygen therapy Breathing support- ventilator Fluids Medical devices- intra-aortic balloon pump and LVAD Meds to help: Prevent blood clots from forming Increase the force with which the heart muscle contracts Treat a heart attack

Arterial blood gas: Purpose: Assess degree to which lungs are able to provide adequate oxygen &remove CO2 & degree to which the kidneys are able to reabsorb or excrete HCO3. Body systems control acid/base system in the body: 1. Respiratory lungs CO2 2. Metabolic kidneys HCO3 pH range is normally 7.35 7.45 (low acidotic and high alkalotic) exact middle is 7.4 CO2 normally is 35 - 45 HCO3 normally 22 28 mmol/ L PaO2 80 100 mmHg PaCO2 35- 45 mmHg Respiratory If pH is decreased, CO2 will increase If pH is increased, C02 will decreased OPPOSITE OF EACH OTHER Metabolic If pH is decreased, HCO3 will decreased If pH is increased, HCO3 will increased SAME DIRECTION

ABG acid base balance + Oxygenation Respiratory Acidosis o pH of < 7.35 and PaCO2 of > 45 mmHg Respiratory Alkalosis o pH of > 7.45 and PaCO2 of < 35 mmHg Metabolic Acidosis o pH of < 7.35 and HCO3 o of < 22mmol/L Metabolic Alkalosis o pH of > 7.45 and HCO3 o of > 26mmol/L

General rules of ABG analysis 1. Check the value of each number for acid base status (i.e. pH, PaCO2 & HCO3) Does it represent acidity or alkalinity? Mark with an arrow if the value is increased or decreased Remember the normal value 2. Check the pH if > 7.45 alkalaemia if < 7.35 acidaemia if 7.35 7.45 normal 3. Find the value that matches the acid/base status of the pH If PaCO2 matches, the problem is respiratory If HCO3- matches, the problem is metabolic. 4. Determine compensation If both PaCO2 and HCO3 deviate from normal, where is origin of the problem? HCO3 Greater change from normal = metabolic problem

PaCO2 greater change from normal = respiratory problem

5. Look at the PaO2 & SaO2 Consider in relation to FiO2

ARF: Failure is present when: PaO2 is < or = 60mmHg PaCO2 is > or = 60mmHg. Other criteria: o _ pH of < 7.35 o _ SaO2 of < 90% Causes: By anatomical location Lower airways Alveolar capillary membrane gas exchange unit Pulmonary circulation Chest wall Pleura Upper airways Respiratory centre Spinal cord Neuromuscular junction:

4 mechanisms can impair gas exchange: 1. Alveolar hyopventilation 2. Ventilation/ Perfusion (V/Q) mismatch 3. Shunt (extreme form of V/Q mismatch) 4. Diffusion impairment Vascular Health Alterations: Peripheral arterial disease (PAD): common circulatory problem in which narrowed arteries reduce blood flow to your limbs. Causes: Peripheral artery disease is often caused by atherosclerosis. In atherosclerosis, fatty deposits (plaques) build up in your artery walls and reduce blood flow. Risk factors: Age Pre-existing health issues Exertive leg symptoms

Signs and symptoms:

 Complications:

Intermittent claudication o Ischaemic muscle ache / pain Parathesia pins and needle sensation Decreased pulse Leg elevation pallor

Delayed wound healing Arterial ulcers Amputation

Management: Education (Decrease risk factors e.g. smoking, HT, cholesterol) Anti-platelet drugs Exercise Diet Surgical interventions