Term
Transtheoretical Model
5 Stages of Change |
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Definition
5 Stages of Change
1. Precontemplation (not ready to change)
Encourage reevaluation, explain and personalize the risk
2.Contemplation (thinking of changing)
Encourage evaluation of pros/cons of behavior change, identify and promote new, positive outcome expectations
3.Preparation (ready to change and has a plan)
Encourage small initial steps, promote positive outcomes
4.Action (making the change)
Help with restructuring cues and social support, enhance self-efficacy for dealing with obstacles
5.Maintenance (change is made and relapse is avoided)
Reinforce internal rewards, discuss coping with relapse |
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Term
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Definition
Transtheoretical Model (TTM)
Stages of Change
Basis for developing effective interventions to promote health behavior change
Model describes how people modify a problem behavior or acquire a positive behavior
Model focuses on the decision making of the individual (model of intentional change)
Core constructs: processes of change, decisional balance, self-efficacy and temptation
In order to identify appropriate intervention, clinicians must listen to patient to understand which stage patient is in relation to change |
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Term
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Definition
Developed specifically for adult learning
Emphasizes that adults are self-directed and take responsibility for decision
In adult learning, the focus is more on process and less on content (problem centered rather than content-oriented)
Principles:
Adults need to be involved in the planning and evaluation of instruction
Experience provides basis for learning
Most interested in subjects that have immediate relevance to either their work or personal life |
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Term
| Behavioral Theories for Change |
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Definition
Theory of Andragogy
Knowles (1970s)
Theory developed specifically for adult learning
Emphasizes that adults are self-directed and take responsibility for decisions
Transtheoretical Model of Change
Prochaska and DiClemente (1980s)
"Stages of Change" Model
Health Belief Model (HBM)
U.S. Public Health Service (1950s)
Addresses patient compliance and preventive health care practices
Addresses the relationship between a person’s beliefs and behaviors
Health Promotion Model (HPM)
Pender (early 80s, revised 1996)
Ultimate goal is to improve a patient's wellbeing |
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Term
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Definition
For patients
Can be stressful
May lead to fear of failure
Can affect patient financially
Requires effort
For providers
Requires time and patience
Requires the ability to encourage
Attention to detail/checking in with patient
Follow up with support |
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Term
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Definition
Compliance Issues
Motivating patients to make better lifestyle choices, change behaviors, take their medications
(Christensen, 2004) review of literature
Showed high rates of non-adherence to treatment plans
20-40% for acute illness
30-60% for chronic illness
80% for prevention |
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Term
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Definition
Proposes that a person's health-related behavior depends on person's perception of:
the severity of a potential illness
the person's susceptibility to that illness
the benefits of taking a preventative action
the barriers to taking that action
Especially important on issues focusing on patient compliance and preventative health practices |
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Term
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Definition
Model focuses on: individual characteristics and experiences, behavior-specific cognitions, and behavioral outcomes
Based on the perception that individual characteristics and experiences effect the likelihood of engaging in health promoting behaviors
Health promoting behavior on the part of the patient is the endpoint of the HPM and the desired behavioral outcome |
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Term
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Definition
Focuses programs on activities to improve the well being of the people
NPs should work toward empowerment for self care and enhancing the client's capacity for self care through education and development |
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Term
| Motivational Interviewing |
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Definition
Counseling style developed in the 80s
Self determination theory (SDT) proposed framework
Motivation framework for changing behavior
amotivation (no intention to engage in a behavior)
extrinsic (external reward or punishment avoidance)
intrinsic (engage in behavior because it is enjoyable)
Motivation and Autonomy linked
As motivation becomes more autonomous (intrinsic) and competence increases, self determination increases |
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Term
| Uses for motivational interviewing |
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Definition
Counseling method for promoting change using "directive, client-centered counseling style for eliciting behavioral change by helping clients explore and resolve ambivalence"
Adapted for use across the spectrum
Treatment adherence, HIV risk reduction, diet and exercise, health safety practices, smoking cessation and sex offending
Reflective listening is an essential part |
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Term
| How do we make a difference in healthcare? |
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Definition
Nurse practitioners focus on preventative care.
Berry (2007) study notes:
AANP states “besides clinical care, NPs focus on health promotion, disease prevention, health education, and counseling.” (AANP 2007)
ACNP states NPs focus “largely on health maintenance, disease prevention, counseling, and patient education in a wide variety of settings.” (AANP 2003) |
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Term
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Definition
Resistance is dealt with as a flaw rather than useful information that needs to be explored.
We don’t spend time identifying how patients make sense of illness and treatment and how we can help.
What benefits do they derive from tobacco?
What do they know and understand about the risk of not treating the illness?
New models of communicating with patients are needed. |
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Term
| Prochaska and DiClemente’s Change Theory |
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Definition
| Closest model for motivational interviewing |
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Term
| Motivational interviewing |
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Definition
Motivational interviewing is a person-centered (Rogers) directive (guided) method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence and resistance.
Note the focus on ambivalence and resistance; this is the key. |
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Term
| Why use motivational interviewing? |
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Definition
It’s evidence based:
Hettema (2005) article examined more than 400 articles on MI (including >70 outcome trials).
Found that the effect of MI is maintained and enhanced over time when it precedes or is added as standard treatment.
Smith (2004) randomized controlled trial of patients with DM type 2 who received MI group sessions.
MI randomized sessions receiving weight-control education lost more weight and maintained (over 18 months) vs. placebo. |
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Term
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Definition
Key Points
Motivational interviewing is focused on assessing a patient’s motivation for change, not motivating the patient.
The skills used in motivational interviewing are matched to the patient’s motivation (or readiness) for change.
Create a climate that is safe to change and safe to learn.
Assist the patient in making the argument for change.
A look over the fence: smoker/weight loss
What would have to change? |
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Term
| The spirit of motivational interviewing |
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Definition
Agape
Caring
Collaboration
Patient is the focus, not me
“You people”
“I only signed up for the decrease in premiums and no, I don’t want to quit smoking.” |
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Term
| Key Concepts: Decisional Balance |
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Definition
Health behaviors involve voluntary behavior change.
Patients develop an internal decisional balance about the change (pros and cons, benefits and risks, etc.).
This balance may be subjective, but it must be explored and “tilted” in favor of the benefits if change is to take place.
The balance is quantitative and qualitative.
Exploring the decisional balance:
Benefits of pros
Downside or risks or cons |
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Term
| Motivational Interviewing Skills |
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Definition
READS principles.
Roll with resistance.
Express empathy.
Avoid argumentation.
Develop discrepancy.
Support self-efficacy. |
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Term
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Definition
Example:
Patient: I just don’t see how I can quit smoking when my wife smokes too and she won’t quit.
HCP: You suspect that it will be much more difficult for you to quit smoking if your wife continues to smoke.
Patient: Right…I just don’t see that working.
HCP: How important is it for you to quit right now? |
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Term
| Application of expressing empathy |
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Definition
"You seem ___."
"In other words..."
"You feel ___ because ___."
"It seems to you..."
"You seem to be saying..."
"I gather that..."
"You sound..."
Example 1:
Patient: Everyone makes it sound so easy—just take the medicine, quit smoking, change your diet, and exercise more!
HCP: You sound frustrated. You have been asked to make a lot of changes to control your diabetes and blood pressure, and people don’t seem to appreciate how overwhelming and difficult all of it can be.
Example 2:
Patient: I know smoking is bad for me; it’s just that all of my friends smoke and we hang out together.
HCP: You realize that smoking can have harmful effects on your health, yet it has been difficult for you to quit because your friends smoke and they are important to you.
Expressing empathy to prevent losing face:
Patient: Other people have blood pressure that is much higher than mine. Mine is not so bad.
HCP: You are right; there are many people whose blood pressure is quite a bit higher. May I tell you what concerns me?
Repeating back the words with the feeling
Slight/major paraphrasing
To clarify the motivational issue
Framing |
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Term
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Definition
Patient: My doctor says I need to lose weight, take the medicine, quit smoking, and reduce the salt in my diet. I don’t think I need to quit smoking, do you? How about cutting back?
HCP: It sounds like a lot to do. It’s great that you are willing to take your medicine and watch your salt intake. Cutting back on your smoking would be a great first step. Ultimately, quitting smoking would be the healthiest thing to do. What are your thoughts? |
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Term
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Definition
Example:
Patient: I want to lower my blood pressure and reduce my risk of stroke or heart attack.
HCP: On the one hand, taking your medicine as you do really supports your goal of lowering your blood pressure. On the other hand, smoking raises your blood pressure and interferes with your goal.
HCP: On the one hand, you hate feeling ashamed because you keep going back to smoking. On the other hand, you actually started to feel better when you quit, but stress in your life triggers your smoking.
Things to say to a patient to help him or her "look over the fence" and see the other side
"If you were to wake up tomorrow and you were no longer a smoker, what would you like about that? What would be the benefits to you?"
“If you could snap your fingers and be at the weight you wanted to be at, what would you like about that? What would you see as the benefits?” |
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Term
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Definition
Example 2:
Patient: I’ve thought a little more about what you said about quitting smoking.
HCP: Great. Tell me more about what you have been thinking. What’s got you thinking about it? |
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Term
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Definition
It sounds like you know smoking is bad for you, yet it is difficult for you to quit. If you were to wake up tomorrow and were no longer a smoker, what would you see as the benefits?
You see long-term negative effects to smoking. What concerns you the most?
What would have to change for you to consider quitting?
What makes it most difficult for you to quit?
On the one hand, you see smoking as bad for your health, but on the other hand, you are not ready to quit.
On a scale from 1 to 7, where 1 is not at all important and 7 is very important, how important is it for you to quit smoking?
May I tell you what concerns me about your continuing to smoke?
You are certainly right about smoking being bad for you. Tell me more about that.
Earlier you told me that you have a goal of reducing your risk of stroke and heart attack. On the other hand, smoking increases those risks. What are your thoughts about that?
It has been hard to quit smoking even though you are concerned about its impact on your health. |
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Term
| Summary of Motivational Interviewing |
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Definition
What does the patient know and understand about the illness and its treatment?
What is the patient’s understanding of what can happen if the illness (behavior) is not changed?
What are the patient’s goals?
What options are available to the patient?
What does he/she want to work on first?
Explore the decisional balance.
Respond to the patient’s core concern(s).
Focus on one issue at a time, based on what is of paramount importance to the patient.
Respond with empathy throughout. (Be explicit.)
Stay in the spirit. |
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Term
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Definition
1980-2008: Global Increase in Obesity.
United States (2010): 33.9% adults obese and 68.3% overweight
In 2011, no state had a prevalence of obesity less than 20%.
No state met the Health People 2010 goal to reduce obesity prevalence to <15%
Obesity is not consistent across race & ethnicity.
Compared to whites, blacks and Hispanics have a 51% and a 21% higher prevalence of obesity respectively. |
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Term
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Definition
Obesity accounts for 5% to 15% of deaths in the United States
Related Costs: $147 billion annually
Consumers spend roughly $42 billion dollars a year on diet aids and products.
More than 60% of all Americans are overweight and or obese. |
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Term
| Classification of obesity |
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Definition
Overweight & Obese:
BMI
Overweight: BMI is 25-29.9
Obesity: BMI is 30 or greater
Calculating BMI:
Weight(kg) x Height(m)squared
Weight (lbs.) x 703 / height (inches) squared
Waist circumference:
Men: > and equal to 40 inches is a high risk value
Women: >35 inches is a high risk value |
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Term
| Correlation of medication to weight gain |
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Definition
Drugs Possible Weight Gain Alternative Drugs Less Likely to Cause Gain
Allergy Drugs
Cetirizine (Zyrtec)
Diphenhydramine (Benadryl)
Fexofenadine (Allegra)
Hydroxyzine (Vistaril)
1% or more
Loratadine (Claritin) or desloratadine (Clarinex)
Anti-depressant
Selective serotonin reuptake inhibitors*
such as fluoxetine (Prozac) and paroxetine (Paxil)
Tricyclic antidepressants such as
amitriptyline and imipramine (Tofranil)
10% or more
5 to 10% or more
Bupropion (Wellbutrin) or escitalopram (Lexapro)
Desipramine (Norpramin)
Blood Pressure Drugs
Alpha-blockers such as
prazosin (Minipress) and terazosin (Hytrin)
Beta-blockers such as
atenolol (Tenormin) and propranolol (Inderal)
1 to 4%
Facine (Tenex) |
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Term
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Definition
Drugs Possible Weight Gain Alternative Drugs Less Likely to Cause Gain
Diabetes Drugs
Sulfonylureas such as
chlorpropamide (Diabinese) and glyburide (Glynase)
Thiazolidinediones such as
pioglitazone (Actos) and rosiglitazone (Avandia)
5 to 10% or more
Metformin (Glucophage)
Seizure and Nerve-Pain Drugs
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Alproic acid (Depakote)
5 to 10%
Topiramate (Topamax)
Psychiatric Drugs
Clozapine (Clozaril) and olanzapine (Zyprexa)
Quetiapine (Seroquel) and risperidone (Risperdal)
4 to 10%
3 to 7%
Aripiprazole (Abilify) or
ziprasidone (Geodon)
Steriods
Cortisone (Cortone)
Dexamethasone (Decadron)
Hydrocortisone (Cortef) Prednisone (Deltasone)
7% or more
Various options depending on
why the steroid was prescribed. |
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Term
| Health consequences of overweight/obesity |
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Definition
What do you think having a BMI of 25 or greater causes in terms of health consequences?
Risk of morbidity from hypertension
Dyslipidemia
Type 2 DM
Coronary Heart Disease
Stroke
Gallbladder disease
Osteoarthritis
Sleep apnea and respiratory problems
Increased risk for cancers (endometrial, breast, prostate and colon) |
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Term
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Definition
Childhood obesity (NHANES) data from 2007-2008:
9.5% of children <2 are overweight
12% children age 2 to 19 have BMI > or = 97%
16.9% children age 2 to 19 have BMI > or = 95%
31.7% children age 2 to 19 have BMI > or = 85%
A major risk factor for:
Cardiovascular disease
Certain types of cancer
Diabetes Type 2
The percentage of children aged 6-11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2010. Similarly, the percentage of adolescents aged 12-19 years who were obese increased from 5% to 18% over the same period.
In 2010, more than one third of children and adolescents were overweight or obese. |
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Term
| at the heart of childhood obesity |
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Definition
Sugary drinks and less healthy food choices at school and in the community
Advertising of unhealthy foods
Regulatory variation among daycare center licensing requirements – quality of food served not always a factor in licensure
Lack of daily quality physical activity in all schools – need 60 minutes daily!
Lack of safe/appealing place to play in many communities
Limited access to affordable healthy foods
Increased portion sizes
Lack of breastfeeding support
TV and media: Children 8-18 spend an average of 7.5h a day on entertainment media!!!! |
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Term
| US preventitive services task force recommendation: Children and Adolescents |
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Definition
U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. |
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Term
| U.S. Preventive Services Task Force Recommendation: Adult |
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Definition
U.S. Preventive Services Task Force
The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multi-component behavioral interventions. |
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Term
Goals Healthy People 2020
Obesity Prevalence Objectives |
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Definition
Baseline: 33.9 percent of pts ≥ 20yo were obese in 2005-08 (age adjusted to the year 2000 standard population)
Target: 30.5 percent
Target-Setting Method: 10 percent improvement
Baseline: 16.1 percent of children and adolescents age 2-19yo were considered obese in 2005-08
Target: 14.5 percent
Target-Setting Method: 10 percent improvement |
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Term
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Definition
Baseline: 48.7 percent of primary care Physicians regularly assessed body mass index (BMI) in their adult patients in 2008
Target: 53.6 percent
Target-Setting Method: 10 percent improvement
Baseline: 49.7 percent of primary care physicians regularly assessed body mass index (BMI) for age and sex in their child or adolescent patients in 2008
Target: 54.7 percent
Target-Setting Method: 10 percent improvement |
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Term
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Definition
Baseline: 28.9 percent of physician office visits of adult patients who are obese included counseling or education related to weight reduction, nutrition, or physical activity in 2007 (age adjusted to the year 2000 standard population)
Target: 31.8 percent
Target-Setting Method: 10 percent improvement |
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Term
| Interventions recommended by CDC |
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Definition
Increase consumption of fruits and vegetables.
Increase physical activity.
Increase breastfeeding initiation, duration, and exclusivity.
Decrease consumption of sugar drinks.
Decrease consumption of high-energy-dense foods, which are high in calories. |
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Term
| Walk the walk: live by example |
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Definition
Do you think you can?
Breastfeed (if able)
Aerobic physical activity (3-4 times /week)
Limit pregnancy weight gain
Strength training two non-consecutive days a week
Only 1 alcohol drink per day or less
Sleep 7 to 8 hours per night
Eat only whole grains, 4 to 5 daily servings of vegetables, 4 to 5 daily servings of fruit, 2 to 3 servings of low-fat or non-fat dairy foods, 2 servings or less of meats, poultry and/or fish per day. |
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Term
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Definition
10% Weight Loss – make it an obtainable goal!
Practice Motivational Interviewing – are they ready?
Educate your patient, discuss risks/benefits
Provide resources
Encourage and evaluate if ready to make a change |
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Term
| Surgeon generals report 2012 |
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Definition
Every day, more than 1,200 people in this country die due to smoking. For each of those deaths, at least two youth or young adults become regular smokers each day.
Almost 90% of those replacement smokers smoke their first cigarette by age 18.
There could be 3 million fewer young smokers today if success in reducing youth tobacco use that was made between 1997 and 2003 had been sustained.
Rates of smokeless tobacco use are no longer declining, and they appear to be increasing among some groups.
Cigars, especially cigarette-sized cigars, are popular with youth.
One out of five high school males smokes cigars, and cigar use appears to be increasing among other groups.
Use of multiple tobacco products—including cigarettes, cigars, and smokeless tobacco—is common among young people.
Prevention efforts must focus on young adults ages 18 through 25, too.
Almost no one starts smoking after age 25.
Nearly 9 out of 10 smokers started smoking by age 18, and 99% started by age 26.
Progression from occasional to daily smoking almost always occurs by age 26. |
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Term
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Definition
Cigarette smoking is pervasive in movies
Evident in at least ¾ of box-office hits
Average, 10.9 smoking incidents per hour
Charlesworth and Glantz. (2005). Pediatrics 116:1516–1528.
There is a dose-response, causal relationship between exposure to smoking in movies and youth smoking initiation
National Cancer Institute. (2008). The Role of the Media in Promoting and Reducing Tobacco Use.
70% of adults support assigning an “R” rating to movies with smoking.
For more information on smoking in movies, go to Smoke Free Movies |
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Term
| Compounds in tobacco smoke |
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Definition
An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens
Gases Particles
Carbon monoxide
Hydrogen cyanide
Ammonia
Benzene
Formaldehyde
Nicotine
Nitrosamines
Lead
Cadmium
Polonium-210
Nicotine is the addictive component of tobacco products, but it does NOT cause the ill health effects of tobacco use. |
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Term
| Health Consequences of smoking |
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Definition
Cancers
Acute myeloid leukemia
Bladder and kidney
Cervical
Esophageal
Gastric
Laryngeal
Lung
Oral cavity and pharyngeal
Pancreatic
Pulmonary diseases
Acute (e.g., pneumonia)
Chronic (e.g., COPD)
Cardiovascular diseases
Abdominal aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Reproductive effects
Reduced fertility in women
Poor pregnancy outcomes (e.g., low birth weight, preterm delivery)
Infant mortality
Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes |
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Term
| Health Consequences of smokeless tobacco |
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Definition
Periodontal effects
Gingival recession
Bone attachment loss
Dental caries
Oral leukoplakia
Cancer
Oral cancer
Pharyngeal cancer |
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Term
| Pidemiology of Tobacco Use: Summary |
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Definition
About one in five adults are current smokers; smoking prevalence varies by sociodemographic characteristics.
Nearly half a million U.S. deaths are attributable to smoking annually.
Smoking costs the U.S. $193 billion per year. Lifetime financial costs of smoking approaches one million US dollars for a heavy smoker.
At any age, there are benefits to quitting smoking.
The biggest opponent to tobacco control efforts is the tobacco industry. |
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Term
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Definition
| Compulsive drug use, without medical purpose, in the face of negative consequences” |
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Term
| Neurochemical and related effects of nicotine |
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Definition
N → Dopamine → Pleasure, appetite suppression
I → Norepinephrine → Arousal, appetite suppression
C → Acetylcholine → Arousal, cognitive enhancement
O → Glutamate → Learning, memory enhancement
T → Serotonin → Mood modulation, appetite suppression
I → β-Endorphin → Reduction of anxiety and tension
N → GABA → Reduction of anxiety and tension
E |
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Term
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Definition
Tobacco users maintain a minimum serum nicotine concentration in order to:
Prevent withdrawal symptoms
Maintain pleasure/arousal
Modulate mood
Users self-titrate nicotine intake by:
Smoking/dipping more frequently
Smoking more intensely
Obstructing vents on low-nicotine brand cigarettes |
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Term
| Nicotine Pharmacology and Addiction: Summary |
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Definition
Tobacco products are effective delivery systems for the drug nicotine.
Nicotine is a highly addictive drug that induces a constellation of pharmacologic effects.
Nicotine activates the dopamine reward pathway in the brain, which reinforces continued tobacco use.
Tobacco users who are dependent on nicotine self-regulate tobacco intake to maintain pleasurable effects and prevent withdrawal. |
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Term
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Definition
Ask
Advise
Assess
Assist
Arrange |
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Term
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Definition
Ask about tobacco use
“Do you ever smoke or use any type of tobacco?”
“I take time to ask all of my patients about tobacco use—because it’s important.”
“Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?”
“Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?” |
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Term
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Definition
Advise tobacco users to quit (clear, strong, personalized)
“It’s important that you quit as soon as possible, and I can help you.”
“Cutting down while you are ill is not enough.”
“Occasional or light smoking is still harmful.”
“I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.” |
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Term
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Definition
Assess readiness to make a quit attempt
Assist with the quit attempt
Not ready to quit: provide motivation (the 5 R’s)
Ready to quit: design a treatment plan
Recently quit: relapse prevention |
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Term
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Definition
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Term
| Stage 1: Not ready to quit |
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Definition
The 5 R’s—Methods for enhancing motivation:
Relevance
Risks
Rewards
Roadblocks
Repetition |
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Term
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Definition
Ready to quit in the next month
Patients are aware of the need to, and the benefits of, making the behavioral change.
Patients are getting ready to take action.
GOAL: Achieve cessation. |
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Term
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Definition
Routinely identify tobacco users (Ask)
Strongly advise patients to quit
Assess readiness to quit at each contact
Tailor intervention messages (Assist)
Be a good listener
Minimal intervention in absence of time for more intensive intervention
Arrange follow-up
Use the referral process, if needed |
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Term
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Definition
Brief interventions have been shown to be effective
In the absence of time or expertise:
Ask, advise, and refer to other resources, such as local group programs or the toll-free quitline1-800-QUIT-NOW |
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Term
| What are tobacco quit lines? |
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Definition
Tobacco cessation counseling, provided at no cost via telephone to all Americans
Staffed by trained specialists
Up to 4-6 personalized sessions (varies by state)
Some state quitlines offer pharmacotherapy at no cost (or reduced cost)
Up to 30% success rate for patients who complete sessions
Most health-care providers, and most patients, are not familiar with tobacco quitlines. |
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Term
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Definition
Nonpharmacologic
Counseling and other non-drug approaches
Pharmacologic
FDA-approved medications
Counseling and medications are both effective, but the combination of counseling and medication is more effective than either alone. |
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Term
| Non Pharmacologic Methods |
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Definition
Cold turkey: Just do it!
Unassisted tapering (fading)
Reduced frequency of use
Lower nicotine cigarettes
Special filters or holders
Assisted tapering
QuitKey (PICS, Inc.)
Computer developed taper based on patient’s smoking level
Includes telephone counseling support
Formal cessation programs
Self-help programs
Individual counseling
Group programs
Telephone counseling
1-800-QUITNOW
1-800-786-8669
Web-based counseling
www.smokefree.gov
www.quitnet.com
www.becomeanex.org
Acupuncture therapy
Hypnotherapy
Massage therapy |
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Term
| Phamacologic Methods: First Line Therapy |
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Definition
Three general classes of FDA-approved drugs for smoking cessation:
Nicotine replacement therapy (NRT)
Nicotine gum, patch, lozenge, nasal spray, inhaler
Psychotropics
Sustained-release bupropion
Partial nicotinic receptor agonist
Varenicline |
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Term
| Summary for smoking cessation |
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Definition
To maximize success, interventions should include counseling and one or more medications
Clinicians should encourage the use of effective medications by all patients attempting to quit smoking
Exceptions include medical contraindications or use in specific populations for which there is insufficient evidence of effectiveness
First-line medications that reliably increase long-term smoking cessation rates include:
Bupropion SR
Nicotine replacement therapy (gum, inhaler, lozenge, patch, nasal spray)
Varenicline
Use of effective combinations of medications should be considered |
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Term
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Definition
Address tobacco use
with all patients.
At a minimum,
make a commitment to incorporate brief tobacco interventions as part of routine patient care.
Ask, Advise, and Refer. |
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Term
| Why is it so important to code correctly |
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Definition
Reimbursement is based on CPT code billed.
Undercoding means less money coming in.
Overcoding may lead to auditing, investigation, and charge of fraud. |
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Term
| Under Both CPT and the HCFA Guidelines |
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Definition
Clinician chooses a level based on documentation of:
History (amount taken)
Physical examination (extent completed)
Medical decision making (complexity of) |
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Term
|
Definition
The CPT manual and CMS guidelines ask, is it:
Problem focused?
Expanded problem focused?
Detailed?
Comprehensive? |
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Term
|
Definition
CPT code numbers are based on amount of history taken:
Problem-focused history
Billable as a level 2 visit (99202, 99212)
Expanded problem-focused history
Billable at level 3 (99203, 99213)
Detailed history
Billable at level 4 (99204, 99214)
Comprehensive history
Billable at level 5 (99205, 99215) |
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Term
|
Definition
What are CMS's requirements for a "problem-focused history"?
Perform and document one to three elements of history of present illness (HPI).
No review of systems or past, family, or social history need be documented. |
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Term
| Expanded problem focus history |
|
Definition
Perform and document 1 or more elements of history of present illness (HPI).
Perform and document 1+ elements of review of systems (ROS).
No past, family, or social history (PFSH) is required. |
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Term
|
Definition
Perform and document 4+ elements of HPI.
Perform and document 2+ elements of ROS.
Perform and document 1+ item from PFSH. |
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Term
|
Definition
Perform and document 4+ elements of HPI.
Perform and document 10+ elements of ROS.
Perform and document 2+ elements of PFSH |
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Term
|
Definition
So, level of history depends upon documented elements of HPI, ROS, PFSH.
History of present illness (HPI)
Review of systems (ROS)
Past, family, social history (PFSH) |
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Term
|
Definition
Onset
Duration
Location
Severity
Quality
Quantity
Associated symptoms
Alleviating factors |
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Term
| Review of systems elements |
|
Definition
Head (Any recent HAs? Recent trauma?)
Eyes (Blurred vision? Poor visual acuity?)
Ears (Trouble hearing? Earache?)
Nose (Rhinitis? Nose bleeds?)
Mouth (Dry? Sore tongue? Lesions?) |
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Term
| Past, Family, Social Hx elements |
|
Definition
Past
Have you had any medical illnesses in the past?
Have you had surgery in the past?
Family
Any family history of cancer, diabetes, hypertension?
Social
Do you smoke? |
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Term
| Medical Necessity will dictate the scope of evaluation |
|
Definition
55-year-old white man c/o headache beginning yesterday.
Pain is constant, over right eye.
10 on scale of 1-10, associated with blurred vision.
Versus
24-year-old healthy man with mild HA behind eyes, off and on for 1 week.
Severity 2 on scale of 1-10.
Worse after long periods of studying. |
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Term
|
Definition
Under CPT and the CMS guidelines, there are four levels of exam:
Problem focused
Expanded problem focused
Detailed
Comprehensive |
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Term
|
Definition
Little is required.
Document why the patient was there and what was done.
The visit need not be conducted by a nurse practitioner or physician; i.e. the visit may be conducted by an RN or assistant. |
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Term
|
Definition
| CPT and CMS have requirements for documenting the level of services provided during these visits. |
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Term
|
Definition
| Choice of code depends upon number of bulleted elements of examination documented. |
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Term
|
Definition
In general, each line of the exam you learn in school is one element.
Each line below is one bullet, or element:
Well developed, well nourished white male
Heart rate 88, BP 120/70, RR 12
Heart regular without murmur
For more examples, see CMS's guidelines (file name: 1997docg) |
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Term
|
Definition
CPT and the CMS guidelines describe the levels of exam as follows:
Problem-focused exam
Expanded problem-focused exam
Detailed exam
Comprehensive exam |
|
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Term
|
Definition
The CPT and CMS descriptions of levels of exam translate as follows:
Problem-focused exam Level 2
Expanded problem-focused exam Level 3
Detailed exam Level 4
Comprehensive exam Level 5 |
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Term
| Number of exam elements required for each visit level |
|
Definition
Problem-focused exam is 1 or more elements.
Expanded problem-focused exam is 6 or more elements.
Detailed exam is 12 or more elements.
Comprehensive exam is 18 or more elements. |
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Term
| Rules for choosing code level for an established patient visit |
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Definition
For an established patient choose the code for which you have met the criteria for two of the three aspects of medical work; i.e.:
History
Exam
Medical decision making |
|
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Term
| Rules for choosing code level for a new patient visit |
|
Definition
For a new patient choose the code for which you have met the criteria for all three of the three aspects of medical work; i.e.:
History
Exam
Medical decision making |
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Term
|
Definition
Under the CPT and CMS rules, there are four levels of medical decision making:
Straightforward
Low complexity
Moderate complexity
High complexity
So, the levels of medical decision making correspond to visit levels and codes as follows:
Straightforward Level 2 (such as 99212)
Low complexity Level 3 (such as 99213)
Moderate complexity Level 4 (such as 99214)
High complexity Level 5 (such as 99215) |
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Term
|
Definition
There are five levels of visit.
A level 1 visit requires no medical decision making.
Level 2-5 visits require the following:
Straightforward decision making Level 2
Low complexity Level 3
Moderate complexity Level 4
High complexity Level 5 |
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Term
| Example of a Level 1 (99211) Visit |
|
Definition
|
|
Term
| What differentiates these levels? |
|
Definition
Under the CMS guidelines, medical decision making is based on three aspects of a visit:
Number of diagnoses or management options dealt with
Amount/complexity of data reviewed
Risk of significant complications, morbidity, mortality |
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Term
| Straightforward decision making |
|
Definition
Number of diagnoses or management options is minimal.
Amount and/or complexity of data reviewed is minimal or none.
Risk of complications, morbidity, or mortality is minimal. |
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Term
| Low complexity medical decision making |
|
Definition
Number of diagnoses or management options is limited.
Amount and/or complexity of data reviewed is limited.
Risk of complications, morbidity, or mortality is low. |
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Term
| Moderate complexity medical decision making |
|
Definition
Number of diagnoses or management options is multiple.
Amount and/or complexity of data reviewed is moderate.
Risk of complications, morbidity, or mortality is moderate. |
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Term
| High complexity medical decision making |
|
Definition
Number of diagnoses or management options is extensive.
Amount and/or complexity of data reviewed is extensive.
Risk of complications, morbidity, or mortality is high. |
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Term
| Medical decision making for an established patient |
|
Definition
Clinician must meet or exceed two of these three to qualify for a given level of decision making:
Number of diagnoses or management options
Amount/complexity of data to be reviewed
Risk of complications and/or morbidity/mortality |
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Term
| Medical decision making for a new patient |
|
Definition
Clinician must meet or exceed all of these three to qualify for a given level of decision making:
Number of diagnoses or management options
Amount/complexity of data to be reviewed
Risk of complications and/or morbidity/mortality |
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Term
|
Definition
Choose a code based on these criteria:
How many diagnoses?
How many tests ordered, analyzed?
How many and what kind of therapies ordered?
How risky is the patient's condition?
How many other experts were consulted?
However, there are no clear point systems given by CPT or CMS, except for diagnoses. |
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Term
Under CMS guidelines
Minimal Risk |
|
Definition
Minimal risk means the patient has:
1 or more self-limited or minor problem
Examples: "a cold," insect bite, tinea corporis |
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Term
|
Definition
Low risk means the patient has:
2+ self-limited or minor problems
1+ stable chronic illness (well-controlled HTN)
An acute uncomplicated illness or injury
Examples: cystitis, allergic rhinitis, simple sprain |
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Term
|
Definition
Moderate risk means the patient has:
1+ chronic illnesses with mild exacerbation, progression, or side effects of treatment
2+ stable chronic illnesses
An undiagnosed new problem with uncertain prognosis
An acute illness with systemic symptoms
An acute complicated injury |
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Term
|
Definition
High risk means:
1+ chronic illnesses with severe exacerbation, progression, or side effects of treatment
Acute or chronic illnesses or injuries that threaten life or bodily function
An abrupt change in neurologic status |
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Term
| Diagnostic Procedures Ordered |
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Definition
The more ordered, the higher level of medical decision making.
But, the rules give no means of connecting levels of decision making with numbers of tests ordered.
However, CMS guidelines give examples of tests that might be ordered for low-, moderate-, and high-risk patients. |
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Term
| A minimal risk patient might need |
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Definition
Laboratory tests requiring venipuncture
Chest X-rays
Urinalysis
KOH prep |
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Term
| A low risk patient might need |
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Definition
Might need:
Physiologic tests not under stress
Superficial needle biopsy
Lab tests requiring arterial puncture |
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Term
|
Definition
Might need:
Physiologic tests under stress
Deep needle or incisional biopsy
Obtain fluid from body cavity |
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Term
|
Definition
Might need:
Cardiac electrophysical tests
Cardiovascular imaging studies with contract with identified risk factors
Diagnostic endoscopies with identified risk factors |
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Term
|
Definition
Rest
Gargles
Elastic bandages
Superficial dressings |
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Term
| Low risk pt management options |
|
Definition
Management options might include:
Over-the-counter drugs
Minor surgery with no identified risk factors
Physical or occupational therapy
IV fluids without additives |
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Term
|
Definition
Management options might include:
Minor surgery with identified risk factors
Elective major surgery
Prescription drug management
IV fluids with additives
Closed treatment of fracture without manipulation |
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Term
|
Definition
Might include:
Elective major surgery with identified risk factors
Emergency major surgery
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate |
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Term
| You are seeing a 48 year male in clinic for an upper respiratory illness. He is a 1 ppd smoker. Besides treating his symptoms, you begin to explore his smoking habit and potential desire to quit. which of the following question would be most appropriate to ask? |
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Definition
| Can you tell me about some of the triggers that make you want to smoke? |
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Term
|
Definition
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Term
| Assessing a patient’s readiness to quit enables clinicians to |
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Definition
| Deliver relevant appropriate counseling messages |
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Term
| Thomas, age 42, has a 20 pack year smoking history. His father, age 64 just died from an MI after smoking for 40 years. Thomas has a PMH of depression, mild HTN, hyperlipidemia, and closed head injury after and MVA in 2011. He is requesting your help to quit smoking. Which is the best treatment approach for Thomas? |
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Definition
| Start nicotine patch with nicotine gum for breakthrough cravings. |
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Term
| Preconception Health Promotion |
|
Definition
The preconception movement is based on the realization that:
Prenatal care starts too late to prevent many of these poor pregnancy outcomes
Women who have higher levels of health before pregnancy have healthier reproductive outcomes
Preconceptional Health Promotion provides a pathway to the Primary Prevention of many poor pregnancy outcomes beyond that available through traditional prenatal care |
|
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Term
| Where does US rank in preconception health promotion/Early prenatal care |
|
Definition
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Term
| Primary Prevention of congential anomolies |
|
Definition
Prevention of neural tube defects
50-70% can be prevented if a woman has adequate levels of folic acid during earliest weeks of organogenesis
Birth Defects related to poor glycemic control of mother (including sacral agenesis, cardiac defects and neural tube defects)
Can be reduced from 10% to 2-3% through glycemic control of the mother before organogenesis |
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Term
| What is preconception care? |
|
Definition
Giving protection
Managing conditions
Avoiding exposures known to be teratogenic |
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Term
|
Definition
Wouldn’t it be more efficient to limit preconception health promotion information to women who are intending to become pregnant in the near future? No!
50% of pregnancies in the US are unintended
Most preconceptional health promotion is appropriate to all women
Women are not likely to come for an additional encounter |
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Term
| For everywoman who is child bearing age/ every time she is seen |
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Definition
Opportunities to Incorporate “Every Woman, Every Time”
Well woman visits
Annual exams
Family planning encounters
Chronic disease visits
Postpartum exams |
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Term
| Family Planning and Reproductive Life Plan |
|
Definition
Recommendations on the Clinical Content of Preconception Care (AJOG,2008)
Family planning and reproductive life plan
Screening women for intentions to become or not become pregnant, short and long term
Risk of conceiving (intended or not)
Information and counseling about contraception, emergency contraception consistent with reproductive life plan and risk of pregnancy |
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Term
| Recommendations: Weight Status |
|
Definition
Body mass index (BMI) calculated at least annually
BMIs > 26kg/m2
Counsel
Offer specific behavioral strategies
BMI < 19.8kg/m2
Counsel
Assess
May require referral for further evaluation of eating disorders |
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Term
| Recommendations: Nutrient Intake |
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Definition
All women of reproductive age
Should be assessed for nutritional adequacy
Recommend a multivitamin supplement if any question of food source adequacy
Advise to ingest 0.4mg(400µg) of synthetic folic acid daily |
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Term
| Recommendations: Immunizations |
|
Definition
All women of reproductive age
Check immunization status for
tetanus-diphtheria toxoid
diphtheria-tetanus-pertussis
measles, mumps, and rubella
Screen annually for health, lifestyle, and occupational risks for other infections, offer indicated immunizations |
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Term
| Recommendations: Infectious Disease |
|
Definition
STIs
Human papilloma virus (HPV)
Human immunodeficiency virus
Gonorrhea
Chlamydia
Syphilis
Herpes simplex virus
Hepatitis C
Tuberculosis
Toxoplasmosis
Cytomegalovirus
Listeriosis
Parvovirus
Malaria
Asymptomatic bacteruria
Periodontal disease
Bacterial vaginosis (BV)
Group B Streptococcus |
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Term
| Recommendations: Substance Use |
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Definition
Assess use of tobacco at each encounter
Counsel smokers
Assess alcohol use patterns and behavior
Provide with appropriate counseling
Advise all women of the risks to the embryo/fetus of alcohol exposure in pregnancy, no safe level has been established |
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Term
| Recommendations: Chronic Disease |
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Definition
Assess likelihood of pregnancy affecting the mother’s health
Assess likelihood of medical condition affecting the pregnancy
With certain conditions
Advice on modifying the treatment of the condition
Avoidance or timing of a potential conception
Refer to a provider with expertise in the management of condition during pregnancy, for preconception counseling, when appropriate |
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Term
| Recommendations: Medication Use |
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Definition
Review of all medications (prescribed and over-the-counter) at all encounters
Simplest effective regimen
If using a teratogenic medication, consider switch
If unavoidable, careful counseling on risks, alternatives, plan for contraception initiated
Counsel on what to do with medication regimen in the event of pregnancy |
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Term
| Recommendations: Reproductive History |
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Definition
Prior preterm birth infant
Evaluate for remediable causes
Treatment with progesterone in subsequent pregnancy
Prior cesarean delivery
At least 18 months before next pregnancy
Possible modes of delivery
Prior miscarriage
Women with sporadic SABs
Women with > 3 consecutive early SABs
Prior stillbirth
Thorough investigation at the time
Increased risk of adverse pregnancy outcomes
Possible referral
Work-up to determine cause if needed
Modify risk factors
Uterine anomalies
Uterine septum
Other anomalies |
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Term
| Recommendations: Reproductive Hx cont |
|
Definition
Family & Genetic History
Maternal age
Maternal and paternal medical conditions
Obstetric history
Family history (ideally 3-generation, covering genetic disorders, congenital malformations, developmental delay/mental retardation, and ethnicity)
Possibility of genetic disease
amily & Genetic History, cont.
Ethnicity-based
Counseling
Screening
Referral
Previous pregnancies
At least 1 member of a couple has conceived a pregnancy with a known genetic or chromosomal disorder: refer to appropriate specialist
Known genetic conditions
May require further work-up prior to conception |
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Term
| Barriers to prenatal care |
|
Definition
Unrecognized Pregnancy
Denied Pregnancy
Limited Finances
Inaccessibility of the Health Care System
Safety Concerns
Language Barrier |
|
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Term
| The initial prenatal visit |
|
Definition
Confirmation of Pregnancy
History
Menstrual history—last normal menses, normal pattern.
Contraceptive history—last time used, dates of unprotected intercourse.
Obstetric history – dates and types of previous deliveries, weights of newborns, lengths of labors, any complications with pregnancies, labors, or deliveries
Gynecologic history – sexually transmitted infections, abnormal cervical cytology and treatment, if any
Sexual history—number of partners, high-risk behavior.
Surgical history—especially surgical procedures affecting the uterus
Physical Examination
Establish Due Date (EDD, or Estmated Date of Delivery) EDD is calculated using the first day of the last menstrual period (LMP), and Naegele’s Rule (add 7 days to the date of LMP, subtract 3 months from that date).
Laboratory Tests.
Risk Assessment.
Prenatal Educational Materials
Anticipatory guidance and teaching
Schedule Follow-Up Visits |
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Term
| Subsequent Prenatal visit: First Trimester |
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Definition
First trimester
Vigilance for hyperemesis
Anticipatory guidance about SAB
Counseling on early testing options
Start checking for FH at 10-12 weeks |
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Term
|
Definition
Weeks 12-16
Offer genetic screening
FH should be auscultated
Weeks 16-20
Quickening
Offer anatomy u/s
Encourage childbirth education classes |
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Term
| subsequent prenatal visits |
|
Definition
Weeks 24-28
If Rh negative recheck antibody screen and administer Rhogam
Screen for gestational diabetes
CBC
Consider risk for pre-term labor
Begin assessing fetal position
Weeks 28-35
Counseling on breastfeeding, choosing pediatrician, importance of fetal movement counting
Weeks 35-37
Vaginal/anorectal culture for GBS
Assess for active HSV
Re-test for Gonorrhea and Chlamydia if positive earlier in pregnancy
Weeks 37-40
Assess fetal position and presentation
Counseling re: postpartum contraception, infant car seat, breastfeeding |
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Term
|
Definition
Weeks 40 and beyond
Consider cervical exam and membrane sweeping
Begin fetal surveillance per practice protocol |
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Term
| Skin in head during pregnancy |
|
Definition
Skin
Increased vascularity
Increased pigmentation
Face (chloasma)
Areola
Abdomen (linea nigra)
Genitalia
Striae of breasts and abdomen
pigmentation
Head
Mild changes in scalp
Excessive oiliness or dryness |
|
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Term
| Mouth and respiratory/cardiovascular |
|
Definition
Mouth
Edematous gums
Increased gingivitis
Respiratory/Cardiovascular
Physiologic dyspnea of pregnancy
Progressive elevation of the diaphragm
Hand/pedal edema
Leg and vulvar varicosities and hemorrhoids
Exaggerated heart sounds, particularly functional murmurs in systole |
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Term
|
Definition
Breasts
Increased fullness, tenderness, enlargement
Excretion of colostrum common by 3rd trimester
Abdomen
Distention due to increased uterine size
Diminished bowel sounds as peristaltic movements are slowed
Enlarging uterus, which displaces abdominal organs |
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Term
| External genitalia, vagina, cervix |
|
Definition
Genitalia/Reproductive
External
Increased pigmentation
Pubic hair may lengthen
Near term, pelvic congestion and overall swelling of labia majora
Vulvar varicosities
Prominent vaginal rugae
Cervix
Chadwick’s sign (Bluish color)
Goodell’s (softening) sign
May soften, dilate, and efface close to term |
|
|
Term
|
Definition
Uterus
Hegar’s sign (softening) by 6 weeks’ gestation
By 12 weeks: fundus at symphysis pubis
By 16 weeks: fundus midway between symphysis and umbilicus
Enlargement: 1 cm per week
Fundus at the umbilicus at approximately 20 weeks, measures 20 cm
By 36 weeks fundus just below xiphoid process, measures approximately 36 cm
Fundal height drops slightly near term (lightening). Measurement may then no longer correspond with week of gestation.
Adnexa
Discomfort with exam due to stretching of the round ligaments
Ovaries not palpable once uterus fills the pelvic cavity |
|
|
Term
|
Definition
Urinary
Bladder may be palpable
Frequency and incontinence are common
Rectal
Increased vascular congestion with resulting hemorrhoids |
|
|
Term
| Musculoskeletal and endocrine |
|
Definition
Musculoskeletal
Relaxation of pelvic structures
Lordosis, sciatica, and discomfort at the symphysis pubis
Pain from round ligaments stretching
Endocrine
May have mildly enlarged thyroid |
|
|
Term
| Risk Assessment in pregnancy |
|
Definition
Screening for conditions that could cause adverse outcomes
Intervention
May help determine most appropriate location for delivery and most appropriate provider
Assessment continues throughout pregnancy, and risk may increase and decrease
Be wary of labeling “high risk” |
|
|
Term
| Screening for risk during pregnancy |
|
Definition
History
Symptoms and complaints in present pregnancy (hyperemesis, risk for SAB)
Historical risk factors (multiple SABs, previous complications, medical conditions, prior c-sections)
Nutritional risk factors (adolescent, eating disorder, medical condition)
Genetic risk factors (AMA, CF carrier)
Psychosocial (stress, homelessness, limited support)
Physical exam
Abnormally shaped pelvis, cardiac condition, breech presentation
Lab tests
Cystic fibrosis carrier, elevated risk on quad screen, positive PPD
Screening should ideally be done at the initial visit, during each remaining trimester, and whenever necessary. |
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Term
|
Definition
Family History - inheritance pattern , help identify what further testing may be necessary
1st Trimester screening. Blood test combined with nuchal translucency measurement on sonogram – 11-14 weeks
2nd Trimester screening
Amniocentesis - 15-18 weeks
Chorionic Villus Sampling – 10-12 weeks
Quad screen - 15-20 weeks
Level 2 Ultrasound/Fetal Scan – 18-20 weeks |
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|
Term
|
Definition
Preterm labor is the presence of regular uterine contractions causing cervical dilation and effacement prior to 37 completed weeks’ gestation and after 20 completed weeks. The etiology of preterm labor is unknown.
Risk factors
Multiple gestation
Diethylstilbestrol (DES) exposure
Hydramnios
Uterine anomaly
Cervix dilated more than 1 cm at 32 weeks’ gestation
2 second-trimester abortions, More than 2 first-trimester abortions
Previous preterm labor or delivery
Abdominal surgery during pregnancy
History of cone biopsy
Cervical shortening of less than 1 cm at 32 weeks’ gestation
Uterine irritability
Cocaine abuse
Febrile illness
Bleeding after 12 weeks’ gestation
History of pyelonephritis
Cigarette smoking—more than 10 per day |
|
|
Term
| Intimate Partner Violence |
|
Definition
Unique position to assess and intervene
Violence is more likely to begin or intensify in pregnancy
Predisposes women to complications
Related to stress
Delayed start of prenatal care and lack of compliance
Higher rates of substance abuse and smoking
Direct complications of violence
Preterm labor
Fetal injury or death
Assess throughout pregnancy
Universally screen all pregnant women for intimate partner violence once each trimester |
|
|
Term
| General concepts for nutrition in pregnancy |
|
Definition
Poor nutrition in pregnancy: increased risk for
Anemia
Preeclampsia
Obesity
Underweight or with little weight gain during pregnancy a/w fetal growth restriction/SGA, PTL
Obese or excessive weight gain: increased risk for
Preeclampsia
Gestational diabetes |
|
|
Term
|
Definition
Pre-pregnancy weight and BMI
24 hour dietary recall
Economic, cultural, religious, other variables
Nutritional risk factors
Obesity, h/o bariatric surgery
Current or recent lactation or closely-spaced pregnancy
Smoker, substance abuse
Adolescent
Pre-existing medical condition
Multiple gestation
Hyperemesis gravidarum
Pica |
|
|
Term
|
Definition
Postpone nutritional counseling until after first trimester, if necessary
Provide weight gain target goals
3 meals/day and 2 snacks to avoid prolonged fasting
5 fruits/veggies day
Fiber-rich carbs, limit carbs with high glycemic index
2 servings low-mercury fish/wk (or supplement)
Avoid food-borne illness
Cook meat, poultry, fish and eggs well
Only pasteurized dairy and fruit juice
Avoid soft cheeses, processed meats, raw sprouts
www.mypyramid.gov |
|
|
Term
| Dietary guidelines n pregnancy |
|
Definition
Normal PPW (BMI 18.5-24.9)
Increase caloric intake by 300 in the last two trimesters
Aim for weight gain of 25-35 lbs
Underweight (BMI
Weight gain 28-40 lbs
Overweight (BMI 25-29.9)
Weight gain 15-25 lbs
Obese (BMI >29.9)
Weight gain 11-20 lbs |
|
|
Term
|
Definition
1000mg recommended in pregnancy
Dairy products, green leafy vegetables, tofu, canned salmon, egg yolks, whole grains, legumes, and nuts
Dairy products, green leafy vegetables, tofu, canned salmon, egg yolks, whole grains, legumes, and nuts
Calcium carbonate or citrate supplement may be necessary
May interfere with absorption of other vitamins, so take separately from PNV |
|
|
Term
|
Definition
Important for fetal bone development, implicated in other diseases as well
Intake from diet and sun usually adequate in summer
Supplementation of 200-2000 IUs suggested in winter months and for women with dark pigmented skin |
|
|
Term
|
Definition
Supplementation of 400-800mcg recommended for all women of childbearing age
Reduced neural tube and other birth defects
H/o NTD or other elevated risk for NTD: 4mg of folic acid
Smoking and alcohol use decrease serum folate levels |
|
|
Term
|
Definition
Iron needs double in pregnancy
Iron deficiency anemia increases risk for low birth weight, perinatal mortality, preterm birth
27-30mg elemental iron/day supplementation recommended (60mg if Hct st and 3rd trimesters, nd trimester)
Dietary sources: red meat, clams, oysters, dark green leafy vegetables, lentils, chickpeas, fortified cereals. (Consume with citrus fruits to enhance absorption) |
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|
Term
|
Definition
Vital component of cell membranes, vital to cell function
Cannot be synthesized by the body
Maternal liver converts essential fatty acids into long chain polyunsaturated fatty acids that are used for fetal brain, nervous system, and cell membrane development
Inadequate levels associated with preeclampsia, preterm birth, low birth weight, fetal growth restriction
Improvements in PP depression and neonatal/pediatric development and health with supplementation
Omega-6 abundant in SAD. Omega-3 only in fish, fish oils, select nuts and seeds. Supplement containing 200-300mg/day recommeded if diet inadequate
Risk of exposure to mercury and other toxins. FDA: Safe for pregnant and BF women to eat low-mercury fish up to 2x/wk |
|
|
Term
|
Definition
71g/day recommended in pregnancy
Needed for
Growth of fetal tissue, including brain
Growth of breast and uterine tissue
Sources: fish or seafood , meat, poultry, nuts, tofu, legumes |
|
|
Term
| Vegetarian Diets in pregnancy |
|
Definition
Reasons: cultural, religious, personal, philosophic reasons
2.5% American adults, 1% of those are vegan
Types:
excluding all animal food sources
including milk, eggs, fish, and/or poultry
fruit as a main dietary staple
macrobiotic
Dietary recommendations in pregnancy
1-2 servings dark green vegetables
4-5 servings other vegetables and fruits
3-4 servings bean and soy products
6 or more servings whole grains
1-2 servings nuts, seeds, and wheat germ
Concerns:
Diet may be low in vitamin B-12, vitamin D, calcium, protein, and iodine
Strict vegans will need B12 supplement
Protein sources: legumes, nuts, tofu, and eggs |
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Term
| Prenatal vitamin supplementation |
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Definition
Advise against mega-supplements
Routine iron supplementation?
Should contain:
15 mg zinc
2 mg copper
250 mg calcium carbonate or citrate
2 mg B6
400 mcg folate
50 mg vitamin C
200 IU vitamin D
15 IU vitamin E
100 to 320 mg magnesium |
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Term
| Management of nutritional concerns in pregnancy |
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Definition
Assess for pregnancy complications which may be causing the nutritional complaint
Assess for socioeconomic concerns, psychosocial concerns, knowledge deficits
Little research into what kind of nutritional counseling works best |
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Term
| Danger Signs in pregnancy |
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Definition
First Trimester
Spotting or bleeding, cramping, painful urination, severe vomiting and/or diarrhea, fever higher than 100ºF, low abdominal pain located on either side or in the middle, lightheadedness, and dizziness, particularly if accompanied by shoulder pain.
Second Trimester
Same as first trimester plus regular uterine contractions; pain in one leg or calf, often increased with foot flexion and redness, heat, and tenderness, or coldness, numbness, and whiteness; sudden gush of fluid that cannot be controlled by Kegel exercises; absence of fetal movement for more than 24 hours after quickening; facial swelling; or severe upper abdominal pain or headache with visual changes and/or photophobia.
Third Trimester
Same as first and second trimesters plus a decrease in the daily fetal movement.
If umbilical cord is in the vagina, client should call an ambulance and assume knee-chest position.
When to call provider in labor:
Contractions 3 to 5 minutes apart, lasting 45 to 60 seconds
Ruptured membranes
May vary based on pregnancy risk, distance client lives from birthing location, history of precipitous labor |
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Term
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Definition
obacco, Alcohol, and Drugs of Abuse—covered in substance-abuse lecture
Artificial Sweeteners
Stevia—Generally recognized as safe by FDA
Equal or Nutrasweet—Deemed safe by FDA, but recommended to limit intake
Splenda—Safe in pregnancy
Saccharin—Crosses placenta, safety in pregnancy in question
Some evidence of link to preterm delivery
Caffeine
March of Dimes recommends no more than 200 mg (1 cup) coffee per day.
Not teratogenic.
May increase risk of spontaneous abortion (conflicting studies).
Diuretic, displaces more nutritious food choices, can exacerbate mood swings, disturb rest.
Can cause fetal or newborn heartbeat irregularities.
Over-the-Counter Medications/Vitamins/Herbs
Do not take any medication/vitamin/herb without first consulting a health care provider.
Megadoses of vitamins (e.g., vitamins A and D) could be harmful.
Prescription Drugs
Some are harmful.
Report all medications to health care provider.
Make sure all providers are aware of pregnancy. |
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Term
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Definition
Women of childbearing age comprise a significant proportion of the U.S. workforce.
Exposure to chemicals and infectious agents, demanding labor, dangerous working conditions.
Teratogens: substances or disorders with the potential to alter the fetus permanently in form or function.
Effect is dose related; greatest during fetal organogenesis.
Avoid chemical exposure before and during pregnancy, particularly when organogenesis is occurring in the first trimester.
Ensure that work areas are well ventilated and wear protective gloves.
Avoid inhaling chemical fumes, particularly from paint or turpentine.
Wash off any chemicals on the skin immediately.
Notify a health care provider, call a poison control center, or go to an emergency room if exposed to toxic chemical.
Resources:
Reproductive Toxicology Center—subscription service available to professionals
National Pesticide Information Center
Occupational Safety and Health Administration |
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Term
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Definition
Fetal effects
Poor fetal growth
Developmental delays
Potential impacts on sexual maturation and future fertility on female fetuses
Sources
Renovation on homes built before 1978
Working in construction, other industrial occupations
Traditional lead glazed pottery
Certain alternative remedies, imported foods, cosmetics
Pica
Elevated risk for recent immigrants |
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Term
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Definition
The Workplace
Continue to work until delivery if pregnancy is uncomplicated and the job presents no special hazards.
Physically intense labor, prolonged standing, pulling, pushing, or lifting of more than 10 to 25 pounds, decreased rest periods, shift or night work, plus significant fatigue from work can increase likelihood of complications
low birthweight, preterm labor and delivery, pre-eclampsia
Modifications
Work less than 8 hours per day, 48 hours per week, avoiding shift and night hours.
Take at least two 10-minute rest periods and one meal break per shift with adequate rest and restroom facilities available.
Jobs should be modified if safety may be compromised by dizziness, loss of balance, nausea, and vomiting.
Jobs with strenuous workloads—heavy lifting, prolonged standing, shift or night work—should be modified.
Jobs where workers are exposed to extreme temperatures, high humidity, smoke, irritating gases, and chemicals should be modified.
Health care workers exposed to ionizing radiation, chemotherapy, anesthetic agents, and infectious diseases should be protected.
Day care providers, animal care providers, and meat handlers should be protected from diseases.
Avoid stained glass, ceramics, pottery making, painting, and refinishing.
Pregnancy Discrimination Act requires the employer to treat pregnancy as any other temporary disability.
Occupational Safety and Health Administration ensures that employers either provide a workplace free of hazards or provide information about dangerous chemicals or substances.
Family and Medical Leave Act provides mandates for maternity leave, benefits, and job security. |
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Term
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Definition
Avoid contact with disease.
Immunizations should be up-to-date prior to pregnancy.
Assess susceptibility to hepatitis B, rubella, and varicella-zoster at initial visit.
Toxoplasmosis
Avoid raw meat or gardening without gloves, and avoid outdoor sandboxes and litter boxes.
Cytomegalovirus
Half of pregnant women have previously been exposed.
Primary infection during the first half of pregnancy carries greatest risk of fetal infection with very serious sequelae.
Day care providers: avoid contact with saliva, respiratory secretions, urine, and feces with hand washing and cleaning of toys and cooking, eating, and drinking utensils.
Fifth’s Disease (Parvovirus B19)
At least half of pregnant women have previously been exposed.
Avoid exposure to children with undiagnosed rashes.
Can cause fetal hydrops if infected while pregnant.
Varicella-Zoster
Dangerous if client becomes infected during first half of pregnancy or close to delivery.
No history of varicella illness or vaccination? Avoid exposure.
Immunization prior to pregnancy is recommended; wait 1 to 3 months before conceiving.
If exposure occurs, contact provider immediately for immunity testing and possible immune globulin within 96 hours of exposure.
Mumps
May cause miscarriage or congenital infection leading to sequelae.
If not immune or vaccinated, avoid exposure and receive vaccination postpartum.
Measles
May cause miscarriage, IUFD, PTL, or severe illness in mother.
If not immune or vaccinated, avoid exposure and receive vaccination postpartum.
Lyme Disease
Negative effects on fetus minimized by proper treatment.
Avoid tick bites—long pants tucked into boots and long sleeves in grassy or wooded areas, insect repellant applied to clothes (not directly to skin).
Contact provider with suspected exposure.
Rubella
Significant harm to the fetus with maternal infection in early pregnancy.
Prenatal or preconceptional immunity testing and vaccination recommended; counsel on need to wait one month to conceive.
If nonimmune (prenatally), advise to avoid exposure to anyone with undiagnosed rash.
Contact provider immediately for possible exposure.
Listeriosis
Avoid unpasteurized milk, soft cheese, shellfish, undercooked meat, poultry, fish, or eggs; cold lunch meats, raw seafood.
Risk of SAB if contracted early in pregnancy.
Neonatal infection—fever, feeding, breathing problems, which may not develop until several weeks after birth.
Tuberculosis
Advise PPD for anyone at high risk for latent tuberculosis infection.
Refer to physician for active tuberculosis infection, consultation, or latent infection.
Contact provider immediately for possible exposure.
Sexually Transmitted Infection
Some STIs can pose health threat to fetus or complications in pregnancy (PTL).
Advise condom use if multiple partners or new partner, if unsure of partner’s sexual or drug use history, or if partner has multiple sexual partners. |
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Term
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Definition
Physiologic changes may enhance pleasure or diminish sexual response.
Reported concerns
Fear of causing miscarriage or harm to fetus
Need for modifications in positioning with advancing gestation
Fluctuating libido by both partners
Body image changes
Reassure about normal sexual activity unless contraindications exist.
Reassure that fetus will not be injured by intercourse, nor is fetus able to understand what is happening.
Encourage experimentation with positions that may be more comfortable.
Contraindications to Sexual Intercourse
History of repeated miscarriage
History of cervical incompetence, without cerclage
Threatened abortion
Placenta previa
Undiagnosed vaginal bleeding
Premature rupture of membranes, preterm labor
Severe vulvar varicosities. |
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Term
| Exercise during pregnancy |
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Definition
Benefits—Increases well-being, improves sleep, helps control weight gain, tone muscles, hastens recovery after delivery.
Continue prepregnancy activities.
General Guidelines
Avoid sports with high risk for impact, falling, and abdominal trauma (e.g., hockey, soccer, gymnastics, horseback riding, downhill skiing). Avoid scuba diving and high-altitude activities.
Exercise three to four times per week, not sporadically.
Hydrate before, during, and after exercise.
Eat a light snack before exercising.
Be sure calorie intake includes exercise expenditure.
Do not exercise in hot, humid conditions or when feeling ill.
Exertion should be moderate, stopping if fatigued, breathless, profusely sweating, or unable to converse.
After the first trimester, do not lie on back more than a few minutes at a time.
Weightlifting exercise may be continued if started preconception, without increasing the weight.
Modify exercise program as the physical load of pregnancy increases.
Stop exercising and contact provider if any of the following occur: pain, bleeding, suspected membrane rupture, dizziness that does not resolve quickly after rising, shortness of breath (unable to talk comfortably), palpitations, faintness, tachycardia, back pain, pelvic pain or pressure, or difficulty walking.
Absolute Contraindications to Exercise in Pregnancy
Preterm labor, hypertensive disorders of pregnancy, ruptured membranes, incompetent cervix, multiple fetuses, persistent second or third trimester bleeding, placenta previa after 26 weeks gestation, and significant cardiac or respiratory disease. |
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Term
| Saunas, Hot Tub, whirl pool , Tanning Beds |
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Definition
Do not use!
High water temperature could raise body temperature above 39ºC (102.2ºF).
Potential for syncope.
Tanning is not advised due to risk of serious sunburn, dehydration, and skin cancer. |
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Term
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Definition
Ionizing Radiation (X-ray, radiation therapy)
Less than 5 rad ionizing radiation has not been shown to harm fetus.
Greatest risk of fetal harm is between 2 and 7 weeks (organogenesis) and 8 and 15 weeks (early fetal period) of gestation.
General guidelines:
Avoid unnecessary X-rays or wait until after 15 weeks, or use ultrasound.
No evidence of negative effects from MRI.
Inform anyone ordering or taking an X-ray of pregnancy; shield abdomen with lead shield.
Try to utilize a regularly inspected facility staffed with certified technicians and supervised by a radiologist.
Microwaves
Emissions from microwave ovens are low.
For safety, don’t stand close to the oven while in use.
Ultrasound
Has not demonstrated fetal or maternal harm. |
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Term
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Definition
Regular dental care is important during pregnancy; elective procedures should be postponed until after delivery.
Reassure and educate clients who are under the impression that dental care is contraindicated in pregnancy.
Dentist must be told of pregnancy and X-rays performed with an abdominal shield.
Local anesthesia usually safe—Lidocaine is category B. |
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Term
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Definition
Travel is usually fine until 36 weeks.
General Guidelines
Check with health care provider prior to traveling.
Contraindicated with risk for preterm labor, repeated spontaneous abortions, gestational hypertension, placental abnormalities, bleeding, intrauterine growth retardation, or a medical condition, e.g., cardiac disease, sickle cell anemia.
Check with airline about restrictions, which usually start at 36 weeks; most sea cruise liners will allow travel up to seven months of pregnancy.
Do not fly in unpressurized planes above 8,000 feet.
Stand up and walk for 10 minutes every two hours while traveling.
If driving, plan to make stops; if flying or traveling by train or bus, arrange for an aisle seat.
Drink adequate fluids.
Seat belt should be worn at all times; lap portion placed below the abdomen, across upper thighs, shoulder belt between breasts, both belts worn snugly.
Advise client to bring names of providers in area she will be traveling to, and bring copy of prenatal record in case of unexpected complications.
Travelers to high altitudes or where additional immunization is required should consult provider for individual risk assessment.
Foreign Travel Guidelines
Immunizations required for travel should be received at least three months before conception.
Avoid travel to areas with high risk for malaria and other serious illness if possible.
Standard precautions for avoiding water and food-borne illness.
Water purification tablets containing iodine not safe in pregnancy. |
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Term
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Definition
Methods
The Lamaze Method
Techniques that focus mother’s attention on breathing and relaxation exercises as well as massage.
Perception of pain is lessened.
Father or other support person’s involvement is important.
The Bradley Method
Goal is unmedicated labor and delivery.
Training techniques are directed toward the coach, “husband-coached childbirth.”
Coach is educated in massage/comfort techniques to use during labor and delivery.
Hypnobirthing
Teaches women how to use natural ability to give birth.
Relaxation techniques and natural childbirth education enhanced by hypnosis.
Other Options
Read method, or “natural” childbirth, also based on relaxation and breathing technique.
Wright method, based on psychoprophylaxis but with less active breathing than Lamaze.
Sheila Kitzinger’s psychosexual method—chest breathing and simultaneous abdominal release.
Birthing From Within—“mindfulness” and awareness, not necessarily aiming for unmedicated childbirth. |
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Term
| Preparation for surgical intervention |
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Definition
Preparation for Surgical Intervention
Cesarean Birth
Greater than 30 percent of deliveries in the United States are by cesarean section.
Indications include various types of labor dystocia, fetal distress, abnormal presentation such as breech and transverse, and having multiple prior cesarean deliveries.
Rate has risen dramatically since 1970 (4.5 percent).
More advanced-age pregnancies and nulliparous women
Greater use of continuous electronic fetal monitoring (EFM), more diagnoses of fetal distress
Fewer forcep, vacuum, and vaginal breech deliveries
Higher rates of labor induction
Higher rates of obesity
Increases in elective cesarean delivery
Decreases in availability of vaginal birth after cesarean (VBAC)
Greater threat and incidence of legal malpractice suits
Risks : maternal mortality, damage to proximal organs, wound infection, and risk of complications in future labor and delivery.
Performed under regional or general anesthesia.
Rates of vaginal birth after cesarean birth (VBAC) 5 percent in 1985, to 28 percent in 1996, and again to 8.5 percent in 2006; primarily due to concerns about uterine rupture during labor ACOG recommends that VBAC only be offered in hospitals with staff and facilities “immediately” available for emergency management.
Controversy surrounding elective, patient-choice cesarean section. Offer comprehensive, unbiased information, so the client may make the most informed decision possible.
Forceps Delivery and Vacuum Extraction
Provide added traction and rotation, in order to facilitate vaginal delivery with greater speed, when needed
Indications: worsening maternal medical conditions or exhaustion, prolonged second stage of labor, or compromised fetal status
Risks: large vaginal lacerations, possibly extending into the rectum, long-term urinary and fecal incontinence, uterine infection, and trauma and morbidity to the fetus
Episiotomy
Surgical incision into the vaginal mucosa and musculature, to widen the vaginal opening and hasten delivery
Often made under local or regional anesthesia
Once performed routinely, now 30-35 percent of vaginal deliveries (varies by type of provider)
Indications: fetal distress, shoulder dystocia, operative vaginal delivery, and cases where the perineum is noted to be abnormally short, increasing the likelihood of a significant, spontaneous laceration
Complications: bleeding, hematoma, infection, and postpartum discomfort and dyspareunia |
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Term
| Accidents of Blows to the abdomen |
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Definition
Accidents or Blows to the Abdomen
Amniotic fluid and abdominal structure usually protect the fetus.
Very serious blow to the abdomen could cause injury (e.g., hitting the steering wheel during an auto accident).
Contact a health care provider if an abdominal blow should occur.
Danger signs: vaginal bleeding or fluid, abdominal pain, uterine contractions, decreased fetal movements. |
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Term
| Fetal Hiccups, Bathing and Infant safety seat |
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Definition
Fetal Hiccups, Bathing, and Infant Safety Seats
Fetal Hiccups
Felt by mother as a tapping or jumping sensation usually in the lower abdomen
Common, no clinical significance
Bathing
No contraindication, as long as membranes not ruptured
Safety precautions to prevent syncope and falls
Infant Safety Seats
Infant cannot be discharged without seat.
Can be rented or purchased at charitable organizations and government social service offices. |
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Term
| Feeding Method: Breastfeeding |
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Definition
Feeding Method—Breastfeeding
Breast milk is ideal infant food, should be strongly encouraged.
American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for six months, continue after complementary foods are introduced, for at least six additional months (a total of one year).
Advantages:
Changes as the infant grows, adjusting to fulfill nutritional needs
Digestible, economical, and always ready
Encourages bonding between mother and child
Speeds up uterine involution
Suppresses ovulation
Helps weight loss
May decrease risk of developing ovarian and breast cancer
Helps to develop the infant’s jaws, teeth, and palate
Antibodies, hormones, enzymes, and growth factors provide protection against disease, reduce the development of allergies, and aid growth and development.
Fewer childhood illnesses, fewer work absences for parents, and reduced cost and environmental impact of breastfeeding as compared to formula feeding.
Disadvantages. Breast discomfort, sore or leaking nipples, increased incidence of mastitis, engorgement, less personal time than if bottle feeding; vaginal dryness, decreased libido have been reported.
Contraindications. Certain infections (e.g., active, untreated tuberculosis, human T-cell lymphotropic virus types I and II, varicella, and herpes lesions on the breast, certain medications or drugs or alcohol, certain metabolic disorders (e.g., galactosemia). Women who are HIV positive and live in industrialized countries with access to clean, safe water, such as the United States, are advised not to breastfeed.
Preparation for Breastfeeding:
Encourage reading, support groups, etc., during prenatal period.
La Leche League
Supportive friends or family members, who have had successful breastfeeding experiences.
Nipple preparation is unnecessary, even in the case of inverted nipples. |
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Term
| Feeding Method: Formula Feeding |
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Definition
Feeding Method—Formula Feeding
Advantages
Return to work more easily.
Can go on a strict weight-loss diet.
Others can share in the baby’s feeding.
Disadvantages
Increased risk of acute and chronic illness and neonatal mortality.
Infants do not reap the many health benefits of breast milk.
Shorter interpregnancy intervals.
Mothers more likely to experience diabetes, osteoporosis, breast and ovarian cancer later in life.
Substantial cost.
Costs to the community—increased health care costs, missed work and lost wages due to childhood illnesses, negative environmental impacts from production and disposal of formula and formula packaging.
Preparation for Bottle Feeding
No medication required to stop flow of milk after delivery.
Wear supportive bra and use over-the-counter pain relievers and ice packs to relieve pain.
Various forms of formula: concentrated (need to be diluted with equal amounts of water), powdered (to be mixed with water), ready to use (poured directly into bottles), prepackaged (ready to use in disposable bottles).
Follow directions for preparation carefully, never over- or underdilute formula.
Clean bottles and nipples with soap and water, store away from sources of contamination.
Hold infants during feedings for bonding, do not prop bottle against infant (may cause formula aspiration). |
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Term
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Definition
American Academy of Pediatrics (AAP):
Some evidence of health benefits of circumcision, but not strong enough to recommend the procedure routinely.
Risks
Bleeding, infection, isolated reports of rare but serious procedural complications.
Potential benefits
Decreased incidence of urinary tract infection, penile cancer, possible association with reduction of risk for HIV and syphilis.
Encourage parents to consider religious, cultural, and ethnic traditions.
Informed consent is essential. |
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Term
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Definition
Danger signs
Significant decrease in fetal movement
Menstrual-like bleeding
Constant, severe contractions without relief
Fever
Rupture or suspected rupture of membranes?
If the umbilical cord is in the vagina the client should call an ambulance and assume a knee-chest
When to go to the hospital/birth center or call the homebirth provider
Contractions 3 to 5 minutes apart if primipara
5 to 8 minutes apart if multipara
Contractions lasting 45 to 60 seconds |
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Term
Pre-Labor/Subjective
(Sometimes called false labor) |
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Definition
Can begin one month to one hour before labor begins
Cervical softening, effacement, some dilation of the cervix
Subjective
Lightening, dropping, engagement
Easier breathing but increased pelvic pressure
Cramping
Low back pain
More frequent urination
Primiparas - two to four weeks before labor
Multiparas - as late as during labor
Increasing (nesting) or decreasing energy levels
Vaginal discharge
Loss of the mucous plug and/or bloody show
GI Upset
Braxton-Hicks contractions |
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Term
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Definition
Physical examination
Softening of the cervix, effacement, and possibly some dilation
Cervix moves more anterior
Fundal measurement may decrease and presenting part may be palpated vaginally |
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Term
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Definition
Contractions
Felt in the back, legs, or lower abdomen
Grow longer, stronger, regular, and closer together
Essential triage questions
Fetal movement
Membranes status
Vaginal bleeding |
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Term
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Definition
Fetal assessment with a fetal monitor or hand held Doppler
Contraction pattern
Physical assessment of the woman
Vital signs
Sterile speculum exam
Sterile vaginal exam
Diagnosis of labor
Latent labor = from onset of regular contractions to 3-4 cm
Active labor = 3-4 cm + regular, painful contractions, progressive dilation
Palpation of the umbilical cord during a pelvic exam |
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Term
| Risk of substance abuse in pregnancy |
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Definition
Associated with
Intrauterine growth restriction (IUGR)
Fetal anomalies
Fetal addiction
Prematurity
Low birthweight
Placental Abruption
Stillbirth
Hepatitis B and HIV infection
Importance of preconception care |
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Term
| Physical Exam- Substance Abuse |
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Definition
Needle or track marks
Dazed appearance
Inappropriate behavior or affect
Extreme agitation or stupor
Frequent Conjunctivitis
Tremors
Flecks of paint around the mouth and nose
Fetal/maternal tachycardia
Poor maternal weight gain (or weight loss) |
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Term
| Screening: How to respond |
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Definition
Know how to respond
negative screen (no risk determined):
Review the benefits of abstinence
Reassurance
positive screen (risk determined):
Review what she has just reported to you
State concern
State need to stop
Discuss possible strategies
Referral
Follow-up appointment
Maintain communication with treatment provider
Be positive
Pregnancy management
Nutritionist
Fetal surveillance
Value of prenatal care |
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Term
| Possible Questions to ask |
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Definition
Have you ever used recreational drugs? If so, what, when, and how much?
Have you ever taken a prescription drug other than as intended? If so, what, when, and how much?
Have you used any legal or recreational drugs during this pregnancy? What, when, and how much?
How often do you drink alcohol? What, when, how much?
How often do you smoke cigarettes? How many per day?
What are your feelings about drug use during pregnancy? |
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Term
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Definition
How many drinks does it take for you to feel high? (Tolerance)
Have people Annoyed you by criticizing your drinking?
Have you ever felt you ought to Cut down on your drinking?
Have your ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener)
[More than two drinks on the tolerance question is 2 points. Each yes to the additional three questions scores 1. Score of 2 or more is a positive screen, woman should be referred to specialist for further assessment.] |
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Term
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Definition
Have you ever used drugs or alcohol during this Pregnancy?
Have you had a problem with drugs or alcohol in the Past?
Does your Partner have a problem with drugs or alcohol?
Do you consider one of your Parents to be an addict or alcoholic?
[A way to begin discussion. Yes to one or more questions should be referred for further assessment.] |
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Term
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Definition
How many drinks does it take for you to feel high? (Tolerance)
Does your partner (or do your parents) ever Worry or complain about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener)
Have you ever Awakened the morning after some drinking the night before and found that you could not remember part of the evening before?
Have you ever felt that you ought to K/Cut down on your drinking?
[2 points on the tolerance questions if she reports that she can hold more than five drinks without falling asleep or passing out. Positive response to the worry question scores 2 points, positive response to each of the last three questions scores 1 point each. Total score of 2 or more indicates a risk drinker and requires further assessment.] |
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Term
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Definition
Counseling must continue
Behavior of drug-exposed infants – may act as trigger
Feeding difficulties
Sleeping short intervals
Shrill cry
Difficult to console
Avoiding eye contact
Relapse |
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Term
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Definition
Risks
SAB or ectopic pregnancy
Preterm labor and delivery, PPROM
Maternal hypertension
Placenta previa
Placental abruption
Low birthweight/ IUGR
Perinatal death, including IUFD, SIDS
Possibly long term developmental delays
Increased incidence of childhood respiratory infections
Reduction in fetal blood flow
Congenital anomalies
SIDS
Alcohol and smoking combined
Effect of amount and duration |
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Term
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Definition
Encourage cessation
Referral
Nicotine replacement products
Decrease smoking cues and behaviors
Support groups for smoking cessation
Immediate and long-term impact
Seek appropriate outlets to replace smoking
Benefits of cessation |
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Term
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Definition
Risks
Low birthweight
Fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE)
Craniofacial dysmorphia, intrauterine growth restriction, microcephaly, and congenital anomalies such as limb abnormalities and cardiac defects.
Long-term sequelae include postnatal growth restriction, attention deficits, delayed reaction time, and poor scholastic performance.
Fetal alcohol effects
Intrauterine fetal demise, SAB
No known safe threshold for alcohol consumption
Combined, additive effects of alcohol and smoking
Over-the-counter cough and cold medications |
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Term
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Definition
Cocaine
Cocaine toxicity
Vasoconstriction, tachycardia, and hypertension
Uteroplacental insufficiency
Spontaneous abortion, preterm labor with rupture of membranes and delivery, intrauterine growth restriction, intrauterine fetal distress and demise, seizures, withdrawal, cerebral infarcts, and complications of the neonatal course, placental abruption, uterine rupture, SIDS, and congenital anomalies |
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Term
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Definition
Intense addiction, neonatal withdrawal
Sudden infant death syndrome (SIDS)
Intrauterine growth restriction
Fetal distress
Persistently small fetal head circumference
Preeclampsia
Premature rupture of membranes
Placental abruption
Meconium staining
Child development deficits
Withdrawal during pregnancy
Methadone substitution |
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Term
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Definition
SGA, Low birth weight
Decreased arousal, increased stress, poor quality of movement in the newborn
Not teratogenic |
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Term
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Definition
Fetal levels are several times lower
Highly correlated with alcohol and cigarettes
Preterm delivery and intrauterine growth restriction |
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Term
| Organic Carbons and Aromatic hydrocarbons |
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Definition
Paints, glue, enamel, varnish, lacquer, and resins
"huffing" or "sniffing"
Easily cross the placenta
Workplace exposure
Intrauterine growth restriction, microcephaly, hydrocephaly, limb anomalies, and craniofacial dysmorphia similar to FAS. |
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Term
|
Definition
| Add 1 week, then subtract 3 months to get due date. |
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Term
|
Definition
| About 28 weeks into pregnancy and within 72 hours after birth, miscarriage, etc. |
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Term
|
Definition
|
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Term
|
Definition
| Monthly until 28 weeks. Biweekley until 36 weeks, and weekly from there on |
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Term
|
Definition
| All pregnant women and significant others |
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Term
|
Definition
| MOM and significant others and other family members |
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Term
| Diagnositic Screening: Amnio(15-18) or CVS(10-12) |
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Definition
| Over 35 and previous child with genetic anomoly |
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Term
Pregnancy- Sinusitis
Temp, sore throat, cough |
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Definition
What is her G?P? G1 P0
What abx would you prescribe and why? PCN, Amox- because they are both safe
Arithromyacin is also Cat B, Zpack Cat. B
How about a decongestant? Nasal spray 3 days max, saline nasal spray, neti pot, Eucalyptus, vicks vapor rub. Benadryl, zyrtec, claritin
Facial Pain? tylenol
Jessica would also like to know about dietary changes now that she is pregnant. What would you recommend?
My pyramid website so she can see what she should be eating. Tell her what to avoid, such as certain types of fish. Nutritional supplements, fiber. Find out what her dietary habits are now. B Vitamins, folic acid. |
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Term
Pregnancy in seasonal allergies (part. ragweed and pollen)
30yo 24 weeks gestation
hx deliver at 36 wks |
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Definition
What is her G?P? G2 P1
Are antihistimines safe to prescribe during pregnancy? What are the risks and benefits? They are safe, Zyrtec, benadryl, claritin are all cat b.
Mary is also walking an hour a day and wonders if she can use the hot tub at her gym. What would you recommend? No, temp is too high. Dont want body temp to get above 39c. Can affect BP.
Can cause sleepiness
How about a spa wrap treatment? Not until after the baby is born |
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Term
Loretta 26yo at 32 wks
Hx of twin delivery @ 37
Hx of spontaneous abortion at 5wks |
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Definition
What is her G?P? G3 P2 A1
What trimester: 3
How often should she be coming in for prenatal care? q2 weeks
In terms of constipation and hemmorrhoids what would you advise her? Take in more water, stool softener, steroid cream, fiber, papaya, donut pillow. Warm bath of epsom salt.
How would you screen her for intimate partner violence? at every visit, ask if anyone hurts, scares her? Who takes care of her? and the other little ones? Screen when alone in the room.
She wonders if she can have a glass of wine since she is nearing the end of her pregnancy. What would you recommend? Drink grape juice instead. Go over alcohol risks. |
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Sarah 25yo 20wks
UTI
Hx induced abotion @ 8wks |
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Definition
G3 P0
What trimester: 2nd
What class of abx would you choose and why? Macrobid/keflex
she would like to fly to visit her relatives at 33wks. What is your recommendation? You could allow it for a short distance. Not after 36 weeks. Prefer not in 3rd trimester. |
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Term
Kelly 34 @ 35wks
Macular papular pruritic rash on her abdomen |
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Definition
G3P2
Topical steroid cream? over the counter hydrocortisone
Antihistimine? Benadryl
Other recommendations? cotton, loose fitting clothing, keeping skin cool, no hot showers. Eucerin cream, oatmeal bath. |
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Definition
Dont lie supine.
Smaller meals.
Lifestyle modification |
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Term
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Definition
| Fast acting bronchodialator. Best to prescribe in pregnancy |
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Term
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Definition
| Increase fluid intake, tylenol if needed |
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Term
| Vision changes/contacts not fitting right |
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Definition
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Term
| Nose bleeds and bleeding gums |
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Definition
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Term
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Definition
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Term
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Definition
| increase fluids and use nasal spray |
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Definition
| Lg. thyroid gland, usually decreases the 2nd semester. Have thyroid level checked. |
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Term
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Definition
| H2 blocker, don't lie down right after you eat |
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Definition
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Term
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Definition
| rest frequently, take naps if needed. |
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Term
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Definition
| watch posture, use pillows to prop back, wear flat supportive shoes no heels. Ice pack, heating pad. Tylenol if needed. |
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Term
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Definition
| common. get off feet as much as possible. support stockings. Can also get into the pelvic area. Swelling. Monitor to differentiate between more concerning things like preeclampsia or DVT's. |
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Term
| Nagell's Rule is calculated by |
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Definition
| Adding 1 week to the first date of LMP and subtracting 3 months |
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Term
| Abdominal enlargement is a _ sign of pregnancy |
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Definition
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Term
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Definition
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Term
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Definition
| Cervical Changes, Intermittent Uterine Contractions, +HCG |
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Definition
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Term
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Definition
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Term
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Definition
| Bluish discoloration of vaginal mucosa |
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Term
| Intermittent uterine contractions are a _ sign of pregnancy |
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Definition
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Term
| When should diabetic screening be performed |
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Definition
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Term
| Amenorrhea is a _ sign of pregnancy |
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Definition
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Term
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Definition
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Term
| Quad screening during pregnancy occurs at _ weeks |
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Definition
Between 15-20 weeks.
High risk includes AFP, HCG, estriol, inhib a |
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Term
| When should intimate partner violence screening occur |
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Definition
| First prenatal visit, at every trimester, and if signs indicate |
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Term
| When are fetal heart tones detected |
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Definition
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Term
| Which vaccine is considered safe in pregnant women |
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Definition
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Term
| The quantitiaive serum bHCG measure is preferred over serum qualitative bHCG in which schnario |
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Definition
| Identifying possible miscarriage |
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Term
| at 32 weeks pregnant the patient should be visiting her provider how often |
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Definition
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Term
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Definition
C: Hydraminos
Smoking if they are smoking more than 10 cigarettes per day |
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Term
| What is a positive sign of pregnancy? |
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Definition
| Visualization of fetus on U/S |
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Term
| A pedigree of family hx in graphic form should include all of the following except |
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Definition
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Term
| Preconception care is based on the realization that |
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Definition
| prenatal care starts too late in pregnancy to prevent many poor pregnancy outcomes, women who have higher levels of health before pregnancy have healthier reproductive outcomes, preconception health promotion provides a pathway to the primary prevention. |
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Term
| What is important for the nurse practitioner movement? |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
Health screening activities
Primary, secondary, tertiary |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| Theories- Familiy, systems |
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Definition
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Term
| Therapeutic Interventions |
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Definition
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Term
| Motivational interviewing |
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Definition
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Term
| Structural Functional Theory |
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Definition
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Term
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Definition
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Term
| Primary Care: Pathway to the nations health |
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Definition
Emerged in 1960s as contemporary method of personal health care
Success measured in terms of preventing disease, halting disease progression, disability
Greater significance as nation has redirected attention to cost-effective health care
Catapulted into prominence by the advent of health maintenance organizations
Now determined by three things:
Access
Cost
Coordination of care |
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Term
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Definition
"...essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally acceptable through their full participation and at a cost that the community and country can afford."
—Alma-Ata Declaration, WHO, 1978
Organized by the World Health Organization and UNICEF
Population-based health care
Goal is health for all
Focuses on health care for the community |
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Term
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Definition
...provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnership with patients, and practicing in the context of family and community
—IOM, 1994
Primary care is a term used for the activity of a health care provider who acts as a first point of consultation for all patients.
Focuses on health care for the individual |
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Term
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Definition
Patient Protection and Affordable Care Act passed March 2010
Estimated to help 32 million Americans obtain health insurance coverage (49 million uninsured)
Many different ways to affect health care
Graham, M., & Graham, T. (2011). "What does it mean for NPs?" The Nurse Practitioner, 36(5), 41-47.
Primary care workforce
NPs part of the solution |
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Term
| Health Care Reform Timeline |
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Definition
2012
People with Medicare receive a 50 percent discount on brand-name prescription drugs and a 14 percent discount on generic prescription drugs while in the doughnut hole.
2013
People with Medicare receive a 52.5 percent discount on brand-name prescription drugs and a 21 percent discount on generic prescription drugs while in the doughnut hole.
9 of 25
Health Care Reform Timeline (cont)
2014
People with Medicare receive a 52.5 percent discount on brand-name prescription drugs and a 28 percent discount on generic prescription drugs while in the doughnut hole.
Insurance exchanges begin offering health coverage with comprehensive benefits.
Premium subsidies are available for people with limited incomes who buy health insurance through an exchange.
Insurance companies are banned from putting annual limits on health coverage.
Insurance companies can't deny anyone health coverage because of a preexisting condition. |
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Term
| Patient Centered Medical Homes |
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Definition
Focuses on strengthening the patient-physician relationship
Increasing access to care
Endorsed by several main physician organizations (AAFP, AAP, ACP, AOA)
Focuses on a team-based approach (with physician as the leader)
Emphasis on transitions of care and continuity |
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Term
| Patient Centered Medical Home model |
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Definition
Measured by nine core competencies:
Access and communication
Patient tracking and registry functions
Care management
Patient self-management support
Electronic prescribing
Test tracking
Referral tracking
Performance reporting and improvement
Advanced electronic communication
Still being evaluated and tested by the NCQA |
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Term
| What is healthy people 2020 |
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Definition
Objectives and goals set to improve health status of Americans
Builds on previous 10-year goals
Changed based on new advances |
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Term
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Definition
1979: The Surgeon General’s Report on Health Promotion and Disease Prevention
1980: Promoting Health/Preventing Disease: Objectives for the Nation
1990: Healthy People 2000
2000: Healthy People 2010
2010: Health People 2020 |
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Term
| Leading health indicators |
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Definition
Physical activity
Overweight + Obese
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury + Violence
Environmental quality
Immunization
Access to health care |
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Term
| Healthy People 2010: Where did it fail? |
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Definition
Goals: To increase quality + years of healthy life and eliminate health disparities
Obesity increased from 25% to 35%.
Births by cesarean section increased.
Percentage of infants born very small and fragile increased.
Toothy decay in young children worsened from 16% to 20%.
Hypertension increased from 28% to 29%. |
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Term
| Healthy People2010: What did we improve? |
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Definition
Not all bad news!
Improvements seen in areas of childhood vaccination rates, cancer death rates, number of work injuries, and increased smoking laws.
Even if goals were not met for other measures, progress was made toward 70% of them. |
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Term
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Definition
The study of the distribution and determinants of health-related states or events in specified populations and the application of this study to the control of health problems.”
Who, What, When, where, Why, How |
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Term
| Objectives of epidemiology |
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Definition
Identify etiology or the cause of a disease and risk factors—that is, factors that increase a person’s risk for a disease.
Determine extent of disease found in the community.
Study the natural history and prognosis of disease.
Evaluate new preventive and therapeutic measures and new modes of health care delivery.
Provide foundation for developing public policy and regulatory decisions related to environmental problems. |
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Term
| Key Epidemiologic Concepts |
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Definition
Incidence/Prevalence
Morbidity/Mortality
Positive Predictive Value
Sensitivitiy/Specificity
Prevention |
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Term
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Definition
The percentage of the population currently with the disease, measures the overall disease burden on the population
# of case/ # of people in population *1000 |
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Term
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Definition
Number of new cases relative tot hose considered at risk
# of new cases in a designated time period/# of people at risk *1000
High incidence = High disease occurrence
Low incidence = Low disease occurrence
Incidence of disease is helpful in determining causes and likelihood of developing disease |
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Term
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Definition
Morbidity: All persons in a specific population who become clinically ill, injured, or disabled during a defined period of time
A measure of the overall occurrence of disease and disability
Incidence and prevalence are two indicators of morbidity
Mortality: The number of deaths from a specific disease divided by the number of persons in considered at risk (×1000). |
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Term
| Primary Prevention: Preventing the condition |
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Definition
An action taken to prevent the development of a disease in a person who is well and does not have the disease in question
Examples:
Vaccines
Fluorided water |
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Term
| Secondary Prevention: Detection of the subclinical illness |
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Definition
Identification of people who have developed a disease, at an early stage in the disease’s natural history, through screening and early intervention
Examples:
Mammogram
BP check during a complete physical exam
Pap smear |
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Term
| Tertiary Prevention: Treatment and preventing progression of disease |
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Definition
Measures taken reduce complications of an existing disease or disorder and restore health after illness or disease.
Examples:
Cardiac rehab post MI
Controlling HgbA1C levels in a diabetic patient
Self-management programs for patients with chronic illness |
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Term
| Factors Influencing the decision to screen |
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Definition
| Disease characteristics, test characteristics, population characteristics |
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Term
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Definition
-significant effect on quality/length of life
-acceptable methods of treatment are available
-asymptomatic period in which early detection and treatment improves morbidity/mortality
-treatment during asymptomatic period yields better outcomes |
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Term
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Definition
-cost effective and relaible
-easy to adminsiter
-minimal discomfort
-test is valid eg. sensitive and specific |
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Term
| Population characteristics |
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Definition
-sufficiently high prevalence
-accessible
-likelihood for compliance with additional diagnostic tests and treatment |
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Term
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Definition
| Does the test effectively distinguish between those who have the disease and those who do not |
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Term
How precise is the test?
Sensitivity and specificity |
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Definition
How well does it tell you who has the disease?
Sensitivity
How well does it tell you who does NOT have the disease?
Specificity |
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Term
| testing quandaries in practiced |
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Definition
D-Dimer: sensitivity 91-96%, specificity 45-50% (Source: Annals of Internal Medicine)
Erythrocyte sedimentation rate (ESR): disease dependent but generally nonspecific
Rapid influenza diagnostic tests (RIDTs): sensitivity 40-70%, specificity 90-95% (Source: CDC)
Rapid strep test: sensitivity 80-85%, specificity 95% (Source: QuickVue Rapid Strep Kit package insert) |
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Term
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Definition
For a given sensitivity and specificity the predictive value increases or decreases according to the prevalence of the problem in the population being screened.
Positive predictive value: The proportion of people with a positive result who truly have the disease.
Negative predictive value: The proportion of people with a negative result that truly do not have the disease. |
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Term
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Definition
Screening program 1: screening of female blood donors
Prevalence of HIV in female blood donors: 0.01%
Test validity: 100% sensitive, 95% specific
Positive predictive value: 1.9%
Screening program 2: screening of males in an STD clinic
Prevalence of HIV in male patients of STD clinic: 4%
Test validity: 100% sensitive, 95% specific
Positive predictive value: 89%
Screening program 3: screening IV drug users
Prevalence of HIV in IV drug users: 20%
Test validity: 100% sensitive, 95% specific
Positive predictive value: 98% |
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Term
| Human Genome project (1990-2003) |
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Definition
If we can understand and catalogue DNA variation, can we understand human disease?
Scientific Goals:
Identify all the genes in human DNA
Determine the sequences of the 3 billion chemical base pairs that make up human DNA
sequence the genomes of other animals
Store this information in databases
Improve tools for data analysis
Transfer related technologies to the private sector
Address the ethical, legal, and social issues (ELSI) that may arise from the project.
15 year time table |
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Term
| Most common causes of death |
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Definition
Heart disease
Cancers
Cerebrovascular disease
Chronic lower respiratory disease
Unintentional injuries
Diabetes mellitus
Influenza and pneumonia
Alzheimer’s disease
Nephritis, nephroses
Septicemia |
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Term
| What did we learn from the human genome project? |
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Definition
Less than 2% of the genome codes for proteins.
The average gene consists of 3000 bases, but sizes vary greatly, with the largest known human gene being dystrophin at 2.4 million bases.
The total number of genes is estimated at around 23,000
Much lower than previous estimates of 80,000 to 140,000.
Almost all (99.9%) nucleotide bases are exactly the same in all people. |
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Term
| Single Nucleotide Polymorphismn (SNP) |
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Definition
The fundamental unit of genomic diversity is the single nucleotide polymorphism (SNP).
When DNA sequences on a part of chromosome 7 from two random individuals are compared, two single nucleotide polymorphisms (SNPs) occur in about 2,200 nucleotides. |
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Term
| Genes interact with environment to result in disease |
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Definition
Risk of lung cancer is increased with smoking, but the great majority of smokers avoid it.
Alcohol increases risk of cirrhosis, but a minority of alcoholics develop cirrhosis
Only 10% of those exposed to TB ever develop clinical infection
Outcome of head trauma is highly variable
4 of 14
Genes Interact With Environment to Result in Disease (cont)
Risk of lung cancer is increased with smoking, but the great majority of smokers avoid it.
polymorphisms in GST-1
Alcohol increases risk of cirrhosis, but a minority of alcoholics develop cirrhosis
polymorphisms in Epoxide Hydrolase
Only 10% of those exposed to TB ever develop clinical infection
polymorphisms in n-RAMP
Outcome of head trauma is highly variable
apo E polymorphisms |
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Term
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Definition
| Multifactorial disease that is either present or absent |
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Term
| How do we use SNP's? Whole genome association studies? |
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Definition
| Look for differences in the frequency of genetic alleles between “disease individuals” (patients) and healthy individuals “(controls)” |
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Term
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Definition
Risk - new test from Iceland (deCode)
OncoVue® is the first genetic-based, breast cancer risk test that incorporates both individualized genetic-based SNPs and personal history measures to arrive at an estimate of a woman’s breast cancer risk. The OncoVue Breast Cancer Risk Test is a result of research focused on understanding the role that multiple single nucleotide polymorphisms (SNP) along with personal history measures contribute to a women’s risk of developing breast cancer at various stages in her life.
Depending on results, could individualize screening. |
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Term
| Predictive Genetic Testing |
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Definition
Predisposition over Diagnosis
Time-line is very long (decades)
Informs us about a possible future
Adds a new dimension of uncertainty
Affects societal attitudes (GATACA)
Affects insurability? |
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Term
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Definition
May 21 2008 - The President has signed into law the Genetic Information Nondiscrimination Act (GINA) that will protect Americans against discrimination based on their genetic information when it comes to health insurance and employment.
The long-awaited measure, which has been debated in Congress for 13 years, will pave the way for people to take full advantage of the promise of personalized medicine without fear of discrimination.
GINA generally prohibits health insurers or health plan administrators from requesting or requiring genetic information of an individual or the individual’s family members, or using it for decisions regarding coverage, rates, or preexisting conditions.
The law also prohibits most employers from using genetic information for hiring, firing, or promotion decisions, and for any decisions regarding terms of employment. |
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Term
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Definition
Non-discrimination protections do not extend to life insurance, disability insurance and long-term care insurance.
Does not mandate coverage for any particular test or treatment
Does not apply to employers with fewer than 15 employees.
Does not prohibit health insurers or health plan administrators from obtaining and using genetic test results in making health insurance payment determinations.
Does not prohibit the health insurer from determining eligibility or premium rates for an individual based on the manifestation of a disease or disorder in that individual (For individual insurance)
For employment-based insurance, does not prohibit premium increases. |
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Term
| Direct to consumer: Personalized Testing |
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Definition
Health-related, non-health-related, or both
Counseling may or may not be offered; may be separate cost
One-time-only v. ongoing provision of information
Laboratory analysis and interpretation v. interpretive services only
Discrete gene tests (e.g. BRCA) v. “personal genome services”
Privacy policy provided or not provided |
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Term
| Direct to consumer: My genes, My business |
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Definition
Convenience
Personal control
Awareness
Motivation to make positive behavior or lifestyle changes
Knowledge and insight
Avoid discrimination |
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Term
| Direct to consumer: why worry? |
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Definition
Lack of regulations
Laboratory Quality
Lack of Counseling
Misinterpretation
Misrepresentation
Inappropriate test selection
Privacy
Surreptitious Testing
Consequences for other family members |
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Term
| DTC: Recommendations from FDA and CDC |
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Definition
Talk to your healthcare practitioner - make sure you understand benefits and limits of test.
Ask your provider or genetic counselor to help interpret the results.
Discuss results with provider before changing any decisions about diet or health practices.
Protect your privacy. |
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