Nursing 301 Child+Family and Older Person's health

15. Jennifer Shipley, is a 92 year old retired homemaker who lives alone in upstairs pensioner flat in a suburb of Auckland. She is physically well but her neighbours have noticed that she is becoming more socially isolated. Prioritise and outline your interventions

- Wherever possible, lonely people should be offered opportunities to reach out to others so that they retain active involvement in the pattern of their own lives - Build a rapport: Being nice to her, and taking the time to find out her hopes and fears. - Assess safety: ask her about thoughts of suicide, as safety is always important - Local groups (eg, bingo groups/ exercise clubs) may provide a social network for isolated people. These groups should be chosen by Jennifer herself, as this is more likely to foster personal meaning, and allows for autonomy and self-advocacy - Assess for the effects of her loneliness: eg vitamin D deficiency, and educate her about the other negative effects of loneliness - Assess potential underlying reasons behind becoming socially isolated. She may be ashamed of being incontinent and does not want to risk this happening out in public. She may not feel safe in her mobility since she lives upstairs and therefore has excluded her self from society to reduce her risk of falls→ intervention for this may be looking at a flat that is on the ground level where she does not need to walk up or down stairs. - Establishing what facilities already exist (eg, the local pub, a day centre or a lunch club). - As well as receiving visitors and telephone calls and going on outings, lonely older people may be helped by choosing to become pet owners. - Alternative therapies (eg, massage and aromatherapy) can relieve loneliness. - Befriending schemes can be very helpful to those who are housebound. They can be contacted through local churches or community care schemes - One way that housebound people can feel useful is through offering telephone support to others who are isolated, such as carers or other older housebound people. Another useful activity is letter writing, perhaps for a worthy cause or corresponding with a pen pal. - Technology forums such as the internet may provide relief from boredom and loneliness. - Getting a telephone: not only gives the reassurance of being able to request help in an emergency, but also allows the opportunity to chat to friends and family

10.Differentiate between the play requirements of a 2 year old, 4 year old and 7 year old in relation to growth and development theories and describe how this knowledge can be used when preparing a child for a procedure.

2-year-old - Autonomy vs shame or doubt - Builds on children's new motor and mental abilities - Children take pride in accomplishments and want to do everything independently - It is important for parents to recognise toddlers need to do what they are capable of doing, at their own pace and in their own time à children develop a sense of being able to control their muscles and impulses during this time - Important for gaining independence and confidence in abilities to achieve well in adolescence and adulthood - Play requirements: Independence during play and other activities - Preparing for procedure: Toddlers should be allowed to make as many decisions about the procedure as possible in order to give them sense of self-control and to let them do what they are capable of. → A two year old is in between the sensorimotor and perioperative developmental stages according to Piaget. Therefore they are going from only being aware of what is immediately in front of them, focusing on what they see and do, and physical interaction with the current environment to beginning to start symbolic thinking, mature their language and develop memory and imagination. However they cannot grasp complex concepts such as cause and effect. In relation to play, this means that the 2 year old is well able to interact in the present sessions, and with imagination developing this is great for a play specialist to be able to think of some creative, relatable ways to make the 2 year old semi-familiar with what procedure may be happening and for the 2 year old to actually remember this for when the procedure actually happens. HOWEVER memory means that they will remember the pain and remember anything that was not pleasant and without understanding cause and effect, they will not be able to see the future benefits or outcomes. So it is important that the 2 year old can use his imagination and exercise some control in the play preparation for the procedure to eliminate any anxiety. 4-year-old - Initiative vs guilt - Learning initiative is learning how to do things - Children can initiate motor activities of various sorts on their own and not longer merely respond to or imitate the actions of other children or their parents. The same is true for language and fantasy activities (intellectual initiative) - Depends largely on how parents respond to self-initiated activities - Children should be given freedom and opportunity to initiate motor play and fantasy or play activity. Initiative is also reinforced when parents answer a child's questions (intellectual initiative) - Those who do not develop initiative may later have limited brainstorming and problem-solving skills; they wait for clues or guidance from others before acting - Play requirements: Freedom and opportunity to initiate play, motor and fantasy - Preparing for procedure: Promote initiative by encouraging the preschooler to ask questions he/she may have about the procedure and answer these appropriately. 7-year-old - Industry vs inferiority - Children learn how to do things well and have pride in their achievements. - When children are encouraged in their efforts to do practical tasks or make practical things and are praised and rewarded for the finished results, their sense of industry (pride and accomplishment) grows - Play requirements: Require praise for their efforts - Preparing for procedure: Can use rewards or praise for undergoing a procedure well/successfully

38. You are the District Nurse referred to see 79 year old Mrs Ripley. Mrs Ripley was seen by the GP with a skin tear to her leg after a fall. The GP is concerned she may fall again. Describe the assessment process and factors that need to be considered to reduce her risk of falling.

Assessment Physical - Assess her mobility status. This includes her gait, posture, balance, center of gravity, body alignment, range of motion (joints), and muscle mass/tone/strength. o Impaired gait and reduced muscle mass/strength can increase falls risk o Problems with balance can also increase falls risk - Assess her ability to perform her activities of daily living. This includes: dressing (ability to dress herself independently), bathing/showering (e.g. staying standing up and maintaining balance when showering) toileting (e.g. getting to the bathroom, sitting on toilet and standing back up), mobilising around the house and outside o These are assessed to determine whether Mrs Ripley has any difficulty performing ADLs and whether doing them increases her risk of falling (e.g. increased falls risk in the shower if she finds it difficult to stand up for long or without aids, difficulty standing up from the toilet can increase her risk) - Assess for incontinence - Urge incontinence increases risk of falls if the older person feels the sudden urge to urinate and tries to hurry to the bathroom. Urine on the floor increases risk of slipping and falling. - Assess her use of walking aids (if she uses any), including whether she is using them correctly. The use of walking aids can increase falls risk - Assess senses (e.g. vision, sensation in legs and feet). Poor vision increases falls risk as the older person is less likely to see obstacles. Sensory impairment in legs/feet increase falls risk because the older person is less able to feel their feet, so increasing risk of tripping Cognitive and mental health - Confusion and decreased level of consciousness (such as in delirium) increases risk of falls Socioenvironmental situation - Assess the physical environment (and equipment) of Mrs Ripley's home, such as number of floors/stories, stairs, rails in shower or other areas of the house, shower chairs, slippery floors, clutter in the house Factors that need to be considered to reduce her risk of falling - Mobility status and use of walking aids (e.g. the use of walking aids such as canes or walkers can improve balance and reduce risk of falls) - Manage or treat illnesses/conditions/issues that increase her risk of falls e.g. delirium, incontinence - Environmental safety: Mrs Ripley's house should be tidy and free of clutter, to reduce risk of tripping and falling. Install rails in the bathroom and encourage use of a shower chair to reduce falls risk while showering - Polypharmacy: Review medications, effects, and side effects e.g. diuretics increase urine frequency, which may increase falls risk if the older person is hurrying to the toilet - Carers: To assist Mrs Ripley with ADLs (as required) - Educate Mrs Ripley about how to reduce her falls risk when performing ADLs e.g. sitting down when putting pants on, holding on to rails to get up and down toilet, proper use of walking aids

1. 6 month old Tina has been admitted to your ward with vomiting and diarrhoea. She is diagnosed with gastroenteritis (inflammation of GI tract that involves the stomach and SI) and moderate dehydration. Describe the assessment findings you would expect and the potential treatment to manage her dehydration.

Assessment: - Poor skin turgor - Mucous membranes - Vitals - temperature? Pulse- weak/bounding/thready/etc, - BP - low, HR - Increase - Frequency of stools and vomits - Lethargy, Irritability - Sunken fontanelles - Sunken eyes - Blood or mucus in stool? - specs for occult blood + 10% loss in BW (body weight) - Blood pH - Urine gravity - Blood tests - FBC, EUC (electrolytes, urea, creatinine), BSL - Colour, consistency, volume, odour, etc of stools and vomit Treatment - Oral and IV rehydration therapy - oral if the child hasn't - vomited in a while and can tolerate oral fluids (NBM until vomiting stops) - Oral rehydration therapy is safer and more effective than IV (except for shock). - Encourage oral intake of pedialyte, Rate should be 5 mL/min NG tube can be used if child refuses fluids or has a fluid output greater than 5 mL a minute Closely monitor and have a clinical review at least every 2 hours Give potassium when prescribed and when it is certain the child is not experiencing renal failure Gradually increase food and fluid intake PO at intervals once vomiting has stopped Maintain oral hygiene Continence and hygiene cares for the nappy area Educate and reassure parents Maintain fluid balance chart for input/output

36. You are assigned to care for Sandy, a 10-year-old who has had her appendix removed last night.Describe how you will manage her pain.

Assessment: presence, intensity, location and type of pain, contributing factors, estimate potential impact of pain on the individual - Ask Sandy (Question the child) - self report techniques, Use pain rating scales - (Evaluate) Behaviour assessment: facial expression, cry, poor mood, motor activity - Physiological assessment: heart rate, O2, RR, BP, sweating, routinely - Continue evaluating the effectiveness of pain management interventions - QUESTT(refer to lecture slide) - Take cause of pain into account - Pharmacological intervention: analgesics administration and monitor side effects o Paracetamol should be given before anticipated pain, C/I for hepatotoxicity, mild pain, centrally acting o Tramadol: synthetic opiate, moderate to severe pain, centrally acting, effect evident within 1 hour, S/E less severe than other opiates o Morphine: severe pain, centrally acting, S/E addiction, tolerance, physical dependence - Psychological intervention, anxiety management: parental presence, distraction including books, musical toys, breathing exercises, games, counting, singing, encourage comforting measures - Provide education on pharmacological interventions to the child and parents/caregivers - Participation of parents in providing information as well as involving in the care

14. Four-month-old Jani, has been admitted to your ward with fever, coughing and irritability. She was diagnosed with bronchiolitis. Describe the pathophysiology of bronchiolitis and relate this to the assessment findings you would expect.

Common illness to the respiratory tract Caused by an infection that affects the tiny airways called the bronchioles Airways become inflamed, they swell and fill with mucous, which make breathing difficult. Most commonly caused by respiratory syncytial virus (RSV). responsible for more than half of all cases. Other viruses include rhinovirus, influenza... etc Contagious - main modes of transfer include; sneezes, cough, laughs, touch Children Often affects infants and young children because their noses and small airways can become blocked more easily than those of other kids or adults Typically happens during first 2 years of life, most commonly about 3-6 months of age More common in males, have not breastfed, premature babies, and those who live in crowded conditions. Signs and symptoms related to pathophysiology. Stuffy nose and congestion, runny nose Largely due to the nature of the virus involved, RSV, rhinovirus (common cold), influenza (flu). Also due to the inflammation process which leads to swelling and filling with mucous. Overproduction of mucus and swelling leads to stuffy and running nose. Wheeze due to the collapse of the smaller alveoli from lower airway inflammation. Fever Inflammation. Infection. Normal response Rapid heartbeat and Fast shallow breathing Insufficient O2 within blood. Heart compensates by increasing HR to get limited O2 around body to try maintain. lower airways inflamed causing airway obstruction, further decreasing effective gas exchange and causing ventilation-perfusion mismatch Retractions Shows increased WOB. accessory muscles are being used to create a larger vacuum to get O2 in. Due to increased airway resistance which leads to reduced O2 intake and CO2 release. Flaring of nostrils irritability , with difficulties sleeping and signs of fatigue or lethargy Not enough O2 in body to maintain activity. Anaerobic - increases lactic acid. Build up. Inefficient ATP creation thus lethargy and build up of lactic acid. Cough prolonged coughing occurs due to viral infection leading to irritation and inflammation of the mucosal tissues Crepitations on auscultation.

20. Mrs Lara Crofting is a 83 year old American who is on holiday in New Zealand. She is admitted to your unit confused and disorientated. Outline your assessment to differentiate between delirium and dementia.

Dementia and delirium may be particularly difficult to distinguish, and a person may have both. In fact, frequently delirium occurs in people with dementia. Some differences between the symptoms of delirium and dementia include: Onset. The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time, eg the progressive decline of memory and other thinking skills Cause. Delirium usually has an identifiable cause and is not a disease. The cause is usually an underlying medical issue such as a UTI, influenza, head injury, stroke, interactions between medications, toxicity of medications, ETOH use or withdrawl, allergic reaction, metabolic condition eg low Na or Ca, fever, infection, exposure to a toxin, malnutrition, dehydration, sleep deprivation, emotional stress, acute pain, anaesthesia. Dementia has no cause and is an organic degenerative disease where there is a gradual dysfunction and loss of brain cells eg Alzheimer's disease Attention. The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert. Fluctuation. The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day. Intervention: Delirium usually subsides without any intervention, while dementia will not subside and will get worse Several medications or combinations of drugs can trigger delirium, including some types of: Pain drugs Sleep medications Medications for mood disorders, such as anxiety and depression Allergy medications (antihistamines) Parkinson's disease drugs Drugs for treating spasms or convulsions Asthma medications

17. Johnny is an 11-year-old boy, who lives with his grandparents and 2 younger siblings. He has had asthma since he was 3, but recently he has been admitted three times with exacerbations.Outline an education plan to reduce his hospitalisations.

Education plan: Knowing how to use the medication: one puff when using the spacer, and 6 normal breaths, or appropriate breathing technique when using the inhaler What the different inhalers are used for: the blue inhaler (ventolin) is for quick, short term relief, while the orange inhaler (flixotide) is for prevention of asthma attacks in the long term When to use the different inhalers: preventer should be used twice daily every day, although it may take a few weeks for it to actually work. The preventer is meant to stop the patient from using the blue inhaler (beta 2 antagonist, salbutamol, Ventolin) which should ideally be used 2-3 times a week. If there's a need to use the blue inhaler more frequently, it could mean that there's an ongoing inflammation. The risks of having ongoing inflammation, could result in long-term structural change of the airway and lungs Risks factors: overcrowding, smoking, damp, also dust related. talking about compliance risks of non-compliance identifying triggers identifying when things get worse and what to do.

5. A recent study found loneliness has dramatic consequences on health. What are the effects of loneliness on an older person and describe some nursing interventions to address this issue.

Loneliness can lead to depression due to the lack of comfort, security and support Depression can cause mental and physical health problems. For example, staying indoors for extended periods of time causes issues such as Vitamin D deficiency or complications related to immobility eg constipation Studies show that those who are lonely have a 50% less chance of survival due to the effects of loneliness. Studies show that loneliness increases the likelihood of developing dementia or Alzheimer's Offer ways to find companionship/ support social activity- joining social groups, learning to use computer etc. These activities should be chosen by the client themselves, be something they enjoy doing, and something that they find personal meaning from Encourage client to identify tangible reasons for feelings of isolation and loneliness and support them to develop a plan of action to reduce those feelings Encourage telephone contact with family + friends.

8. Describe how family centred care can improve paediatric nursing related to 4-month-old Irene,who was admitted to your ward with fever and irritability and is tentatively diagnosed with meningococcal disease.

FCC is vital as children are part of a family and are dependent on them for physical/emotional/psychological wellbeing. It is important as nurses to recognise this and understand that families know their children best. Keeping family involved in developing a treatment and management plan for Irene is extremely important for maintaining these connections between the child and her family. Involving family in cares (eg nappy changing, washing, calming her when irritable) is a way in which families can be directly involved in care. Brain abscess and invasion of cranial nerves can lead to blindness, deafness and facial paralysis Hydrocephalus/brain oedema leads to pressure on pituitary gland which increases ADH and increases oedema due to urinary retention Seizures, shock Cranial nerve paralysis Brudzinski's sign, Kernig's sign Bulging fontanelles Diagnosed by analysing CSF from lumbar puncture - increased WBC and protein, decreased glucose Important to involve family in care and informed decision making Prompt treatment is necessary and people often focus exclusively on the child but it is important to make sure the parents know what's going on and receive the necessary education Child is irritable, will be more likely to calm down in the presence of her parents than if care was solely provided by medical staff. Children require affection and this is best provided by their parents when in a hospital setting.

28. What are the factors that impact on New Zealand's high rate of Rheumatic Fever and what population based interventions may reduce this disease?

Factors that influence on the high rate of RF in NZ: Poverty, leading to overcrowding and hence spread of the bacteria Inequitable access to healthcare, related to low income and racism, resulting in sore throats not being treated Lack of education surrounding the causes of RF, so people are unaware of the dangers of a sore throat Poor hygiene such as sharing food with people who are sick, not washing hands properly, poor coughing and sneezing etiquette, causes exposure to bacteria Genetics: some people have genes that make them more susceptible to contracting RF Population based interventions that may reduce this disease: Free throat swabbing in schools and sore throat clinics, with the provision of antibiotics to children with sore throats Widespread distribution of prophylactic antibiotics, and education on the importance of finishing a course of antibiotics Taken from http://www.health.govt.nz/our-work/diseases-and-conditions/rheumatic-fever/rfpp-strategies-and-initiatives Awareness campaigns: what RF is and how to prevent it Education for the primary health care providers and community health workers that work with at-risk families about recognition and prevention Culturally acceptable services that are led by the high-risk populations themselves and are empowering: not so much the top-down "education" schemes, but rather grassroots, strengths-based initiatives that identify what the community already knows, and providing information accordingly. Healthy homes initiatives: reducing overcrowding (but is this actually possible in Auckland??) Social housing fast-track initiatives: providing state houses on a priority basis, where at-risk families (families living in overcrowded houses) are prioritised

7. Choose two of the following minor complications of pregnancy. Explain the underlying pathophysiology of why they occur AND the advice you would give to the pregnant mother about management. Let's do all of them! Haemorrhoids Varicose Veins First trimester nausea Frequency of urination Backache

Haemorrhoids Pathophysiology: The pressure of the enlarging uterus at appox. 25 weeks along with the increase of blood volume to the pelvic area can cause the veins of the rectal area to swell or burst. Often referred to as rectal varicose veins. An aggravating factor for their development is also constipation, due to straining upon excretion putting pressure on the veins causing them to bulge. Management: Prevention measurement- prevent constipation by drinking water, staying active and possibly taking a stool softener Avoid sitting for long periods as this places pressure on the rectal and anal veins. Keegal exercises to improve circulation to the area. Soaking in a warm bath can also help ease the pressure and reduce pain Ice packs can also reduce pain If haemorrhoids are present, the use of an astringent agent can aid tissue to connect and draw back together. Topical agents can be purchased over the counter or prescribed by a doctor. These agents contain mild anesthetic to reduce pain as well as mild steroid to reduce inflammation. Varicose veins - Pathophysiology: During the third trimester of pregnancy, the pressure of the expanding uterus on the inferior venal cava impairs blood flow to the lower extremities. This resistance to blood flow in the venous system can lead to oedema and varicosities of the vulva, rectum and legs. This is exacerbated by the increase in blood volume during pregnancy Management: Avoid standing for long periods of time to prevent oedema (the resistance to blood flow in the venous system increases risk of oedema, particularly when standing for long periods of time as it is more difficult for blood to travel up from lower extremities). Massage feet to promote blood flow in legs. Avoid wearing heels (flat shoes contract the calf muscles more, increasing blogs flow) and tight clothing. Wear compression stockings. Nausea Noticed at the same time when hCG and progesterone begin to rise in pregnancy Increased progesterone and estrogen cause a decrease in GI muscle contractility impairing proper digestion Systemic reaction to increased estrogen and decreased glucose (glucose is used in large quantities by developing baby) Ends after first trimester and is often followed by a huge appetite Alternative treatments such as ginger or peppermint tea sometimes help, as well as acupuncture and weighted wrist bands may help, but tell your LMC Eating small amounts regularly instead of large meals Having a plain biscuit or plain piece of toast first thing in the morning and resting for 20minutes before you get up. Eat what you want when you want, whatever causes the least nausea Eating cold food if the smell of food is a trigger for nausea Frequency of urination 1st trimester: frequent until uterus rises out of the pelvis and lightens pressure on bladder 3rd trimester: frequent again due to baby's head which exerts renewed pressure on bladder Ureters increase in diameter due to hormones Hormone hCG increases blood blow to pelvis and kidneys - meaning kidneys filter more blood and in turn have to excrete waste more frequently Bladder capacity increases Increased risk of UTIs Management: Encourage the mother to keep bladder empty, to prevent UTIs. Leaning forward slightly when urinating help empty the bladder. Pelvic floor (Kegel) exercises strengthen the muscles used for urination, thus assisting with urination. Monitor and encourage mother to monitor for UTI (because urinary frequency may also be a symptom of UTI). Encourage mother not to decrease fluid intake in attempt to decrease frequency of urination as dehydration can have negative outcomes on the mother and the fetus, although it does seem like an easy solution. - Preterm labour may be caused by dehydration in the third trimester as it can trigger uterine contractions. Backache - Pathophysiology: Relaxin and progesterone causes gradual softening of the pelvic ligaments and joints to create pliability and to facilitate passage of the baby through the pelvis at birth. Oestrogen also relaxes the sacro-illiac joint, which can cause lower back pain. The growing uterus may also put pressure on the back. ?? - Management: Even though it is hard, try to maintain good posture, with shoulders back for gravity to reduce lower back pressure, which can assist in reducing back pain. Application of heat packs may help relieve back pain.

26. Sally 30 year old mother of two girls, is 32 weeks pregnant. Sarah, the two year old has had an asthma attack and you visit the home to review her asthma management. Sally tells you that she did not sleep well last night because she was worried about Sarah. She asks you if she can take paracetamol for headache. Using your knowledge on pharmacology, explain the physiological changes in pregnancy that can affect the absorption, distribution, metabolism and elimination of drugs.

Pharmacology - Absorption: decreased gastric -> decreased absorption -> slower to take effect (e.g. paracetamol) - Distribution: increased BV -> more dilution -> decreased distribution (e.g. paracetamol may be less effective for the headache) - Metabolism: increased metabolism in pregnancy -> increased drug metabolism (drug works faster) - Elimination: increased urination -> increased drug clearance Asthma management. Um, this isn't relevant?? - Identify triggers - Educate on proper use of inhalers -> include use of different inhalers e.g. prevention, PRN - Assess home environment e.g. hygiene, ventilation - Chest physiotherapy -> decrease secretions - Posture: sitting up promotes chest expansion - Re-assess asthma

2. A mother asks you about immunising her 4-month-old daughter Sophie. Explain why Mum should get Sophie immunised.

Immunisation is recommended by the World Health Organization, the New Zealand Ministry of Health, and medical authorities. Benefits outweigh the risks This is because the risk from the diseases is far greater than the very small risk from immunisation. Complications from infections are much more dangerous Serious reactions to immunisations are very rare eg anaphylaxis. But this is usually not a problem because you will be under observation for approximately half an hour after the injection so that any signs of anaphylaxis is recognised and treated immediately. The rates of death and complications with immunisations is much lower than the rates of deaths and complications without immunisations The injection site may become swollen and red. Your child may have a mild fever or experience some light-headedness. These side effects, and do not cause long term damage to the body. When comparing these potential side effects to the potential of being infected with a disease, the side effects are almost negligible. It is a natural way of providing immunity Community impact If enough people are immunised against diseases, the diseases can't spread easily. Also, people who can't get immunised due to an underlying condition eg immunosupression, will also be protected because of herd immunity. Financial reasons Immunisations are free to every single child in New Zealand. They help protect against 11 serious diseases: It will also save you money, as getting treated for any potential diseases that you may get in the future will cost a lot, and if the disease is not treatable, the life-long cost of living with disability will cost even more The immune system cannot be weakened or overloaded by the immunisation, as immunisation is simply the introduction of a part of a disease. This is not harmful to the immune system, as the immune system fights diseases every day

16. Joe, a 5-year-old Tongan new entrant at the school where you are the school nurse, has come to see you with a sore on his leg that you diagnose with possible cellulitis in the surrounding tissue.Outline your initial treatment and education to provide to the family.

Initial treatment: draw an outline of the red area, so that we know if the redness is improving or getting worse oral antibiotics eg penicillin, flucloxacillin, dicloxacillin, cefuroxime or erythromycin. Can be taken at home, usually for 5 to 10 days, but the full course must be finished Clean the wound with aseptic non touch technique and apply appropriate dressing if dressing is required Administer paracetamol, after phone consent from parent or caregiver, as cellulitis can be painful and will also work to lower fever if there is an infection. If there are signs of systemic illness or extensive cellulitis, treatment may require intravenous antibiotics either as an outpatient or in hospital Education: Cellulitis is caused by bacteria: the most common infecting organisms are Streptococcus pyogenes (two thirds of cases) and Staphylococcus aureus (one third). It can occur by itself, or complicate an underlying skin condition or wound Cellulitis is potentially serious and should be assessed by a medical practitioner promptly. The management of cellulitis is becoming more complicated due to rising rates of methicillin-resistant Staphylococcus aureus (MRSA) and macrolide- or erythromycin-resistant Streptococcus pyogenes. The full course of antibiotics needs to be finished, even if the wound looks healthy. This is to prevent the bacteria from becoming resistant to antibiotics in the future. Patients with recurrent cellulitis should Avoid trauma, wear long sleeves and pants in high risk activities eg gardening Keep skin clean and well moisturised, with nails well tended Avoid having blood tests taken from the affected limb Treat fungal infections of hands and feet early Keep swollen limbs elevated during rest periods to aid lymphatic circulation. Encourage good hand hygiene of washing hands with soap and water properly when changing dressings and in general good hand hygiene to reduce risk of infections Educating parents around restricting children swimming in unclean water environments such as public pools if they have an open wound or cut as this may increase risk of infection

35. You are asked by a local parent coffee group with infants and pre-schoolers to provide a talk about measles. Outline your key points about what it is, prevention and management.

Measles is a highly contagious viral infection caused by the measles virus that is spread from person to person through the air via breathing, coughing, and sneezing which affects both children and adults. Measles can be life threatening as it can lead to further complications such as: Pneumonia Seizures Ear infections Swelling of the brain Diarrhoea Symptoms of measles virus typically present 7-18 days after infection with the virus: Fever Cough Runny nose Sore and watery 'pink' eyes White spots on the back of inner cheek (called Koplik spots) Later symptoms: A blotchy rash that starts on the face, behind the ears before moving over the head and down the body and lasts for up to a week Prevention Immunisation with MMR (Measles Mumps Ruebella) is the best way to ensure prevention of exposure to the measles virus and requires vaccinations of 2 doses, commonly given to children for life immunity Management See a doctor if any of the above symptoms (especially the rash and white spots inner cheek). Ensure to contact doctors first and warn them of potential measles exposure so they are able to put appropriate precautions in place to reduce exposure to others. Plenty of fluids, rest and paracetamol for fever. Treatment of complications may be necessary. Administration of vitamin A to children with measles has been correlated to decreased morbidity and mortality.

4. A mother new to New Zealand asks you what a "well child" check is. Detail your response

Monitor developmental progress by assessing milestones Program consists of 13 well-child checks following the child from birth to 4 years of age Discover developmental problems early on History taking Growth, vitals, ear, visual and oral assessments Providing support to meet the needs of the parents with community support Providing immunisations and education Overall, well child support the families to optimise their child development potential and health status Free for under 5 years old and run by MoH

37. You are caring for 3 day old baby Perkins and Mum tells you baby has been slower to feed and seems very sleepy. On assessment you notice a yellowish tinge to his skin. Describe the pathophysiology of jaundice in the newborn and relate this to the assessment findings you would expect.

Newborn jaundice is the yellowing of the skin which typically appears on the second or third day of life in 50% of newborns. It is a result of hyperbilirubinemia Hyperbilirubinemia is the breakdown of fetal red blood cells. Fetal red blood cells count is built up in utero but cells are broken down short after birth. The broken down fetal red blood cells cause an increase of bilirubin in the indirect form within the blood in excessive amounts. When the fetal RBC are broken down the by product of haeme and globin are present. Globin is further broken down into iron and protoporphyrin. Protoporphyrin is further broken down into the indirect form of bilirubin. The indirect bilirubin cannot be excreted by the kidneys and immature liver function in newborns inhibits indirect bilirubin being converted to direct bilirubin. The rising levels of indirect bilirubin within the blood are able to permeate tissues from the circulatory system causing infants skin to appear yellow and the sclera of the eye to be yellow on assessment.

31. You are a community based nurse and have been asked to speak to a group of parents and staff at a local child care centre about norovirus. Outline the cause, prevention, symptoms and management at home that you will be including in your talk.

Norovirus is a group of viruses that cause stomach or intestinal infections which lead to vomiting and diarrhoea. Norovirus is spread from person to person by faeces or vomit, as they are high infectious the virus remains on surfaces despite being cleaned with disinfectant substances. It can be spread by consuming contaminated foods, direct contact with infected person, touching infected surfaces then placing fingers in mouth and can also be spread through the air Prevention Don't go to school, early childhood centres or work until you are well or the last episode of diarrhoea or vomiting was over 48 hours ago Don't prepare or handle food for others until you are well or the last episode of diarrhoea or vomiting was over 48 hours ago Use bleach-based cleaning products to disinfect surfaces that have been touched by people with norovirus or have potentially have had vomit or diarrhoea on it Wash hands regularly with soap and water or alcohol based gels Avoid persons who are currently sick with norovirus Symptoms Symptoms usually precipitate 1-2 days after exposure to virus and typically lasts 2 days Nausea Vomiting Diarrhoea Stomach cramps Headache Low grade fever Chills Muscle aches Management at home Keep child at home until they feel well and it has been 48 hours since last vomiting or diarrhoea episode Drink plenty of fluids to keep hydrated. This is particularly important because dehydration is what causes serious illness and hospitalisation. Don't share utensils, food, or cups as this may spread virus onto others there is no specific treatment. The virus will take it's own course and should eventually be killed by the body notify your GP if there is blood in vomit and/or diarrhoea notify your GP if the symptoms do not get better or get worse after 3 days, or new symptoms appear monitor for signs of dehydration, such as a dry mouth, sunken fontanelle, small amounts of dark smelly urine, weak rapid heart rate, fatigue, rapid breathing, floppiness, skin that does not bounce back after pinching. Monitoring for dehydration is most important because this is how the virus causes serious illness. The virus causes a lot of vomiting and diarrhoea, which causes the body to lose a lot of water, and become seriously ill. drink plenty of clear fluids such as water or oral rehydration drinks (more than what you normally drink, to replace the lost fluids) do not take any anti-vomiting and anti-diarrhoeal medications (unless your doctor tells you to), as vomiting is your body's way of getting rid of the virus take paracetamol for fevers, muscle aches, stomach cramps, headaches bed rest, to allow your body to fight the virus by itself eat plain foods, to avoid irritating the stomach, as irritation can cause further vomiting

22. Mrs T is a 77 year old widow from the Cook Islands. She lives with her daughter in South Auckland. She presents to the clinic with mild exacerbation of bronchitis. The following medications has been prescribed for Mrs T: Flixotide 250 mgs BD Serevent 25mcg 2 puffs BD Ventolin 1-2 puffs prn when SOB Hydrocortisone 10 mgs daily Plendil 5 mgs daily Frusemide 40mg BD Explain the pharmacological considerations that you need to take into account when caring for the older adult.

Pharmacological considerations Age-related changes affect pharmacodynamics (what drug does to the body) and pharmacokinetics (what the body does to drugs) in the older person. Pharmacokinetics can be divided into four stages: Absorption, distribution, metabolism and elimination, which are all affected by age-related changes to different systems of the body. Absorption is less effective: Skin: - Age-related changes in skin include subcutaneous fat loss, dermal thinning, decreasing collagen and elastin and a decline in cell replacement rate. - These age-related changes affect the absorption and effect of topical drugs, such as the hydrocortisone prescribed for Mrs T Gastrointestinal: - Older people have reduced secretions in the GI system, thus affecting ability of the drug to be absorbed by the GI tract. Reduced GI motility may also reduce drug absorption. This then causes increased time to peak drug levels. - Reduced GI motility can also increase susceptibility of the older person to drug side effects such as constipation. Respiratory: - Older adults have a decrease in pulmonary function due to respiratory muscle regeneration and reduction in ventilatory capacity. The size of the alveoli also decline. This can reduce absorption of inhaled drugs, such as the flixotide, ventolin and serevent that Mrs T is prescribed. Distribution is slower: The cardiovascular system of older adults is usually less efficient in transporting blood and drugs. This means that the drugs are distributed to the target tissues less efficiently Age-related changes effects on distribution - Increased body fat reduces the amount of free drugs readily available to receptors since fat is used as a reservoir for fat-soluble drugs. This prolongs the action of fat-soluble drugs. - Reduced body water reduces distribution of water-soluble drugs. - Reduced serum albumin can lead to a higher proportion of unbound drugs in plasma, so drug activity and the potential for toxicity is increased. Metabolism is slower: - There is reduced liver function in older adults, so less efficient metabolism and detoxification of drugs. This increases half lives of drugs and increases risk of drug toxicity. Also increased risk of adverse drug reactions due to prolonged half lives of drugs. Polypharmacy may also decrease metabolism if multiple drugs are being metabolised in the liver (by the same enzymes) Elimination is less effective: Renal - Kidney function decreases as one ages. This then affects elimination of drugs through urine, thus increasing risk of toxicity. - Frusemide, a loop diuretic, and its effect can be affected by reduced kidney function Polypharmacy in older adults - Polypharmacy is the excessive and unnecessary use of medication. - Polypharmacy has been associated with: adverse drug reactions, drug interactions and drug-induced disease (iatrogenesis) Hydrocortisone acts as an immunosuppressant which can increase the risk of infections or mask the signs of infections in older people Hydrocortisone, furosemide and ventolin increase the risk of hypokalaemia (electrolyte imbalance)

39. You are the school nurse and a teacher comes to you concerned about changes in Tommy's (6 years) behaviour. There is a possibility of family violence. Identify potential effects of family violence on physical health, mental and emotional wellbeing and social well being for a child like Tommy.

Physical (depends on the actions taken by the abuser): injuries and trauma - brain injuries, fractures (ie. spiral fractures --usually caused by a wrenching force and is frequently associated with child abuse) bruises burns occular damage CNS impairment (ie, whiplash lesion of the spinal cord) disability malnourishment Mental and emotional wellbeing Developmental delay PTSD Suicidality and self-harm Mental health disorders Low self esteem Substance abuse Sleep disturbance Anxiety Difficulty trusting others Phobias Feelings of powerlessness, vulnerability and isolation Sleep disturbances Guilt, depression, anger, violence Loss of ability to concentrate Withdrawn behaviour/non verbal Regression Social wellbeing Disordered attachment Transience Poor academic achievement Poor relationships Anti social behaviour Social anxiety poor academic achievement poor relationships

40. You are working as a nurse in a postnatal ward and a mother shares that she will be going back to work at 6 weeks but still wants to breastfeed, having heard that 'Breast is Best'. She asks about expressing and freezing her breast milk. What safety points would you highlight about freezing and reconstituting breast milk?

Put the expressed breast milk in sterilised bottles or airtight containers. This is to kill any pathogens that may cause illness for the infant. Label bottles with a waterproof label and pen marker with the date and time of expressed milk Breast milk will keep in the freezer for 3-6 months, and in a deep freezer for 6-12 months - the milk may separate into layers but once thawed will mix. Defrost frozen breast milk in the fridge or in a container of warm water - do not defrost in a microwave as this may destroy important qualities of the milk. Warm the milk to temperature in a bowl of hot water - do not microwave to heat as it can cause uneven heating of the milk and burn the baby's mouth. Test the temperature of the milk by putting some on the inside of wrist to ensure it is not too hot. Use the milk immediately and throw away any left over as it is not safe to reheat or refreeze milk.

30. You are a community based nurse and have been asked to speak to a group of older people about the importance of physical activity. Outline the key points of your talk.

Reduces risk of heart disease: P/E cam lower the risk of heart disease by improving inotropy of the heart, reduced vascular resistance and improved vascular responsiveness. - Regular exercise reduces the risk of cardiac events such as stroke, myocardial infarctions, vascular disease, heart failure. - Reduction in BP - Reduction in LDL and total cholesterol, increase in HDL reducing risk of arterial disease such as atherosclerosis. Improved ability of the body to take in and use oxygen. Obesity: Help to reduce body fat, burn calories and build muscle which is energetically favourable as skeletal muscle burns can burn fat for energy. Lowers risk of type two diabetes: exercise helps to improve blood sugar control by increasing insulin sensitivity to glucose and improved glucose uptake by working skeletal muscles. Improves mental health: evidence has shown that moderate exercise is as effective as some antidepressants at reducing symptoms of depression and anxiety. This is thought to occur due to the changes in the brain associated with neural growth, reduced inflammation, sense of structure and calm as well as the release of endorphins which give energy and feelings of satisfaction. Exercise is also good for managing stress, helping to physically release tension and anxiety. Improved emotions/well being: exercise improves brain function, ability to concentrate and perform mental tasks. It also prevents the degeneration of neurons due to age. - Better sleep: can help to regulate sleep patterns - Higher self esteem: gives a feeling of self worth, strength and power. Improve mobility : Prevent muscle loss/ increase muscle strength, maintain bone density. Maintainence of bone and muscle health can aid with improved flexibility, balance and reduce the risk of fractures and conditions like osteoperosis and sarcopenia. Improves social life: exercise can be performed in groups, e.g. group gym classes, walking groups etc. they can facilitate positive social environments to prevent social isolation Strength, aerobic and stretching exercises are important for achieving these benefits. At least 2.5 hours of aerobic training exercises should be completed weekly if at moderate level otherwise 1.25 hours weekly of vigorous exercise to receive the benefits of physical exercise.

25. Peter, aged 3, found an open bottle of Paracetamol Elixir 250mg/5ml. He liked the taste and drank most of a full 100 ml bottle. His mother found him with sticky lips, hands and clothes and has rung you, the Practice Nurse, and asks what should she do?

Remove paracetamol elixir from child Establish with the mother whether there is any paracetamol left in the bottle, if any had been spilt on the floor, if there is a lot covered on the child (sticky lips, hands and clothes) to try to gage how many mls the child has ingested Immediate treatment is required - despite a lack of early symptoms 27 She must take peter to the hospital and general supportive measures must be available Reassure mum ? She needs to stay calm and not feel guilty. Reassuring her that it is developmentally normal for children of Peter's age to try new things and do things that they find pleasurable. Do not induce vomiting? not sure about this... Dosage history, how many times peter has taken paracetamol prev this day. That's all she needs to do??? - Risk assessment o Accurate history of the maximum possible does, approximate time of ingestion, possible other drugs ingested, risk factors that may lead to increased hepatotoxicity - Observation, hydration, correction of hypoglycaemia as in a rare situation, decreased level of consciousness and lactic acidosis can occur - Monitor allergic reactions (flushing, wheeze, angioodema, hypotension, fever) Risk assessment: check an accurate history The maximum possible dose took by Peter (Questions such as 'how many mls left in the bottle before Peter drank it?' and 'How many mls left in the bottle after Peter drank it ?' can be asked). Ask the mother about Peter's weight. Work out the dose per kg. Because if the maximum possible dose is lower than 200 mg/kg, no intervention is necessary. The time of ingestion. The possibility of an earlier ingestion time may place a patient above the treatment line, the possibility of a later ingestion time might require another paracetamol level to be measured. Possible other drugs ingested? Risk factors that may lead to increased hepatotoxicity. E.g. malnourishment, acute or chronic illness. Supportive care Ask mother to observe Peter. The massive ingestions may be associated with early decreased level of consciousness and lactic acidosis. Check Peter's hydration level Correction of hypoglycaemia Ask the mother to go to hospital to check the serum paracetamol level and take further action (NAC therapy) if required. Take him to the ******* hospital ←YASS Reference http://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Paracetamol%20Poisoning.pdf

21. Mrs M is a 70 year old victim of financial and psychological abuse. She has lived alone in her two bedroom unit for a number of years. Her son (41 years old) returned from living overseas a year ago and moved in with her. He has a past history of alcohol and drug abuse which Mrs M was unaware of at the time. Over a period of months the son, under the influence of drugs and alcohol,verbally abused and threatened his mother causing her psychological suffering and fear. She seldom goes out now and he has recently demanded sums of money to pay for alcohol and drugs.What are the known risk factors of elder abuse and neglect and potential nursing interventions for Mrs M?

Risk factors: A shared living situation with her son, who has a past history of substance abuse. Social isolation from other family members (if there is any, except from her son) and friends/living alone for so many years Inadequate social support from not going out Being unaware of her son's alcohol and drug abuse beforehand, so she could not prepare eg get appropriate supports in place Where Mrs M's son are dealing with drugs this also increases the risk of neglect and financial abuse.(demanded sums of money to pay for alcohol and drugs) a mother's attachment to her own child can inhibit her from invoking protective strategies such as seeking a trespass order or asking him or her to find other accommodation. ageism Potential nursing interventions Provide emotional support Listen to the person's story. Acknowledge what they tell you Validate their experience 2. Assess risk Determine the level and urgency of safety concerns Identify risk that is life threatening, including risk of homicide Identify risk of suicide or self-harm Gaining consent. The process of consent needs to be carried out in a manner consistent with the needs and culture of the older person. Maintaining confidentiality. There are situations where a health care provider will need to pass on information, and this may include a situation of abuse or suspected abuse. Limitations of confidentiality include the following two situations: There is a legal and ethical obligation to take action if serious harm is likely to arise through not doing so; A court may order disclosure of transaction details whether they have been recorded or not, although this rarely occurs. 3. Plan safety If the older person is at risk of serious harm or death, advise the older person of concerns and contact the police if required. Contact EAN services and/or relevant agencies such as social workers, mental health services for older people, or an emergency safe bed facility For all other safety concerns, seek consent to refer and discuss a safety plan and referral options. Educate and support the person whatever their choices, and provide contact information for services. 4. Document Record the action taken and document any current or past injuries 5. Refer Complete appropriate referrals, such as to EAN service providers, health,social and/or legal services. Ensure procedures are in place for the coordination and monitoring of intervention, and follow up as required.

9. Describe the benefits and risks a family caregiver such as Sally Boyle might experience if she was to become Florence Boyle's (her 82 year old mother-in-law) main caregiver?

Risks Family members may not be adequately trained or possess the knowledge necessary to take safe care of Florence --can also result in unintentional neglect Family caregivers have high rates of emotional, physical and mental ill-health Depression and stress Removes them from workforce Decreases income for the family puts stress on the relationship Can become quite attached to her, which can make it difficult to surrender care to others, or difficult when she passes Benefits Not having to pay for outside help Familiarity Can apply to get money from WINZ if the sole carer is a family member support? strengthening the relationship

19. Mrs Jane Doe has been in hospital 2 months. She weighs 45kgs and is diagnosed with sarcopenia. Discuss her management from a nutritional perspective.

Sarcopenia: an age related change where there is loss of muscle mass and strength which affects balance, gait and ability to perform ADLs Increase caloric intake: Increasing sources of fats, especially poly- and mono-unsaturated fats will help in increasing caloric intake. Fortifying foods is another option in increasing calories by adding foods such as margarine, cheese, oils etc... Supplementing food intake with extra snacks throughout the day in between meals to reduce malnutrition by adding snacks such as soup, yoghurt and puddings. Adding nutritional supplements, such as Fortisips, which are high calorie milk flavoured drinks once or twice a day to increase calorie and are good supplementation for reducing malnutrition in older adults. Increase muscle mass: In order to maintain and regain muscle strength that is lost secondary to sarcopenia, older adults require more dietary protein than those of younger age and at a rate of 1-1.2g or protein per kg per day.

12. Following a case of Hepatitis A in a rural secondary school, as public health nurse in this area you prepare an education session for the pupils. What information should you include using the following headings: Signs and symptoms Source of the disease and transmission Prevention and control

Signs and symptoms - It is impossible to differentiate between the different types of hepatitis from the symptoms that are present - Symptoms of hepatitis A include: headache, fever, reduced/loss of appetite, yellowing of skin (jaundice) due to slower liver function, dark coloured urine, nausea, diarrhoea - Symptoms last for about a week, then symptoms fade with full recovery Source of disease and transmission - Drinking water or food contaminated with faeces - Not washing your hands thoroughly after going to the toilet can increase risk - Person infected with hepatitis A can be infectious up to 2 weeks before symptoms start to show, and up to 2 weeks after symptoms start - Hepatitis A is not sexually transmitted Prevention and control - Good hand hygiene can help prevent hepatitis A - Treatment for hepatitis A includes rest and eating a good kilojoule intake - eat a good breakfast - Generally, you do not need to go to hospital for hepatitis A and you can recover at home - To prevent other people from getting hepatitis A when you are infected, practice good hand hygiene and do not return to school until 2 weeks after symptoms start - Vaccinations against hepatitis A are available for those at high-risk of getting hepatitis

13. Following a case of pediculosis in an urban primary school, as public health nurse in this area you prepare an education session for the pupils. Using the following headings, what information will you provide? Signs and symptoms Source of the disease and transmission Prevention and control

Signs and symptoms - Lice are tiny insects that live in human hairs and feed on tiny amounts of blood from the scalp - Lice are a very common problem in kids but it is not dangerous - Signs of head lice include: o Lice eggs (nits) that look like tiny yellow, tan or brown dots before they hatch and are on the hairs, close to the scalp - although they look like dandruff, they can't be removed by brushing or shaking them off o Adult lice and nymphs (baby lice) crawling on scalp o Itchy scalp and scratching Source of disease and transmission - Lice are contagious and can spread easily from person to person - Lice can spread through head-to-head contact, sharing items such as combs, brushes and hats - Spread by contact with inanimate objects and personal belongings may occur but is very uncommon. Head lice feet are specially adapted for holding onto human hair. Head lice would have difficulty attaching firmly to smooth or slippery surfaces like plastic, metal, polished synthetic leathers, and other similar materials. Adult head lice can live only a day or so off the human head without blood for feeding. Nymphs (young head lice) can live only for several hours without feeding on a human. Nits (head lice eggs) generally die within a week away from their human host and cannot hatch at a temperature lower than that close to the human scalp. http://www.cdc.gov/parasites/lice/head/gen_info/faqs.html - You can't get head lice from the fleas in your pet. Your pet also can't get head lice from people Prevention and control - Tell your parents or teacher if your scalp gets very, very itchy (??) - Special (medicated) shampoos, creams or lotions can be used to kill head lice. It may take a few days for the itching to stop - Lice can also be removed by hand using a fine-tooth comb every 3-4 days for 3 weeks - Avoid head-to-head contact with other kids when you have head lice and in general - Other family members may also need to be treated, since head lice spreads easily from person to person - Do not share combs, brushes, hats, scarves, hair ties, helmets, or other personal care items with anyone else, whether they may have lice or not - Do not lie on bedding, pillows and carpets that have recently been used by someone with lice

32. You are asked as a nurse working in Public Health to give a talk to a mixed community group about the risks and dangers of skin cancers. Outline the key points of your talk and discuss the types, causes, risks and preventative strategies.

Skin cancer is highly prevalent in New Zealand where we possess the highest rates per population in the world. There are 2 types of skin cancer: Melanoma and nonmelanoma Melanoma is the more serious form of skin cancer which leads to morbidity and mortality. Nonmelanoma is less serious is treated and is the more common form Causes: High UV levels in NZ result in increased UV radiation and in turn increases risk of sunburn which leads to skin cancer. This is what causes 90% of skin cancer in NZ Risks: Lighter natural skin colour Light hair colour (blond, red) Family and personal history Working or playing in areas with high sun exposure History of sunburn early on in life Skin that burns, reddens or freckles easily Blue or green eyes Males: 20% higher incidence rate Greater number of moles (certain moles/ large moles) Preventative Strategies: Wearing high SPF sunscreen whenever going outside in Summer or on sunny days. Reapplying sunscreen every 3-4 hours Wearing a hat in summer and on sunny days Wearing sunglasses as melanoma can occur in the eye (occular melanoma) Wearing long covered clothing to reduce skin exposure to the sun Going into the shade if in sun for long periods of time

24. Paul is a 7-year old Samoan boy who has been admitted for the third time within six months for Acute Bronchitis. He lives with his parents, 4 siblings and paternal grandparents in a 3-bedroom rented house. Both his parents are smokers and his father is the only earning member of the family. Draw a genogram and ecomap for this scenario and list the possible social factors that affect health related to this scenario

Societal Factors - Overcrowding 9 People living in a 3 bedroom house Increases speed of infectious disease Increases frustration and anxiety -> more at risk for violence - Second hand smoke Increased respiratory issues may correlate to development of childhood asthma - Low income Less likely to be taken to the GP May not be able to afford medications - Samoan Ethnicity Overcrowding is highest in NZ among Pacific ethnic groups - Rental housing Increased cost of rental housing -> now pay a larger proportion of income on housing -> limits ability of people to meet basic needs Social factors: Low income family with only one member of family (father) working, means that the family is less able to provide health-promoting activities for all members of the family. Both parents being smokers further reduces the amount of money in the family Overcrowding house with 8 people residing in a 3 bedroom house. Overcrowding, especially during winter months, causes high rates of upper respiratory tract infections. Overcrowding also leads to easier spreading of bacteria and viruses. A rented house is usually not insulated, as it is not a legal requirement and it saves money for the landlord. Poor insulation, cold and damp houses also contribute to this Poor access to health services: this family may only have one mode of transport which the family uses during the day to get to work, therefore may be unable to get access to appropriate health care services parents smoking: cigarettes irritate the bronchi, causing them to create excess mucous. This mucous traps bacteria and viruses, allowing them to colonise in the lungs. Cigarettes also damage the cillia in the bronchi, which usually help move out debris and mucous

11. Elizabeth Windsor, an 88-year-old woman, comes into the local medical centre where you work complaining of frequency, urgency and "little accidents" indicating urinary incontinence. Describe your assessment.

Subjective assessment - How long has she been having the symptoms (urinary incontinence)? - When does it occur? E.g. during the day, at night - conditions such as congestive heart failure can contribute to increased urination at night - How much urine is voided during "little accidents"? - Does anything trigger the "little accidents"? - Incontinence when coughing or exercise could indicate stress incontinence, which can be caused by problems with muscles in the bladder and/or urethra. Urge incontinence may cause little accidents due to a sudden urge to urinate and being unable to get to the toilet on time. - Does she have any pain when urinating? - Assess onset, location, duration, characteristics, alleviating/aggravating factors, treatment (what she's done to try and treat pain). Pain when urinating could indicate UTI due to inflammation of urethra - Has she noticed anything unusual about her urine? E.g. bad smell, less/more than usual per void - could indicate infection - Is she currently taking any medications? - Some medications can cause increased urination e.g. diuretics - How much fluid does she usually drink in a day and what type of fluid? Has this changed recently? - Increased fluid intake would increase urine production and voiding. Some types of fluids/drinks, such as coffee or tea, can increase urination Objective assessment - Assess urine: colour, smell, amount - Take urine sample - lab test to identify any organisms, RBCs and WBCs in the urine, which could indicate UTI - Assess level of consciousness and cognition - Signs of delirium (such as reduced LOC or impaired cognition) could indicate UTI in older people - Temperature: may be febrile secondary to UTI - Other conditions can cause increased urination, such as diabetes so assessing for this may also be useful Assess mobility - Gait, walking ability, use of walking aids etc. - can affect the ease by which Mrs Windsor can get herself to the toilet. This could possibly make urinary incontinence more difficult to manage (or could contribute to incontinence if she is not able to get the toilet quickly enough) and increases her risk of falls so it is important to assess mobility for safety. Assessing mobility also includes ability to independently go to the toilet (i.e. sitting on the toilet and getting back up, moving around in bathroom) Bladder scan: she might be retaining urine and not voiding full amounts, so a bladder scan would be useful pre and post voiding to see the leftover amount in the bladder

18. Jordan, a 15-year-old boy has come to see you as school nurse. He has been referred following a bullying incident, where he has been identified as the bully. Describe how you would approach assessing him.

The HEEADSSS assessment tool can be used to assess Jordan. This tool identifies major/important areas in the adolescent's life, which could give an indication of Jordan's psychological status, as well as give insight on his life (through his perspective) and the reasons for his actions (i.e. bullying). HEEADSSS stands for: Home, Education/employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety from injury and violence. During the assessment, although it is important to provide a positive tone to the interview (by focusing on what is going well for the adolescent) in order to build trust and act as a source of encouragement for the young person, in Jordan's case, his risk and protective factors should also be considered. Risk factors are factors that influence behaviour, which can then result in negative health outcomes. Behaviour that can result in negative outcomes in Jordan's case, is his bullying. Identifying risk factors in the assessment can help identify his reasons for bullying, which is a step towards changing this. By identifying protective factors, Jordan can become aware of these and use them to reduce negative health outcomes or promote positive outcomes. In addition, during the assessment, it is important to be non-judgemental and phrase questions to be neutral, so that Jordan does not feel threatened or defensive about his actions. Jordan should understand the concept and limitations of confidentiality for the interaction e.g. disclosure of intent to harm self or others.

33. You are asked as a nurse working in Youth Health to give a talk to a group of teenagers (Year 11to Year 13) about the dangers of "P" (Methamphetamine). Outline the key points of your talk.

The pleasure fades quickly thus leading to often repeated doses in a "binge and crash" pattern. Can easily lead to addiction - characterized by compulsive drug seeking and use People who use the drug long-term may experience anxiety, confusion, insomnia, and mood disturbances. They also show signs of psychosis, visual and auditory hallucinations, and delusions (for example, the sensations of insects crawling under the skin Psychosis "thought and emotions are so impaired that contact is lost with external reality." Chronic usage is accompanied by chemical and molecular changes in the brain. Changes in dopamine system that are associated with reduced motor skills and impaired verbal learning. Severe structural and functional changes also observed associated with emotion and memory, which may account for emotional and cognitive problems observed in these individuals. Some of these changes persist long after use is stopped although some changes may reverse after being off the drug for a prolonged duration (more than 1 year)

23. Mrs Thora Floyd-Brown is an 88 year old European with three co-morbidities namely, diabetes,cardiovascular disease and osteoarthritis. She was admitted to hospital following a fall in the garden. Thora recalls 'blacking out' when she was hanging out her washing, She sustained a number of superficial facial injuries and a fractured left neck of femur (# L) NOF). She currently weighs 45kgs. Outline the pathophysiology of frailty and nursing assessment for this syndrome.

The term frailty is used to describe a condition (common in old people) of impaired strength, endurance, balance, vulnerability to trauma and other stressors, high risk for morbidity, disability and mortality. Frailty - is an increased state of vulnerability resulting from age-associated decline in reserve and function across multiple physiologic systems, such that the ability to cope with everyday or acute stressors is compromised Assessment - Assess ability to perform ADLs - whether help is required or independent - Nutrition ability to prepare and to feed self - Hydration, drinking enough water/fluid? - Elimination, needs, how will this be managed? - Mobility, are they at risk of falls? -> Thora is at high risk of further falls after breaking her NOF What medications are they on and do these medications increase their falls risk? - Falls (e.g. blood pressure lowering, beta-blockers) - constipation (e.g. opioids for pain relief can cause constipation - haemorrhage in injury (e.g. antiplatelet such as warfarin) Cognitive function -> particularly after having a fall and sustaining facial injuries it is necessary to assess Thora's neurological status for any abnormalities Skin integrity - post surgical pressure area assessment regularly (hourly) Living arrangements e.g. living alone, helper at home e.g. partner or child. And support networks (friends and family vs isolation)

3. A mother asks your advice about immunising her 13-year-old daughter Susan with the cervical cancer vaccine. Outline your response

This vaccine is called Gardasil and is free for girls at your daughter's age (up to 20 years old) It is given in 3 doses in the upper arm spaced out over 6 months The vaccine will help prevent infection from 4 types of Human papillomavirus. 2 of these types cause 70% of cervical cancers The vaccine also helps prevent some rare cancers that are also caused by HPV and protects against 90% of genital warts. The vaccine causes the body to create its own protection against the 4 types of HPV It contains tiny proteins that mimic the virus but cannot cause infection. You cannot be infected by HPV from the vaccine. Protection is expected to be long lasting If a person has HPV, it can be transmitted to their baby during birth The girl should get it even if she is not planning to have sex, as it is only free up to 20 years of age and it is important for prophylaxis However, if a girl does have it, it does not mean that unprotected sex is ok, protected sex is still required to protect against other sexually-transmitted diseases and infections The vaccine does not immunise against all types of HPV, so women should still get regular cervical screening every 3 years from the age of 20 Studies have indicated that the immune response from the vaccine is greater in the 9-15 age group and therefore the vaccine is potentially more effective in creating these antibodies if the vaccine is given in the younger ages hence the reason behind the vaccine being recommended from 12 years.

27. Tom Cruiser, is a 74 year old of European descent. You visit him following a short admission to hospital after a stroke. Mrs Cruiser asks you why her husband's sodium level has dropped. You look to the prescription card and find that he is taking Frusemide 80mg mane and 40mg at noon and some Potassium daily. What do you think has happened and describe your plan of action?

Tom Cruiser may have an incorrect prescription of Frusemide Plan of action: Review dosage of Frusemide, Fluid balance intake and outake, review diet to higher sodium content, get some saline prescribed lel It is known that certain medications such as frusemide which is a loop diuretic can cause diuretic induced hyponatraemia. Loop diuretics inhibit sodium chloride reabsorption and therefore is removed along with water. Tom is 74 years of age, Older age can often be a reason hyponatraemia occurs due to age related changes to how fluid and electrolytes are distributed throughout the body. Frusemide is known to reach its peak effect within 1-2 hours of administration however it remains active for up to 6-8 hours. It can be seen that Tom is taking a dose of 80mg mane and then just 3 hours later having another dose at 1200. This means that the first dose of frusemide is still active within the body resulting in excessive diuresis of water and sodium. For hypertension; a common cause of stroke, the recommended dose is 80mg/daily split into 2 x 40mg doses no less than 6 hours apart. Tom is exceeding the recommended dose. Action: Review dosage and appropriateness of medication. Monitor fluid balance, input and output to determine hydration status FBC + U/E to look at electrolyte status.

6. Ben 18 months, has been admitted to a day stay surgical centre for myringotomy and insertion of grommets for recurrent otitis media. What are the potential health and social issues underpinning chronic ear infections for this age group?

Usually caused by bacteria and often begins after sore throat, cold or upper respiratory tract infection. Eustachian tubes smaller in children than in adults-makes it difficult for fluid to drain out of the ears A child's immune system is not as effective as an adult's as it is still developing-harder to fight off infections Children-as part of immune system adenoids respond to bact. passing thru the nose & mouth sometimes bact. get trapped in the adenoids causing chronic infection that can then pass on to the Eustachian tube and the middle ear. Chronic ear infections can cause permanent damage to middle ear structures which can lead to permanent hearing loss. Can spread from middle ear to the mastoid cells which is a very unfavourable complication Chronic infection of the middle ear can result in effusion due to cellular changes that arise from the closure of the eustachian tube ( goes from being an epithelial cell to secretory cells --the cause of effusion) Over time the secretions become very thick and tenacious and may result in a drop of 20-40 decibels in hearing. Grommets allow air to access middle ear to prevent it from being fluid filled Most children have ~6 months of conductive hearing loss and it normally reverts back to normal (acute otitis media) Hearing loss from damage to the middle ear may slow language and speech development but is more likely if both ears are affected. --both ears will be affected if chronic otitis media since it is bilateral in nature. If left untreated, it can hinder development, employment and opportunities in the future Hearing is important for language development. Children learn language and communication by hearing what others say, and imitating what they hear. Exposure to conversation and and being read to also assists with language development. Hearing loss due to chronic ear infections can significantly impact on language development, as the child is less able to receive information for learning, and will be less able to participate in conversations. Social issues: Poor housing that is damp and cold can cause upper respiratory tract infections in infants and young children. URTI also lead on to cause infections in the ear as bacteria from the throat can spread into the middle ear. If a child is constantly around parents or members of family that smoke it can increase risk of recurrent ear infections as smoke is a respiratory irritant.

34. You are asked as a nurse working to give a talk to a community group, including pregnant women about the risks and dangers of listeria. Outline the key points of your talk and discuss the causes,risks and preventative strategies.

What is Listeria? Listeria monocytogenes is a type of bacteria occasionally found in some foods which can cause a rare but dangerous infection called listeriosis. This infection can be especially serious for pregnant women because if Listeria is transmitted to your unborn baby it can lead to serious complications including miscarriage, premature labour, or stillbirth. The bacteria naturally occurs in the environment (such as in soil and water). Listeria is killed by pasteurization and cooking. Why is Listeria such a problem in some foods? One of the major concerns with Listeria, as opposed to most other food poisoning bacteria, is that it is able to grow at refrigeration temperatures. There are certain foods which are at a higher risk of becoming contaminated with Listeria due to the way they are processed, or the extensive handling they undergo. Risks Pregnant women are at a higher risk of becoming infected with Listeria than your average healthy adult, and the outcomes for your baby can be bad. However, the risk should be kept in context and you should make sensible choices in the food you eat, rather than stressing - which could be worse for the development of your baby One of the highest risk food groups for listeriosis are pre-sliced deli meats and ready-to-eat (RTE) chicken and poultry. Slicing, dicing and shredding of RTE meat products are high risk operations for contamination of these products with Listeria, as it likes to live in the small hard to reach areas of this type of equipment particularly where is a bit of moisture and food particles. Soft cheeses are exposed during the manufacturing process, increasing the chance of contamination by Listeria, and the pH of the cheese is quite high, allowing Listeria to grow during the shelf life of the product if it is there Although refrigerated pâté and meat spreads are fully cooked but require refrigeration. The risk occurs at the point between cooking and packaging, where there may potentially be opportunities for Listeria to contaminate the product. Preventative strategies Sliced deli meats can be safely consumed if they are reheated until they are steaming hot. Choose hard cheeses instead of soft ones. Hard cheeses are quite acidic so that harsh environment means that if any Listeria organisms were present, they will actually die off during the shelf life. Avoid refrigerated, ready-to-eat foods that may have been stored for long periods and look to consume freshly prepared foods wherever possible

29. What are the key public health messages that will improve oral health in children?

causes of tooth decay and the mechanism of disease, relating it to the prevention points prevention of tooth decay: brushing teeth properly and regularly (because it reduces the amount of germs in the mouth), avoiding sugary and acidic food and drinks (because sugar causes teeth to rot), visit your dentist every year regardless (so that any early signs of rotting are noticed and fixed), using fluoride toothpaste and drinking fluoridated tap water (to make teeth stronger) result of tooth decay: tooth loss, unable to eat, unable to grow properly. Outline the parental role in ensuring that their child brushes their teeth every morning and evening. Teeth brushing can be done with the child if possible as it is a way of role-modelling. Parents should be discouraged from buying sugary foods and acidic drinks, and be given a list of items they should avoid. In doing so, it must be acknowledged that these offending foods are often cheaper and they are not entirely to blame when it comes to their unhealthy food choices. Parents should need to be made aware of the free dental care for children under 18 that is available in New Zealand, which reduces the barrier of cost. Other barriers such as transport or time could be addressed by making them aware of the school's dental nurse. Make parents aware of the function of flouride, and where it is found (eg tap water and toothpaste). For parents, the future impact of tooth decay should be outlined, such as the negative effect on growth and development, quality of life, and subsequently the family, and the next generation, not to scare them, but to emphasise the importance of good oral health.