D118 Unit 3 Study Guide

D118 Unit 3 Study Guide

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Western Governors University

D118 Adult Primary Care for the Advanced Practice Nurse

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D118 Unit 3 Study Guide

Module Vocabulary Key Questions

Managing In-Office Health Emergencies

What are the most commonly encountered office emergencies?

The most frequent emergencies encountered in family practice offices include asthma exacerbations, anaphylaxis, shock, seizures, and cardiac arrest. These conditions require immediate recognition and prompt intervention to prevent severe complications or fatalities.

What emergency supplies (equipment and medications) are recommended for family practice offices?

Recommended Emergency Equipment

Recommended Emergency Medications

Anaphylaxis

How is anaphylaxis clinically presented, examined, and treated?

Anaphylaxis varies in presentation and severity. Reactions can be uniphasic or biphasic, occurring minutes to 10–12 hours after exposure. Protracted reactions may persist for 24 to 72 hours and can range from mild pruritic rashes to severe systemic symptoms.

Clinical History and Assessment

Gather detailed patient information, including:

• Past medical history and comorbidities

• Recent domestic or international travel

• Exposure history to allergens, including foods, drugs, insect stings, or environmental factors

• Presence of risk factors such as pre-existing allergic conditions

• Symptom onset and severity

• Medications or supplements currently taken

• Vaccination history

• Timing, location, and duration of the event

Laboratory and Diagnostic Evaluation

• Pulse oximetry for oxygen saturation

• Arterial blood gases (ABG)

• Electrocardiogram (ECG)

• Serum glucose to rule out hypoglycemia

• Additional tests such as plasma histamine levels and serum tryptase to confirm mast cell activation

• Chest X-ray if indicated

Treatment

Administer intramuscular epinephrine (0.2 to 0.5 mg), preferably into the lateral thigh, followed by continuous monitoring of vital signs focusing on airway, breathing, and circulation (ABCs).

Bites and Stings

What are the clinical presentation, examination findings, and treatments for bites and stings from animals, ticks, spiders, mosquitoes, and parasites?

Physical Examination

Initial evaluation should prioritize airway, breathing, and circulation, especially assessing for anaphylaxis. The affected area must be inspected for envenomation severity and secondary infections.

Treatment

Immediate systemic reactions require epinephrine administration as described above. Local care includes:

• Removal of stingers (when applicable)

• Cleaning the wound with soap and water

• Application of ice packs

• Use of antihistamines (H1 and H2 blockers) for itching

• Topical steroids for inflammation

• Antibiotics for secondary infection prevention

• NSAIDs for pain relief

• Eradication of the offending insect

Specific Types of Bites

Cardiac Arrhythmias

What are the clinical presentations, examinations, and management approaches for cardiac arrhythmias?

General Considerations

Emergency hospital transportation is necessary for arrhythmias causing hemodynamic instability, acute myocardial infarction (MI), or ischemia. Immediate cardiology referral is essential for new onset arrhythmias, suspected structural heart disease, or uncontrollable symptoms.

Tachyarrhythmias

Clinical Presentation

Patients may experience palpitations, dizziness, syncope, dyspnea, or fatigue—the latter being most common in atrial fibrillation (AF). Symptoms arise due to irregular ventricular rates, loss of coordinated atrial contraction, and sympathetic activation. Severe cases can lead to hypotension, chest pain, heart failure, altered consciousness, or sudden cardiac death.

Management

Treatment focuses on stabilizing hydration, oxygenation, electrolytes, and minimizing stress. If caused by toxins, antidotes or clearance are essential. Long-term antiarrhythmic therapy should be personalized. Any new atrial fibrillation requires cardiology evaluation.

Bradyarrhythmias

Clinical Presentation

Symptoms include irritability, fatigue, dizziness, syncope, confusion, and congestive heart failure signs. Cognitive changes such as forgetfulness and apathy can also occur.

Management

Identify and remove causative factors including medications (beta blockers, calcium channel blockers, digoxin, clonidine, opioids). Atropine is the first emergency drug to increase atrial rate, with pacing as backup. Referral guidelines include:

• Stable patients with no treatable cause: cardiology referral

• Patients with syncope, symptoms, or ventricular rate <40 bpm: emergency transfer to ED

Physical Examination of Arrhythmias

Evaluation includes blood pressure, pulse, temperature, mental status, diaphoresis, respiratory effort, and anxiety signs. Orthostatic vitals help exclude orthostatic hypotension, dehydration, or hypovolemia, which might cause reflex tachycardia needing urgent intervention.

Patient Hydration and Cardiovascular Examination

The assessment of a patient’s hydration status involves examining skin turgor and mucous membranes for signs of dehydration or fluid imbalance. Evaluating the neck includes inspection for jugular venous distention (JVD), which can indicate heart failure, and the presence of a goiter, which may suggest thyroid disorders. Observing the neck vasculature may also provide insight into atrial activity.

Palpation of carotid pulses is essential to assess their amplitude, contour, timing, and to detect any thrills. Auscultation of the carotid arteries is performed using the stethoscope’s diaphragm to identify higher-frequency arterial bruits and the bell for low-pitched sounds associated with significant stenosis.

Heart auscultation focuses on detecting the regularity and rate of heartbeats, murmurs, clicks, or extra heart sounds. During examination, overall patient appearance is important to evaluate for discomfort, restlessness, dyspnea, or distress. Lung auscultation checks for rales, wheezes, or rhonchi, and the presence of cyanosis.

Additionally, physical signs of thyroid dysfunction such as exophthalmos, lid lag, enlarged or nodular thyroid gland, and skin, nail, or hair changes should be noted. For patients presenting with syncope, dizziness, confusion, or altered consciousness, a neurological examination helps rule out non-cardiac causes.

Diagnostic Tools for Cardiac Arrhythmias

Several diagnostic modalities are used to detect and monitor cardiac arrhythmias:

Clinical Presentation and Treatment of Acute Bronchospasm

Acute bronchospasm requires urgent evaluation. Immediate emergency department referral or physician consultation is recommended if patients exhibit respiratory distress, oxygen saturation below 92% on room air, failure to improve after multiple nebulizer or epinephrine treatments, or peak expiratory flow less than 80% predicted.

Symptoms range from mild anxiety to severe respiratory difficulty and may arise spontaneously or be triggered by allergens or infections. Common clinical signs include wheezing, breathlessness, chest tightness, and coughing. Skin color may vary from normal to pale or flushed, with additional signs like pruritus, rash, tachypnea, tachycardia, and slightly elevated blood pressure. Hypotension signals anaphylaxis, and pulsus paradoxus indicates severe respiratory compromise.

Treatment primarily involves supplemental oxygen and inhaled short-acting beta2-agonists (e.g., albuterol, levalbuterol). Additional therapies include anticholinergics such as ipratropium bromide and systemic corticosteroids (e.g., prednisone).

Managing Hypotension, Syncope, and Hypovolemic Shock

Hypotension occurs due to dysfunction in one or more of the following: vascular muscle tone, intravascular volume, and cardiopulmonary function. Evaluation includes monitoring vital signs, ECG, serum hemoglobin, electrolytes, renal function tests, and occult blood in stool. In women of childbearing age, pregnancy testing is crucial to rule out ectopic pregnancy.

Syncope must be differentiated from seizures or altered consciousness due to medications, intoxication, or metabolic causes. Syncope is classified as neurally mediated, orthostatic, or cardiac in origin. Diagnostics are aimed at excluding cardiovascular obstruction, transient ischemic attack, pulmonary embolism, arrhythmias, and hypovolemia. During an episode, the patient should be placed supine, with loosened clothing and the head turned to prevent aspiration.

Hypovolemic shock management targets maximizing oxygen delivery, controlling hemorrhage, and fluid resuscitation.

Sepsis and Septic Shock: Risk Factors, Symptoms, and Management

Sepsis involves a systemic inflammatory response to infection and may progress to severe sepsis, septic shock, and multi-organ dysfunction syndrome (MODS). Risk factors include immunosuppression (e.g., steroids, cancer, HIV), chronic illnesses (e.g., diabetes, liver or renal disease), prosthetic devices, advanced age, and prior exposure to infectious agents.

Symptoms typically include fever, hypotension, rapid breathing, increased heart rate, leukocytosis, and elevated inflammatory markers such as C-reactive protein (CRP).

Treatment priorities begin with airway, breathing, and circulation (ABCs), followed by fluid resuscitation with central venous pressure monitoring, early administration of broad-spectrum antibiotics within one hour, tight glycemic control, and corticosteroids if indicated.

Phases of Emergency Management

The Federal Emergency Management Agency (FEMA) categorizes emergency management into four interconnected phases:

1. Mitigation: Efforts to reduce disaster impact through structural and policy measures, such as flood-resistant construction and fire safety protocols.

2. Preparedness: Planning and readiness activities, including developing emergency response plans, stockpiling essential supplies, and training responders.

3. Response: Immediate actions during a disaster to save lives and protect property, including search and rescue, medical aid, and evacuation.

4. Recovery: Long-term activities to restore and improve community infrastructure, provide ongoing support, and enhance resilience to future events.

Acute Illnesses of the Eye, Ear, Nose, and Throat (EENT)

Eye Disorders: Hordeolum, Blepharitis, and Chalazion

Anterior blepharitis affects the front eyelid margin near eyelashes, often due to staphylococcal infection or seborrhea. Posterior blepharitis involves the meibomian glands and may associate with rosacea. Both forms disrupt the ocular surface, potentially causing dry eye and predisposing to hordeola or chalazia.

A hordeolum is an acute, painful infection of an eyelid gland presenting with erythema and swelling. Without treatment, it may progress to a chalazion, a chronic, painless, sterile granulomatous lesion of the meibomian gland.

Treatment emphasizes lid hygiene through warm compresses, lid scrubs (e.g., diluted baby shampoo), and antibiotic ointments like erythromycin. Artificial tears help alleviate dryness.

Conjunctivitis: Types and Management

Infectious conjunctivitis is viral or bacterial, while noninfectious types arise from allergies or irritants.

• Viral Conjunctivitis: Characterized by red eyes with watery discharge and follicles on the conjunctiva; self-limited, treated supportively.

• Bacterial Conjunctivitis: Presents with thick purulent discharge, sticky eyelids, often worse in the morning; antibiotics are reserved for persistent cases.

• Allergic Conjunctivitis: Features itching, clear discharge, and periorbital changes such as “allergic shiners”; treated with antihistamines and supportive care.

• Vernal and Atopic Conjunctivitis: More severe, often in children, presenting with intense itching, thick discharge, and cobblestone papillae; treated with mast cell stabilizers.

Corneal Surface Defects and Foreign Bodies

Corneal defects occur when the epithelium is disrupted by trauma or chemical exposure, common among contact lens users and certain occupational hazards. Symptoms include severe eye pain, blurred vision, redness, tearing, photophobia, and blepharospasm.

Diagnosis utilizes fluorescein staining viewed under cobalt blue light, highlighting abrasions or foreign bodies. Foreign body injuries are preventable with proper eye protection.

General Eye Examination Components

A thorough eye exam assesses:

• Visual acuity and pupil reaction to light.

• Eyelid swelling and conjunctival injection.

• Corneal clarity and the presence of haze or opacities.

• Anterior chamber depth and signs of inflammation or penetrating injury.

• Urgent referral is required for signs such as hypopyon, anterior chamber flattening, irregular pupil, or penetrating trauma.

Eye Conditions Warranting Ophthalmology Referral

Urgent referral is indicated for acute eye pain, decreased vision, or photophobia. Chronic, uncontrolled red eye or suspected herpetic infections also warrant evaluation. Specific conditions requiring referral include persistent conjunctivitis beyond 4–7 days, pterygium impairing vision, unresolved subconjunctival hemorrhage, corneal abrasions with complications, and any globe puncture.

Common Eye Conditions: Signs and Treatments

Common ENT Conditions: Clinical Features and Management

Tinnitus presents as ringing or buzzing, possibly bilateral or unilateral. Management includes eliminating ototoxic drugs, hearing aids, cognitive behavioral therapy, and sometimes medications like Ginkgo biloba or melatonin.

Otitis Externa manifests with ear pain, canal swelling, and discharge. Treatment involves careful canal cleaning and topical antibiotics (e.g., Ciprodex, ofloxacin). Analgesics are used for pain control.

Otitis Media features ear pain, fever, and a bulging tympanic membrane. Pain relief and antibiotics (e.g., amoxicillin) are standard. Complicated cases may involve purulent discharge if perforation occurs.

Otitis Media with Effusion causes hearing loss and a feeling of fullness. It often resolves spontaneously, but nasal decongestants, antihistamines, and nasal steroids may be used.

Allergic Rhinitis includes nasal itching, sneezing, congestion, and pale mucosa. Treatment involves antihistamines, nasal steroids, and avoiding allergens.

Acute Bacterial Rhinosinusitis presents with facial pain, purulent nasal discharge, and fever. Antibiotics and supportive care are indicated.

Chronic Rhinosinusitis, Pharyngitis, and Influenza have variable presentations but require symptomatic management and specific antiviral or antibiotic therapy as appropriate.

Ophthalmology Same-Day Care Indications

Emergent ophthalmology referral is needed for acute eye pain, sudden visual changes, severe photophobia, trauma, or evidence of infections with potential for rapid deterioration.

Ocular Foreign Body Removal: Procedure and Precautions

Fluorescein staining helps identify corneal abrasions or foreign bodies. Preparation includes confirming the patient is not wearing contact lenses and applying topical anesthetic drops. Care is taken to avoid patient touching the eye while anesthetized to prevent corneal injury.

Upper eyelid eversion is critical for locating hidden foreign bodies or injuries. After removal, the eye is irrigated, and follow-up care or referral is arranged as needed.

Ear Foreign Body Removal: Indications and Procedure

Foreign objects lodged in the ear canal must be removed to prevent infection or tympanic membrane damage. Contraindications include tympanostomy tubes, recent ear surgery, or perforated membranes.

Precautions include avoiding water if vegetable matter is present, as it may swell. The procedure involves careful history-taking, visual inspection, and gentle extraction, with patient comfort monitored throughout.

Cerumen Disimpaction and Tympanometry

Cerumen removal is indicated when blockage causes symptoms such as hearing loss or discomfort, with contraindications similar to ear foreign body removal.

Tympanometry assesses tympanic membrane mobility and middle ear function and is contraindicated in young infants or active otitis externa. Preparation includes patient reassurance and sometimes restraint for younger children.

Audiometry and Nasal Procedures: Emergency Considerations

Audiometry evaluates hearing loss and should be performed in appropriate clinical settings.

Urgent ENT consultation is needed in cases of periorbital edema, diplopia, severe epistaxis, high fever, or neurological signs.

Nasal Packing and Foreign Body Removal in the Nose

Nasal packing is indicated for severe epistaxis, with careful attention to contraindications and patient comfort. Foreign body removal requires appropriate visualization and technique to avoid trauma.

Dental Trauma: Post-Tooth Avulsion or Fracture Management

Teeth avulsed or fractured should not be handled if facial fractures or socket lacerations are suspected. Proper preservation of the tooth involves storing in suitable media (e.g., milk or saline) rather than tissues. Immediate referral to dental specialists is essential.

References

• American Academy of Family Physicians. (2022). Clinical guidelines for in-office emergencies and management of acute illnesses.

• Federal Emergency Management Agency. (n.d.). Emergency management phases. FEMA.gov.

• Mayo Clinic. (2023). Eye conditions: Diagnosis and treatment.

• UpToDate. (2024). Cardiac arrhythmias: Diagnosis and management.

• American College of Emergency Physicians. (2023). Sepsis and septic shock management guidelines.

• Centers for Disease Control and Prevention. (2023). Management of otitis media and otitis externa.

• National Institutes of Health. (2023). Allergic rhinitis and sinusitis: Diagnosis and treatment.

• American Academy of Ophthalmology. (2024). Corneal abrasions and foreign bodies.

• American Academy of Family Physicians. (2020). Office-based emergency preparedness. Retrieved from [AAFP resources]

• Lieberman, P., & Camargo, C. A. (2019). Anaphylaxis: Clinical aspects and diagnosis. The Journal of Allergy and Clinical Immunology, 144(3), 594–602. https://doi.org/10.1016/j.jaci.2019.04.017

• Centers for Disease Control and Prevention. (2021). Tickborne diseases of the United States. https://www.cdc.gov/ticks/diseases/index.html

• Blee, T., & Mir, M. (2018). Management of black widow and brown recluse spider bites. Emergency Medicine Clinics, 36(2), 355–368.

• Zimetbaum, P., & Josephson, M. E. (2017). Evaluation and management of arrhythmias. Circulation, 135(3), 258–276.