THE APN ROLE IN SAFETY AND PROTECTION ACROSS THE LIFESPAN

1
THE APN ROLE IN SAFETY AND PROTECTIONACROSS THE
LIFESPAN

• BY
• ANN TER HORST
• DEB LEIBEL
• SUE HANDKE

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INTRODUCTION TO SAFETY AND PROTECTION
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INTRODUCTION TO POLYPHARMACY

• DEFINITION The concurrent use of multiple
  prescription drugs and over-the counter
  medications
• -Healthy People 2000

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ADVERSE DRUG REACTIONS (ADR)

• Classified as any unwanted response to a drug
• Account for 10-30 of acute hospital admissions
• 1 in 1000 hospital deaths are a result of ADR
• In spite of these statistics, writing a
  prescription is the most common therapeutic
  intervention in medicine

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VITAL STATISTICS

• People over 65 represent 12.6 of the US
  population
• People over 65 consume 35 of prescription meds
  50 of nonprescription meds
• The risk of drug-drug interaction near 50 with 5
  meds, 100 with 8 meds
• Estimated rate of noncompliance in the elderly is
  30-75

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FACTORS INCREASING THE RATE OF ADRs IN THE
ELDERLY

• Multiple coexisting diseases
• Several providers prescribing therapies
• Patients self-medicating
• Lack of patient education
• Use of multiple pharmacies
• Pill for every ill syndrome
• Age-related physiologic changes

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PHYSIOLOGIC CHANGES

• Absorption -movement of a drug from the site of
  administration to the blood stream
• Distribution -movement of a dug throughout the
  body
• Metabolism occurs primarily in the liver
• Elimination occurs primarily through the kidney

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IMPLICATIONS FOR THE APN IN DRUG THERAPY
MANAGEMENT

• Include the patient in decision making
• Each contact review drug history -include OTC
  alternative therapies
• KEEP IT SIMPLE
• Maintain a high index of suspicion regarding ADRs
• Educate, Educate, Educate!!!

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SOUTH DAKOTAS MEDICATION REDUCTION PROGRAM (MED
RED)

• 289 participants in SD from rural and urban
  regions
• After 3 months 82 discussed meds with Dr., 41
  reported less meds after this
• 80 credited the program with easing their med
  regimen
• Average amount spent per month down from 100 to
  70 after participation

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INTRODUCTION TO LEAD POISONING

• Standard classification for lead poisoning is a
  venous blood level of 10ug/dL or above

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ITEMS OF INTEREST

• Lead poisoning is one of the most common and
  preventable health problems today
• Between 75-80 of privately owned homes built
  before 1980 contain lead based paint
• Not discriminatory against race, religion,
  gender, or economic status
• 1 in 6 children under 6 years old have elevated
  lead levels in the US, SD is unknown

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• Kids learn by exploring with their mouths, kids
  absorb up to 50 of lead ingested
• If caught early, harmful effects can be reduced

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COMMON SOURCES OF LEAD EXPOSURE

• Lead based paint, most common
• Lead dust
• Lead based plumbing fixtures
• Ceramics, pottery, crystal, fishing wts., old
  batteries
• Leaded gasoline used in older cars

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S/S OF LEAD POISONING

• Ataxia
• Hearing loss
• Diminished LOC
• ADD/ behavior problems

• Fatigue/insomnia
• Stomach pain/ constipation
• Mental retardation

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A CALL TO ACTION FOR THE APN

• Screen with each well child visit
• Provide anticipatory guidance
• Obtain venous sample interpret results
• Appropriate follow-up
• Parent education

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PATHOPHYSIOLOGIC EFFECTS OF LEAD POISONING

• Entry via the mouth
• Stored in the bone
• Decreased hemoproteins in nervous system gt poor
  development of neurons, axons glia
• Biosynthesis of HgB disturbed gt anemia

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• Liver detoxification impaired
• Bit D synthesis disrupted gt renal endocrine
  problems

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LONG TERM CONSEQUENCES

• Developmental problems
• Poor Academic Success
• Decreased Cognitive Functioning
• _________________________________
• Profound amount of health care

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INTRODUCTION TO ACCIDENTAL POISONING
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NATIONAL VITAL STATISTICS

• 2,092,088 poison exposures reported in 1997
• Average of 8.8 per 1000
• A child is accidentally poisoned every 3 seconds
• Approx one million children per year
• More than 50 occur _at_ home

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THE 2 MOST COMMON SUBSTANCES

• Acetaminophen represents 70 or over 94,000

22

• Alcohol represents 15 in children lt 6yrs, over
  36,000

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MANAGING A POISONED PATIENT

• When in doubt, call 1-800-POISON-1
• Stabilize
• Coma Cocktail
• Get a history
• Physical exam /additional studies
• Decontamination

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APNs ROLE

• When in doubt, call 1-800-POISON-1
• Anticipatory guidance
• Enc parents to keep a bottle of Ipecac syrup at
  home
• Enc child proofing the home

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INTRODUCTION TO SEAT BELT SAFETY

• Traffic crashes leading cause of death between
  ages of 1-34
• 1996 estimated 31.2 of SD _at_ risk r/t lack of
  seat belt use
• When used properly, 45 reduced fatal injury
  50 reduced moderate-critical injury

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PRESIDENTIAL VITAL STATISTICS

• 1996 SEAT BELT USE WAS 68
• By 2000, goal of 85 seat belt use
• q 14 seconds injury in a traffic crash
• q 12 minutes a fatality in a traffic crash
• Unbelted motorist can be killed when going as
  slow as 12 mph

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1997 SOUTH DAKOTA VITAL SATISTICS

• of reported crashes 20,899
• of crash injuries 8,161
• of fatalities from crashes148
• of occupants in cars killed 132, only 26
  wearing seat belts
• Amounts of motor vehicle property damage79
• Economic loss from traffic crashes 302 million

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SAFE KIDS COALITION

• Each year approx 1800 kids under 14 killed in the
  US
• SD in 1997, 2 unrestrained kids killed vs 0
  restrained
• Each yr more than 280,000 kids injured
• When used correctly reduced fatality risk by as
  much as 71
• 4 out of 5 car seats are used incorrectly

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GENERAL REGULATIONS FOR SAFE CAR SEAT USE IN KIDS

• In the back seat until after age 12
• Infants to 20 or 1 yr must be rear-facing
• Over 40, use booster seat
• Once the lap and shoulder belts fit, use these

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HEATH CARE COSTS AND SAVINGS

• q spent on child car seat saves US 32
• Trend more seat belt use gt less injuries gt less
  health care spent
• Seat belt use is the most effective way to
  decrease injuries and fatalities in motor vehicles

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THE ROLE OF THE APN

• Role model - USE your seat belt
• Anticipatory guidance with each well child
  check-up
• Instruct parents on proper car seat safety
• Enc parents to take advantage of car seat
  check-ups locally

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SEAT BELT LAWS

• 2 Types of Enforcement Laws
• Primary officers can write citations for seat
  belt violation alone
• Secondary officers must stop motorists for
  another violation, seat belt incidental
• SD under secondary enforcement

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BICYCLE SAFETY

• Bicycle crashes are one of the most frequent
  causes of injury-related deaths in young children
• In 1996, 761 bicyclists were killed,
  approximately 59,000 were injured in traffic
  related crashes. Children 14 and under account
  for 29 of these fatalities
• 400,000 children, 14 and under are treated in ER
  for bike related injuries

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• Bicyclists age 14 and under are at a 5 times
  greater risk for injury than older cyclists
• 70-80 of all fatal bicycle crashes involve head
  injury, only 18 of all bicyclists wear helmets
• Bicycle helmets are 85-88 effective in
  preventing head injuries
• Estimated cost of bicycle related injuries and
  deaths (for all ages) is 8 billion each year.
  Plus these injuries can endure through a persons
  lifetime

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• Every dollar spent on a bike helmet saves society
  30 in direct medical costs and other costs to
  society
• If 85 of all child cyclists wore bicycle
  helmets in one year, the lifetime medical cost
  savings could total between 109 million and 142
  million

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RECOMMENDATIONS FOR BICYCLIST

• Wear a helmet
• See and Be Seen
• Follow the Rules

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APN ROLE

• Advocate for helmet use
• Provide education in the schools and community

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CRIB SAFETY

• The U.S. Consumer Product Safety Commission
  reports that more than one child dies in an
  accident involving a crib every single week
• Only cribs made after 1991 are likely to meet all
  current safety standards

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THINGS TO REMEMBER WHEN BUYING A CRIB

• Slats no wider than 2 3/8 apart
• End posts not to extend above end panels by 1/16
• Mattress should fit snugly with no more than two
  finger widths between the edge of the mattress
  and crib
• Drop side latches must be safe from accidental
  release
• No cutout areas on the head or foot board

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OTHER BABY EQUIPMENT

• Playpen
• Hinges -easy for adult, impossible for child
• Mesh siding should be fine- to prevent fingers
  from poking through
• Check built-in toys for safety
• Baby walkers are extremely dangerous and are not
  recommended
• Baby swing- use only with supervision

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APN ROLE

• Anticipatory guidance
• Education

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SUDDEN INFANT DEATH SYNDROME (SIDS)

• Definition SIDS is the diagnosis given for the
  sudden death of an infant under one year of age
  that remains unexplained after complete
  investigation. Because most cases of SIDS occur
  when a baby is sleeping in a crib, SIDS is
  sometimes called crib death.

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• SIDS is the leading cause of death in infants
  between 1month and 1 year of age
• Most occur between 1 and 4 months
• African American babies are 2 -3 times more
  likely than white babies to die of SIDS
• Native American babies are about 3 times more
  susceptible
• More boys are SIDS victims than girls
• --National Institute of Child Health and
• Human Development

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RISK FACTORS FOR SIDS

• Babies who sleep on their stomachs
• Mothers who smoke during pregnancy are three
  times more likely to have a SIDS baby
• Passive smoking around baby doubles a babys risk
  for SIDS
• Mothers who are less than 20 years old at the
  time of their first pregnancy
• Babies born to mothers who had no or late
  prenatal care
• Premature or low birth weight babies

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RISK REDUCTION MEASURES

• Good prenatal care, includes good nutrition and
  no alcohol
• Create smoke-free environment, during pregnancy
  and after birth
• Healthy babies should sleep on their back
• Have baby sleep on a firm mattress
• Avoid bed-sharing
• Babies should be kept warm, but not too warm
• Breastfeed if possible
• Regular well baby check-ups and immunizations
• There is no evidence that electronic home
  monitors can prevent SIDS

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• SIDS is not contagious
• SIDS is not caused by immunizations
• SIDS is not caused by child abuse
• SIDS is no ones fault

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APN ROLE

• Anticipatory guidance
• Education
• Community Involvement

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ADOLESCENT SAFETY

• Suicide is the third leading cause of adolescent
  death in the U.S. with a 150 increase among 15
  to 24 year olds from 1960 -1989
• Females are four to five times more likely than
  males to attempt suicide, but males are four
  times more likely to die
• Approximately 500,000 attempt suicide every year

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RISK FACTORS

• History of severe emotional problems
• Depression
• Talk or suicide or a previous suicide attempt
• A family history of suicide
• Preoccupation with death
• Substance abuse
• Absence of social ties
• Recent breakup of a strong relationship

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APN ROLE

• Help adolescents make healthy choice
• Help communities create healthy environments for
  teens
• Serve as a caring adult role model
• Provide prevention guidance
• Be a good listener

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ELDERLY SAFETY

• By the year 2000 it is estimated 34.7 million
  Americans will be over age 65
• Falls are the 6th leading cause of death among
  people over age 65
• Fractures from falls are leading cause of
  disability in this age group

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FACTORS INCREASING RISK OF FALLING IN ELDERLY

• Loss of muscle strength
• Medications
• Alcohol
• Dementia

• Arthritis
• Osteoporosis
• Poor vision (cataracts
• Poor mobility
• Poor posture

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APN ROLE

• Assessment and early diagnosis of underlying
  health problem
• Encourage home safety assessment
• Appropriate referral when needed (i.e.to
  Geriatric Health Institute)

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CHILD ABUSE

• DEFINITION The willful injury as a result of
  the acts or omissions of a person responsible for
  the care of the child

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CHILD ABUSE FACTS

• In America every day 8,470 children are reported
  abused or neglected.
• In South Dakota every 58 minutes a child is
  reported abused or neglected (approx. 23 per day)
• More than 3 million children are reported to be
  abused or neglected each year.
• Almost 1 million of these are confirmed cases.

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• Most child abuse occurs at home and by a person
  they know and trust.
• 77 by parents
• 11 by other relative
• Child abuse is 15 times more likely to occur in
  families where domestic violence occurs

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RISK FACTORS FOR CHILD ABUSE

• See handout

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LONG TERM CONSEQUENCES

• Developmental delays
• Refuses to attend school
• Separation anxiety
• Anxiety disorder
• Increase substance abuse
• Aggressive behaviors
• Criminal Behaviors

• Somatic illnesses
• Depressive and affective disorders
• Personality disorders
• PTSD
• Panic attacks
• Schizophrenia
• Abuse of children and spouse.

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CAUSES OF ABUSE

• Simple Cause and Effect Models
• Ecologic Model

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APN ROLE

• Recognize, report, document
• Advocate
• Educator
• Community involvement
• Supportive office atmosphere
• Anticipatory Guidance

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DOMESTIC VIOLENCE

• DEFINITION A pattern of coercive control and
  terror that one person uses over another.
• Domestic violence usually continues over a long
  period of time and gets more frequent and more
  severe over time.

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DOMESTIC VIOLENCE IS A GROWING NATIONAL PROBLEM

• Health care implications
• Costly ER visits
• Repeated clinic visits
• Lost work days
• Hospitalizations
• Mental health counseling
• Approximately 150 million in medical costs per
  year.

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FAR GREATER ARE THE EMOTIONAL AND PSYCHOLOGIC
COSTS

• Depression
• Anxiety, panic attacks
• Eating disorders

• Sexual dysfunction
• Suicide attempts
• Alcohol or drug use
• Low self esteem

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SOMATIC COMPLAINTS

• Insomnia
• Depression
• Irritability
• Suicidal thoughts

• Abdominal pains
• Pelvic pain
• Chest pains
• Headaches

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WHO ARE..

• THE VICTIMS? ANYONE
• THE BATTERERS? ANYONE
• Batterers have a strong need to control and
  dominate

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VICTIMS AT HIGHER RISK

• Single, separated, or divorced
• Age 16-28
• Abuses drugs or alcohol, or batterer does
• Pregnant (8-17 of pregnant women are battered)
• Partners are excessively jealous or possessive

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CYCLE OF VIOLENCE

• Tension building
• Violent explosion
• Honeymoon phase

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APN ROLE

• Recognize and document
• Facilitator not a rescuer
• Community involvement
• Educator

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ELDER ABUSE

• Elder abuse is a serious threat to those 65 and
  older.
• 1 in 25 Americans, 65 experiences abuse
• Approximately 1 million elderly were victims in
  U.S. in 1996.

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TYPES OF ABUSE

• Physical
• Sexual
• Emotional
• Neglect

• Financial or Material exploitation
• Abandonment
• Self-Neglect

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WHY DOES THIS OCCUR

• Caregiver stress
• Impairment of dependant elder
• Cycle of violence
• Unprepared for responsibility of care
• Alcohol or substance abuse of caregiver
• Mental illness
• Lack of social support
• Economically dependant on elder

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POSSIBLE SIGNS AND SYMPTOMS

• Bruises- various ages
• Untreated injuries, in various stages of healing
• Broken eye glasses
• Sudden behavior changes
• STD or genital injury or infection
• Over or under medicated

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ROLE OF APN

• Recognize, document and report
• Advocate
• Educate
• Community involvement

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THE HEALTH BELIEF MODEL

• For an individual to take action to avoid a
  disease, four factors must be present
• Susceptibility
• Severity
• Appropriate Action
• Benefits vs. Costs