| Age | >60 years | 1 point |
| Blood pressure | >140/90mmHg | 1 point |
| Clinical signs | Unilateral weaknessSpeech disturbance | 2 points1 point |
| Duration of symptoms | 0-59 mins60 mins or more | 1 point2 points |
| Diabetes | Diabetes | 1 point |
Score 4 or more indicates significant risk of CVA
Thanks to Practice Nurse 41 8 for this.
Type I diabetes occurs when there is a loss of insulin secretion ability due to automimmune destruction of the beta cells in pancreatic tissue. Patients generally present with the symptoms of hyperglycaemia including ketoacidosis.
Type I diabetes is the most common form in young people (affecting aout 0.5% of the population); bringing with it the potential for problems such as retinopathy, neuropathy, nephropathy and vascular disease.
Small amounts of insulin are produced by the pancreas throughout the day to ensure cells have access to glucose, and suppress the release of stored glucose from the liver. During fasting periods, glucagon is released to ensure glucose supplies for brain function.
Carbohydrates are digested in order to provide glucose, which results in the release of insulin titrated to the supply of glucose to use and store glucose in suitable quantities.
Insulin needs to be replaced in type I diabetes patients to ensure 24 hour cover. Boluses may also need to be prescribd to match carbohydrate intake at mealtimes. Often this can be suitably treated with a twice daily insulin if the patient’s daily routine is predictable, for patients whose lifestyle is more varied, titrated insulin may be required perhaps involving a pump or more frequent injections.
Carbohydrate awareness is important for those with type I diabetes because it is carbohydrates that affect blood glucose levels, and therefore patients need to be aware of the carbohydrate values of the foods they consume. This is particularly important for those titrating their insulin.
One of the ways insulin titration is done is through ‘dose adjustment for normal eating’ (DAFNE) which was designed for those with type I diabetes and can contribute to an improved quality of life and satisfaction for patients. Research shows that patients on DAFNE treatment are less likely to be admitted to hospital with ketoacidosis or hypoglycaemia, and also the treatment can make huge cost savings for providers. It consists of a 38 hour training course delivered in a group session based around competency skills. The scheme is successful in promoting understanding of diabetes, awareness of implications regarding diet, and the skills and knowledge required to count carbohydrates and titrate insulin accordingly with the use of DAFNE algorithms.
Taken from Independent Nurse 21/11/2011 p29
Washing hands with water increases the accuracy of blood glucose testing, a Japanese study has found. Cleaning with alcohol swabs did not improve accuracy, however.
Hirose, T. (2011) Glucose monitoring after fruit peeling: pseudohyperglycaemia when neglecting handwashing before fingertip blood sampling. Diabetes Care 34, 3, 596-597
Psoriasis is a common chronic inflammatory skin condition; it is characterised by dry, raised, silvery or red scaly plaques and often follows an unpredictable pattern of exacerbations and remissions. The plaques form as the skin regenerates far quicker than in normal skin (4 days compared with 28 days for normal skin).
The erythema is caused by the capillaries in the dermal layer dilating. This is generally initiated by T cells or antigen presenting cells. The areas most commonly affected are scalp, sacrum, nails, knees and elbows; but psoriasis can affect any area.
The average age of onset of psoriasis is about 33 years, and is equally prevalent in both men and women. Type 1 psoriasis generally begins when the patient is in their 30s, type 2 occurs when patients are in their 40s or 50s. Psoriasis generally declines in those in their 70s.
Psoriasis is found in people with a family history of it, but often it is triggered by factors such as stress or illness. Lifestyle factors such as smoking, poor diet or alcohol consumption can exacerbate psoriasis. Exposure to sunlight can improve it, or can exacerbate it depending on the patient. ACE inhibitors, NSAIDs and some anti-malarials can also make it worse.
There are several types of psoriasis; these include (flexural or inverse psoriasis (affects the flexure of the axillae or knees, generally less scaly than plaque psoriasis), chronic plaque psoriasis (also termed psoriasis vulgaris. This involves red plaques with white scales, normally found on the extensor surfaces of elbows and knees. Sometimes it affects the scalp and occasionally the lumbar region and umbilicus), guttate psoriasis (red scaly papules, many patients with this type of psoriasis will eventually develop chronic plaque psoriasis in time), facial psoriasis (as it implies, but has the most effect on body image), scalp psoriasis (affects the skin within the hairline, often affects the entire scalp), erythrodermic psoriasis (widespread overage, at least 90% of the skin, often connected with systemic illness), palmar-plantar psoriasis (affects the palms or soles), pustular psoriasis (characterised by widespread erythema and sterile pustules).
Psoriasis patients may also be affected by nail disease (this affects around half of patients with psoriasis), and psoriatic arthritis (affects around 30% of psoriasis patients), other co-morbidities may include ankylosing spondylitis and IBD.
Generally GP consultations for psoriasis are referred for specialist treatment, often in nurse-led clinics. As there is no cure for psoriasis, symptom control is the only option. Emollients are the baseline treatment and are used to reduce irritation, moisturise and soften skin scales. Topical therapy may be employed, this is for applications to small areas and includes preparations of corticosteroids, retinoids (vitamin A analogues), and keratolytics. If phototherapy is ineffective or does not provide sufficient relief from symptoms, phototherapy may be employed. This is the application of UVA or UVB light, although this comes with the side affect of increasing the risk of developing squamous cell carcinoma. Systemic therapy may also be employed with the use of drugs such as methotrexate, fumaric acid esters (not currently licensed, but available in some specialist centres), acitretin and ciclosporin. Methotrexate has the added benefits of being suitable for long-term use and effective in the treatment of psoriatic arthritis. Occasionally biologic therapy may be used such as adalimumab, infliximab, ustekinumab and etanercept. These are given either subcutaneously or IV (infliximab); but their use is restricted due to cost.
Although there are therefore many different treatment options for psoriasis, currently there is no cure, so symptom control is the aim.
Most respiratory conditions are treated with an inhaled drug. This enables the drug to effectively target the receptors in the lungs.
Although the nebulising unit of air compressor, mask, chanmber and tubing is commonly referred to as the nebuliser, it’s actually the small contraption attached to the mask which contains the fluid which is the nebuliser. It is this that transforms the liquid drug into fine aerosol. In many cases, inhalers employed with spacers and the proper technique are as effective, or more effective as nebulisers. This may be because of the inefficiency of the method with around 12% of the drug actually reaching the target receptors. This depends on the patients’ breathing rate and depth, the health and age of the patients’ lungs, the volume of the drug being administered and the type of nebuliser chamber. The nebuliser chamber, its components, and air flow rate, determine the size of droplets produced. If the droplet size is too small, the drug will end up in the peripheries of the lungs which decreases the efficacy of the drug. Overfilling the chamber will also affect efficacy as well as prolonging the time taken to administer; this should be 5-10 minutes. Once the nebuliser has finished there is likely to be a small residue of the drug in the chamber.
Nebulisers are not generally indicated for mild-moderate asthma because it has been shown that this can often lead to an overuse of bronchodilators rather than preventers.
Nebulisers are used to administer anticholinergics, corticosteroids, bronchodilators, antifungals and antibiotics as well as recombinant human deoxyribonuclease (used to increase expectoration and reduce viscosity in cystic fibrosis patients). If the nebuliser is used with antibiotics or corticosteroids a mouthpiece should be used to avoid contact with the skin and eyes.
Generally nebulisers are no more efficient than inhalers, and in fact some inhaled drugs are not available in nebuliser form, they can promote over-dependence on bronchodilators in asthmatics and also be habit-forming if the patient enjoys the cooling sensation. It is, however, helpful for patients with reduced manual dexterity or patients receiving palliative care.
Patients with a history of myocardial infarction will need appropriate follow-up in primary care to manage risk factors as far as possible, provide patient education and ensure patients are on correct medication.
Patient education to reduce risks of further MIs is important. In particular, patients should be advised to increase their fruit and vegetable intake to at least 5 portions daily, reducing salt and fat intake, adopting a Mediterranean-style diet including consumption of oily fish. Additional supplements of beta carotene, vitamin C or E are not connected with improving outcomes and reducing cardiac risks. NICE guidelines recommend post-MI patients to consume at least 7g of omega-3 fatty acids per week (2-4 portions of oil fish). For patients unable to achieve this, 1g daily omega-3 ester (Omacor) can be prescribed for up to four years for patients who have had an MI in the previous 3 months. Patients should also be advised to reduce their alcohol consumption to low-moderate levels (less than 21 units per week for men and 14 for women).
Obesity needs to be monitored and managed, as this will not only reduce lipid levels as well as blood pressure but also other conditions such as diabetes.
Smoking cessation help should be offered if appropriate. Nicotine replacement therapy is not advised immediately after an MI, but in the long-term continuing to smoke is a serious risk factor.
All post-MI patients should be offered cardiac rehabilitation with an emphasis on exercise. NICE guidelines recommend moderate exercise for 20-30 minutes (enough to feel lightly breathless) five times per week. Brisk walking is ideal. Sexual activity poses no more risk of a further MI, than in a person who had not had an MI. Although when treating erectile dysfunction it is important to remember that PDE5 (phosphodiesterase 5) inhibitors should be avoided in patients using nicorandil, but can be considered in stable patients six months post-MI.
The optimum lipid target is a total cholesterol of <4mmol/l, LDL cholesterol of <2mmol.
A brief anxiety and depression assessment may be required – referring on to mental health services if necessary.
Air travel can be considered three weeks post-MI, and although the DVLA need not necessarily be notified, it is inadvisable to drive in the four weeks immediately post-MI.
Optimum prescribing for post-MI patients includes:
Daily aspirin (proven to reduce death rate by 25%). This is a lifelong treatment and is a first-line drug. Clopidogrel may be prescribed instead of aspirin if a patient has a well-documented hyper-sensitivity. Clopidogrel may be prescribed alongside aspirin for 12 months in patients with non-ST segment elevation acute coronary syndrome.
ACE inhibitors (particularly in patients with left ventricular dysfunction or heart failure), although current NICE guidelines recommend all patients post-MI should be prescribed ACE inhibitors, after checking renal function. If the patient develops a severe cough or oedema, this would need to be reassessed.
Beta-blockers are responsible for a reduction in mortality of up to 25%. New patients may need to be informed that beta blockers can cause lethargy, but this should resolve after a few weeks.
Statins help reduce lipid levels, and it has been found that after five years’ use they prevent further cardiovascular events in 10% of patients. Statins can be started after liver function and CK has been measured to determine the patient’s baseline, although raised liver enzymes should not necessarily rule out the patient from statin therapy. A statin may be augmented by ezetimibe to reduce LDL and total cholesterol.
A low HDL cholesterol (<1mmol/l) is of particular risk to patient with type II diabetes. Fibrates are effective at raising HDL cholesterol.
Particular attention needs to be paid to the patient’s blood pressure – for post-MI patients the target is <130/80mmHg. To achieve this the beta blocker dose may need to be increased or the patient may also require a diuretic or calcium channel blocker.
Herpes zoster is also known as shingles and is caused by the human herpes virus type 3 (same as chicken pox). Herpes zoster opthalmicus presents as painful skin around the eye and blistering rash. It is more common in older people and those who are immunocompromised, those who are malnourished or under physical or emotional stress.
The varicella virus enters the respiuratory system, although it can also be transmitted through direct contact with infected mucosa. After chicken pox is resolved, the virus lies dormant in the body and can remain dormant for many years. When it is reactivated it tends to present as skin eruptions. Herpes zoster opthalmicus generally involves one nerve on one side of the body, therefore it affects one eye and not the other. The symptoms are pain, itching, and rash, conjunctivitis, severe inflammation of the surrounding skin, keratitis, periorbital oedema in the early phases. New lesions can appear for up to 5 days. Complications include post-herpetic neuralgia (has been linked with suicide in those over 70 years) keratitis, conjunctivitis, papillitis, retinitis, optic atrophy and dry eyes. Generally diagnosis is determined by presenting symptoms, not necessarily with the use of viral culture (unless specifically required).
Generally, herpes zoster opthalmicus is treated with systemic anti-virals taken orally. Symptom relief can also be achieved through the use of corticosteroids, opioids, gabapentin and tricyclic antidepressants for neuralgia. Topical treatments can be prescribed for the relief of itching skin, and good hygiene needs to be employed, bathing the area and dressing the eye area daily.
Research into whether the herpes zoster vaccine ought to be made available for those over 70 is currently being undertaken; although it is important to consider that chicken pox is vastly more serious in the elderly than in younger people.
Using varenicline before planning to quit smoking can improve 12 week success rates, by alleviating withdrawal discomfort and reducing pleasure gained from smoking.
Hajek P. et al (2011) Use of varenicline for four weeks before quitting smoking. Archives of Internal medicine. 171, 8, 770-777.
Gastroenteritis occurs when a person comes into contact with a causative agent which develops an inflammation of the gastro-intestinal tract. This can be caused not just by contaminated food, but also in some cases by anti-inflammatory drugs or antibiotics. It also may be as a result of a food allergy, which may present as nausea and vomiting, adominal pain and diarrhoea.
There are various bacteria that can cause gastroenteritis; shigella, salmonella, clostridium difficiel, staphylococcus, yersinia, salmonella, campylobacter jejuni. E coli is one that cause severe gastroenteritis, with patients often presenting with severe watery (non-bloody) diarrhoea and fever.
Gastroentiritis caused by viruses is frequently referred to as ‘stomach flu’ despite not being related to the influenza virus. Half of gastroetniritis is caused by norovirus, although this generally is prevalent in the period from October to April.
Rotavirus is more common in infants under one year old and is seasonal, as is the astrovirus which affects predominantly children and the elderly, whereas the adenovirus is not seasonal and generally affects children up to two years old.
Gastroenteritis can be caused by parasitic infections, generally Giardia. The parasite grows in the gut and symptoms of gastritis appear after about a week, but can last for a further six if not treated. Generally this would be treated with metronidazole. Cryptosporidium is another parasite that can cause gastroenteritis.
Care needs to be taken that the patient doesn’t become dehydrated; watching particularly for signs of dry mouth or tongue, drowsiness, dizziness or light-headedness, fainting, reduced urine output, lethargy or sunken eyes.
