Patient: Juana Negron
- Influenza, 1 dose annual
- Tetanus- Tdap for Td once, Td booster every 10 years
- Varicella- 2 doses
- MMR- 1 to 2 doses depends on indication
- PPSV23- 1,2 or 3 doses depending on indication
- Alcohol misuse
- Hypertension àborder line high blood pressure
- Tobacco use and cessation
- HIV infection
- Hepatitis Càpatient born between 1945-1965 (patient 52, born in 1965)
- BRCA gene screeningàincreased risk bc family hx
- Lipid disorderàincreased CHD risk, unhealthy diet
- Abnormal Glucoseàoverweight, obese
- Primary prevention breast canceràfamily hx, mother had breast cancer at 55
- Breast cancer à biennial screening, family hx
- Cervical Cancerà PAP+HPV co-testing
- Lung cancerà 40 pack year and current smoker, asthmatic
- Colorectal Canceràfamily hx, father had colon cancer at 50
- Osteoporosisàarthritis in both- hands
- Diet/activity for CVD preventionàoverweight, limited exercise & w/additional CVD risk
- Primary Prevention
- Immunizations, Health lifestyle changes (diet, exercise)
- Secondary Prevention
- Screening for colon, cervical, breast cancer
- Control of BP to prevent hypertensive state, in order to prevent stroke, heart disease, kidney disease
- Tertiary Prevention
- Therapeutic exercise for arthritis to maximize function
- Healthy lifestyle change/control of weight/diet to reduce development of diabetes/blood pressure control/other diseases
- Losing weight will reduce diabetes/cancer risk, decrease weight circumference, ease joint pain and increase self-confidence.
- Start DASH diet- lifelong approach to health eating to help treat/prevent high blood pressure. Mainly reducing sodium in your diet, and eating foods rich in nutrients
- Lower sodium up to 2,300mg a day
- Increase fruits and non-starchy vegetables.
- Include dried beans/legumes/nuts, dietary fibers to control blood sugar.
- Incorporate brown rice instead of utilizing white rice. More grains. More whole grains. Minimize processed carbohydrates
- Try healthy mono-saturated fats/oils, limiting trans-fat. Avoiding processes foods such as crackers, fried items
- Try lean meats, like fish/turkey, instead of pork/chorizo/beef. Try to bake, broil, grill, or toast instead of frying
- Avoid food high in sugar. Also use artificial sweetner. ie Equal, Splenda.
- Avoid any type of fried food, tamales, plantains, chorizo, sausage
- Limit alcohol
- Start slowly, reaching moderate aerobic activity, 150 minutes/week for weight loss
- Low impact exercises because of joint problems
- Walking slowly w/ dogs longer periods of time
- Swimming/slow treading
- Bicycling very light effort
- Moderate level exercises
- Walking briskly
- Bicycling 5-9 mph
- Weight bearing & resistance exercises for better bone health
- Muscle strengthening >2 a week involve all muscle groups
Target HR= 220-52= 168 BPM
Moderate HR= 168*50% = 84 BPM
Vigorous HR= 168*70%= 117.6 BPM
- Follow-up every month to check on progress, to see how exercise changes were going. At this point, exercise frequency and intensity can be increased possibility to 30 minutes daily or even to some higher intensity exercises.
- Encourage “healthy choices” to make at home
- Replacement of tobacco w/ smokeless nicotine alternative, ie patches/gums
First and foremost, we will make the patient comfortable and ask permission to continue questioning, counseling, and creating a plan for both smoking cessation and obesity.
- Ask the patient about her tobacco use
- This patient is a 40-pack year smoker, started smoking cigarettes at the age of 20. It is important to also what the patient smokes and how much of it to assess other factors. Also, asking if the patient has tried quitting in the past, and what she did. So now this time we can set her up for success
- Advise the patient of the risks involved
- Asking for permission and how open they are to receiving counsel is important here. Since she has thought about quitting, she has some knowledge, but detailing the specific consequences of smoking and the effects on the body, may motivate her to make a change. Because patient is overweight and asthmatic, she has greater risks for developing diseases. Therefore, advising her about the harms and discussing possible medications that can help her achieve her goal.
- Assess the level of tobacco dependence and readiness to quit
- Asking them questions from the quit card, assesses their interest in quitting. By asking Ms. Negron questions from the heavy smoking index, would indicate her level of nicotine dependence. She currently smokes half a pack of cigarettes a day. This would help to determine what type of treatment would be best suited for her for example, if a nicotine patch, gums, or the longer forms of oral medications are beneficial. The patient previously stopped for 6 months but then started again because she was nervous, and gaining weight.
- Arrange for a quit plan
- Ms. Negron knows that she should stop and has previously tried. Patient has decided after counseling that she wants to go ahead and quit. Then we would choose a date that is preplanned so the patient knows when they stop smoking, what medications or what kind of options are available to them. For example, using patches, gums, lozenges, sprays, inhalers, even medications like buproprion, varenicline which are best for long term maintenance and preventing cravings.
- Assure quit date and appointment
- Making sure we contact the patient in person, as a follow-up, in person or via telephone to make sure that patient has quit and adhering to the plan. It is important because nicotine withdrawal symptoms occur in the first week. And then asking Ms. Negron to visit within 1 month to measure her progress. This is to ensure Ms. Negron is sticking to the change she made. Also, making sure she has support from friends and family, information about support groups, other resources so she doesn’t cave in. This appointment would also make sure if the medication is properly suited for her body.
- Ask for permission to discuss weight
- This means seeking permission to talk about weight in order to discuss how their weight affects their healthy and quality of life. Ms. Negron knows she is overweight and how it is increasing her chances of developing diabetes and putting at her greater health risks. Using a non-judgmental method would also help to explore the readiness for her to manage weight.
- Assess health status, obesity indicators
- This means asking Ms. Negron about her health status by eliciting important information about her weight gain, asking specifically what her Puerto Rican diet consists of, and how vigorous/frequent her walks are with her dogs also if there are other family members also are overweight/obese and lastly making sure we plan to functional limitations because patient has arthritis. We assess health status by her BMI and her waist circumference, and essentially her psychosocial factors then introducing the weight management accordingly.
- Advise patient of health risks of obesity, benefits of modest weight loss, need for long term management, and treatment options
- This means establishing a relationship that allows Ms. Negron to be identify and accept her being overweight. With this established, asking her for permission to give advice in regards to the increased the health risks and how obesity will impact her way of life. It is important to let Ms. Negron know and feel that her situation is understood and recommending a plan of action to improve her way of life. I would offer her diet plans and exercise plans that works closely with her lifestyle and ways to manage long term.
- Agree on appropriateness of weight loss, expectations, targets, behavioral changes, and treatment plan details
- This means asking Ms. Negron if she agrees with the proposed course of treatment and plan. Developing a diet plan that would work according to her lifestyle as well, and creating goals that are achievable, such as limiting fried foods and losing 2-3 pounds a week and maintain weight afterwards. I would ask if this is a good time to lose weight, making sure there are no hindering factors in her life. Also, it is important to know why she wants to lose weight, what is her motivating factor. Establishing this will help to focus more on improving the Ms. Negron’s mental and physical health rather than just being about the number on the scale.
- Assist/arrange in identifying and addressing behaviors, providing resources, finding/consulting with appropriate professionals, and regular follow-up.
- This means making sure Ms. Negron has a meal plan to follow and/or an exercise regiment, so they feel in control. And if these are not set in place, referring her to who may assist her better, such as nutritionists, dietician. Making sure Ms. Negron has a follow-up appointment so you can measure her progress.