Providing Exemplary & Purposeful Care to the Down Syndrome Patient within a Dental Setting

Abstract

As a dental hygiene professional, one must be prepared to deal with all different types of patients. Along with the vast amounts of personalities, ethnicities, and cultures, a dental hygienist must also be properly equipped to deal with patients that have special needs, in particular, patients that are diagnosed with down syndrome. Down syndrome patients need more skilled training from the healthcare professional in understanding their social, emotional, and physical barriers in comparison with those who are not special needs. There are different techniques that can be utilized to help these patients have an enjoyable experience at the dental office, as well as allow the clinician to do their best to help keep the patient in as much of a healthy state as possible.

Keywords: Dental Professional, Dental Hygiene, Dental, Down Syndrom

Dental Field Concerns.

Persons with Down syndrome are steadily on the rise in the United States. Every year hundreds of children are born with Down syndrome. With thousands of people containing this disease, it makes it very relevant for a dental professional to fully understand what it is, why it occurs, and how you can most appropriately treat the patient upon the caregiver scheduling an appointment with the dental hygienist. With so many people out there with this disease, it is imperative that a dental professional feel comfortable and skilled enough to trust that they have the appropriate training to master this appointment. Training in the dental hygiene program can be very fast paced with a vast amount of information, so sometimes proper treatment for patients with disabilities such as the common Down syndrome can be easily overlooked. This research has been purposely focused for the dental hygiene professional to become familiar and comfortable with treating a patient that is diagnosed with Down syndrome.

What is Down Syndrome.

Down Syndrome is a defect that happens before conception. It is when during the developmental stages, an extra chromosome is formed. This chromosome is considered chromosome 21. Chromosomes make up the bodies DNA and Gene make up which determines several different things such as a person’s physical and mental thought processes (Genes and Genetics Explained 2012). The extra copy of the chromosome is named Trisomy, and since it is chromosome 21, Down syndrome can also be classified as Trisomy 21. It’s been reported that the United States alone averages 6,000 babies a year that are diagnosed with Down Syndrome average out to 1 out of every 700 babies (CDC 2018). Out of all these cases, it is also reported that 80% of diagnosed are done so to mothers that are under the age of 35 years and since it is a genetic condition, after the mother gives birth to one Trisomy 21 child, the chances are far greater that it will happen to the second child (NDSS 2018). This chromosomal condition can be characterized into 3 different forms. Trisomy 21, Translocation Down syndrome, and Mosaic Down syndrome are amongst the 3 with Trisomy 21 account for the biggest of Down syndrome cases. Trisomy 21 is responsible for approximately 95% of people diagnosed with Down syndrome. It is called Trisomy because instead of only having 2 copies of Chromosomal 21, the babies are born with 3 copies of it. Translocation Down syndrome occurs in only 3% of people with Down syndrome and attaches on to another chromosome. The last type is Mosaic Down syndrome which basically means that their chromosome 21 is mixed in with all the chromosome, and some may have 3 and some may have the normal 2. Mosaic Down syndrome only accounts for the last 2% of patients diagnosed with Down Syndrome (CDC 2018).

When diagnosed with Down syndrome, it remains with them for life since there is no cure at the moment. However, with a screening test, parents can usually know pretty early if their child is at risk for Down syndrome. CDC (2018) states, “Screening tests often include a combination of a blood test, which measures the amount of various substances in the mother’s blood (e.g., MS-AFP, Triple Screen, Quad-screen), and an ultrasound, which creates a picture of the baby (CDC 2018). Screening, however, does not guarantee there will be something wrong, but does help get the process started of seeing things that look suspicious such as abnormal extra fluid around the baby’s neck. This then convinces the doctors to run some diagnostic test to confirm what may be going on with the child while developing in the womb. Prenatal diagnostic test usually has a 100% accuracy for the mother on if the child has Down syndrome, which can help the families prepare a little in advance. Prenatal test includes chronic villus sampling (CVS) which needs to be done within the first 9 to 14 weeks, and amniocentesis can be administered within 15-20 weeks of gestation (NDSS 2018). Percutaneous umbilical blood sampling (PUBS) is also another determining factor that can be utilized by blood samples from the umbilical cord, amniocentesis test the fluid in the amniotic sac, and CVS test material in the placenta (CDC 2018).

Clinical Presentations of Patients with Down Syndrome.

Although there are only 3 types of Down syndrome, there are still traits and characteristics that remain similar to every majority of Down syndrome patients. Many patients with Down syndrome are presented with hearing loss, sleep apnea, heart defects such as Mitrovalve prolapse and diastolic dysfunction, eye diseases, and ear infections (CDC 2018). Likewise, there are other visible characteristics that might help one identify a person diagnosed with Down syndrome. Many patients with Down syndrome can be characterized as having short and stubby fingers and hands, and transverse palm crease. These patients are usually present with lack of muscle tone, noticeable awkward waddle, short with a short neck, flattened face and nose that appears to be underdeveloped, cross eyes, and narrow opening eyes. These patients are also known to have seizures, Alzheimer’s disease, weakened immune system, and airway issues.  (Wilkins, E. M. (2017).

When thinking of a special needs patient, most would think that the patient depends on the clinician or the caregiver to do everything for them. Down syndrome patient’s abilities can always vary upon severity, but most are very high function individuals. There may be some negative characteristics such as not being able to focus for long periods of time, the behavior may be spontaneous, stubborn, or there may be some delayed language development. Although, there are positives that come with Downs such as:

• Socially advanced
• High intellectual functions
• Enjoy games and background music
• Admire getting attention
• Not very irritable, happy, sociable
• Observant
• Enjoy imitating

Knowing these different characteristics and traits can later play to the advantage of the clinician in order to better understand the patient. If the clinician is aware that the patient enjoys imitating, music, and games, then it would be advisable to have some fun light-hearted music playing in the background, and have some toothbrushes and teeth to play with to demonstrate appropriately to the patient. (Wilkins, E. M. (2017).

Dental Hygiene Considerations

Dental Characteristics that are common amongst Down Syndrome Patients.

There are a variety of characteristics that are very common amongst persons with Down syndrome that can be observed in and around the oral mucosa. Some of these characteristics include a protruded tongue. Many do not keep their tongue inside their mouth. Mouth breathing occurs a lot amongst these patients, fissured and expanded tongue is present, and narrow and vaulted palate. One must also be aware of scars and broken or fractured teeth due to accidents that these individuals are prone to. Patients with Down syndrome are also present with irregular eruption patterns than those of normal children and adolescents. Along with irregular patterns, they also have congenitally missing teeth, microdontia is sometimes present, and pronounced spacing in-between teeth. These patients are usually present with posterior crossbites and Angle’s Class III (Park, J. U., & Baik, S.H. 2001). Knowing these things can give the clinician an opportunity to explain to the caregivers that this is normal for people with Down syndrome and to not be too alarmed.

Treatment Plan Modification.

Patient Needs.

In response to the patient’s conditions such as airway obstruction due to their sleep apnea, enlarged tonsils, and macroglossia, it is recommended that a clinician thinks about where to appropriate position chair in order for the patient to not gag, and to make sure you have constant suctioning for fluids. Semi-supine position might be best for the patient to feel most comfortable and at ease. Usually, the patient will do just fine if you slowly introduce new things to them and try not to just speed through without allowing the patient to get comfortable with you first because it might evoke unfavorable behavior problems (Wilkins, E. M. (2017).

Systemic Conditions.

Due to patients having increased risk of heart defects, a clinician must first consider if the patient needs a medical clearance before working on them. It is imperative that dental professionals are communicating with their other health care providers if there are other systemic things currently going on. The risk with heart defects can also be correlated to their weakened immune system, and clinicians need to be aware if it patient needs to be medicated before undergoing dental procedures to prevent bacterial infections (Wilkins, E. M. (2017). Persons with Down syndrome also have issues with gastroesophageal reflux which is in part to having hypothyroidism (Underactive Thyroid – NIH 2016). Acid erosion would be visible by the clinician in response to the acid reflux. Celiac disease is also a prominent systemic disease which is good for counseling the patient and caregiver on if they are not aware. Patient’s caregiver should be advised that staying away from gluten might be most appropriate to the patient if they ever begin to see issues or intolerance (NIH 2018).

Dental Hygiene OHI Recommendations for Down Syndrome Patients.

Brushing & Mouth Rinsing.

As far as instructions for the patient, it will vary based on the patient’s cognitive level or hand dexterity that is available. The clinician must be aware if the patient is motivated to brush his or her teeth themselves, and if they are able to do it appropriately. Possibly offering the patient a toothbrush with a big handle or showing the caregiver how to make one utilizing sponge or a tennis ball to make the handle larger for the patient would be great tips to ensure the patient does not struggle and become discouraged while brushing. It would be advisable to also teach the patient how to rinse with mouthwash after each meal to help reach every area of the mouth for proper oral health. Usually, these patients are on many medications for their different systemic issues which could also cause xerostomia, so the dental hygienist must be aware of this and inform patient and caregiver of the necessity to try using a mouthwash with zero alcohol or a Biotene product to keep the mouth from getting to dry (Wilkins, E. M. (2017).

Methods to deliver Oral Hygiene Instructions.

Method of delivery will vary based on the patient’s cognitive level. The clinician must be aware of what patient is able to do and understand themselves or what may be necessary for caregiver to do for them. Although explaining to the caregiver is acceptable, it is recommended that clinician show patient and allow them to try, as well as show caregiver appropriate way to help the patient. The clinician needs to be aware that although caries rate can be low for these patients as children due to the spacing of teeth, there is still the possibility of obtaining caries if food remains on the teeth. Due to the patient having hypotonia, the weak muscles does not allow the masseter to completely chew the food all the way which, in result, causes food to be left on the teeth. Without proper maintenance or brushing, this could eventually cause decay. Not only can decay occur but caregivers must be educated on periodontal disease if there is poor oral health care at home. With malocclusion, bruxism, conical shaped roots, and compromised immune system, it makes them even more susceptible to periodontal disease. Allow the caregiver to understand how much bacteria can be in the mouth and the issues that periodontal disease can cause later for them financially and for the patient’s oral health and eating habits.

Community Involvement and Interventions.

As a dental hygiene clinician, it is imperative that communities are being reached, educated, and encouraged to focus on their oral health and seek treatment. It usually is not that these individuals do not want to take care of their oral health, but perhaps it has been placed on the back burner amongst all other things and never been stressed. When clinicians go out into the community to different facilities or rehabilitation establishments, it allows one to bring awareness to all the individuals. Clinicians should be prepared to bring things for the Down syndrome patients so it can be interesting, interactive, and fun. Clinicians should also bring brochures or pamphlets to go home with caregivers, specifying the importance of oral health and how to prevent periodontal disease. Then it should be group specific somewhere on the pamphlet saying that one is trained and skilled in working with special needs or Down syndrome, this way the caregiver feels as if they will be in good hands if they bring them to the specified clinic. It is the clinician’s job to make the patient feel individualized and important, and to reveal to the caregiver the clinician really cares. Many times, patients without special needs are unaware of the importance of taking care of their oral health, so it is even more imperative for clinicians to advocate to caregivers of special needs who are already compromised and disadvantaged in many ways. One must show concern and that they are aware of all the other things that a caregiver must deal with on a daily basis, but to ensure them that the primary goal is to save the patient’s teeth and prevent malnutrition, and infection. If you clinician can go out in the community and make oral health a daily priority, then this is what makes a difference in patients lives long term.

Conclusion

In conclusion, the findings of this research paper was to inform and educate dental hygienist on how to appropriately treat patients with down syndrome. More often than not, dental hygienist may not have the opportunity to work with a Down syndrome patient while in school, but it is imperative to still be able to adequately assess the patient’s needs and to be a well-rounded clinician that can treat any type of patient even if you only work for a private or general practice, and not a hospital setting. The skills that were addressed may not make the clinician an expert on every patient with Down syndrome, since each case can still vary greatly, but it will at least be a practical guide to be informed on the most common traits of Down syndrome, some appropriate steps to take, and know what it means to work with Down Syndrome, also known as Trisomy 21.

References

• Center for Disease Control (CDC) Birth Defects. (2018, February 27). Retrieved from https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html
• NDSS (2018) Dental Issues & Down Syndrome. (n.d.). Retrieved from https://www.ndss.org/resources/dental-ssues-syndrome/
• Genes and genetics explained. (2012, August 31). Department of Health & Human Services Retrieved from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/               genes-and-genetics#
• NIH – Hypothyroidism (Underactive Thyroid). (2016, August 01). Retrieved from https://www.niddk.nih.gov/health-information/endocrine-diseases/hypothyroidism
• National Down Syndrome Society. (n.d.) What is Down Syndrome? Retrieved from https://www.ndss.org/about-down-syndrome/down-syndrome/
• Park, J. U., & Baik, S.H. (2001). Classification of Angle Class III malocclusion and its treatment               modalities. Int J Adult Orthod Orthognath Surg, 16(1), 19-29.
• Wilkins, E. M. (2017) Clinical Practice of the Dental Hygienist (12th Ed.). Philadelphia, PA: Lippincott Williams and Wilkins.

Assignment essay

Mr George Orwell is a 68-year-old male residing in rural South Australia.  His deceased wife, Heather had terminal breast cancer. Mr. Orwell arrived at, and was admitted to, the Farquharson Memorial Hospital with chest pain. His admission assessment verified he was alert and orientated with unremarkable vital signs. Pre- admission conditions include pitting oedema in both legs prior with an associated diminished pedal pulse, he suffers breathlessness on exertion and has uses an angina relieving spray on average about 4 times a day.  Evidentially, the purpose of the case report is provide information about the pathophysiology of his condition, two nursing problems and required interventions to assist successful management in his respite period as well as the plan for discharge.

The cardiovascular system responsible for the transport of blood throughout the body, consists of the heart, blood and vessels which including arteries, capillaries and veins

(Williams & Bradford, 2015).

The coronary arteries are vital to the hearts function as they deliver a constant supply of blood to heart muscle

(


Williams & Bradford, 2015

).  Coronary circulation provides oxygenated blood throughout the myocardium and returns deoxygenated blood to the right atrium via the coronary sinus (Williams & Bradford, 2015). The two main coronary arteries are the first branches of the ascending aorta, just outside the left ventricle. The left coronary artery divided into the anterior descending and the circumflex arteries providing blood for the left atrium and the left. The right coronary artery supplies the ventricle and part of the posterior wall of the left ventricle as well as the atrioventricular node of the cardiac conduction system (deWit, 2013).  The thin walled small diameter of the coronary arteries makes them vulnerable to the accumulation of fatty plaque build-up that can significantly restrict blood flow through the arteries leading to rupture of the fragile walls a process known as arteriosclerosis, involving clotting causing obstruction of a coronary artery (deWit, 2013).

Stable angina, a chest pain or discomfort due to coronary heart disease heart muscle, occurs when the heart muscle lacks oxygenated blood (Cassar el at, 2009). Likely sensations include pressure or squeezing in the chest. This can also manifest in the shoulders, arms, jaws or back. Angina pectoris occurs when one or more of the heart arteries are narrowed or blocked a condition called ischemia (Cassar el at 2009).  Unstable angina caused by acute coronary syndrome, produces unexpected chest pain, normally commencing during rest, (Fladseth el at, 2018).  This arises due to ischemia.

Hypervolemia is condition of having too much water in your body. The fluid can damage your health. The signs of hypervolemia can be swelling, discomfort in the body, swelling can be edema and usual in the feet, ankles, wrists and face. High blood pressure caused excess fluid in the bloodstream (Kreimeier, 2000). Shortness of breath caused by extra fluid entering your lungs and reducing your ability to breathe normally.

There are many nursing issues that are associated with this disease such as anxiety, pain management, education of patients and their families and falling risk.  A major problem with nursing a patient with coronary artery disease could be the onset of a myocardial infarction event (MI), commonly known as a ‘heart attack’.  This a major life-threatening event that can lead to cardiac arrest and must be addressed by efficient and thorough nursing intervention.  With respect to the context of the case study patient of concern, George, the admission report shows that currently the vital signs show no significant irregularities and hence the patient may be at a stage of partial coronary blood flow restriction rather than arteriosclerosis onset as determined by further examination

(Maryati & Dioso 2017).

However, if fatty plague is an issue then arteriosclerosis leading to an MI event could occur at any time.  One of the first major nursing interventions is to assess the vital signs of the patient as the signs of a MI incident can occur with clear irregularities in particular signs. Palpitations and irregularity of heart beat as symptoms of a MI will show up in pulse readings, and associated conditions such as dangerously low blood pressure or hypertension can occur in blood pressure reading, shortness of breath and other breathing irregularities can occur in respiration rate readings (Maryati & Dioso 2017).  Low oxygen saturation due to failing heart function in a MI could occur in O

₂

saturation readings. This is required on an hourly basis as the event could occur at any time after initial presentation (Williams & Bradford, 2015).  Often the patient is placed on a cardiac monitor to determine if life-threatening dysrhythmias have occurred during an MI.   Heart failure, causing low cardiac output, has an adverse affect on vital signs with specific affects on the different measurements. Therefore, the nurse ought to monitor the vital signs, note the changes-likely subnormal, record, adjust the nursing care plan and report the abnormality to the physician (Park et al 2017).  The pulse rate is likely to be high, as a compensatory mechanism to low cardiac output and hypoxia. The volume, (pressure of the pulse) is likely to be shallow, a clear consequence of low cardiac output. Furthermore, the patient presents with arrhythmia, indicating uncoordinated cardiac output by poor performing heart. The blood pressure is likely to be subnormal (Park et al 2017). While the systolic pressure is designated to be lower than normal, the diastolic pressure may be disproportionately elevated , thus signifying circulatory congestion due to poor venous return by the weakened heart. The patient’s saturation may be lower than normal, i.e. less than 90%, following low cardiac output with low oxygen distribution and pulmonary congestion. The respiration may be fast to compensate for hypoxia, yet conversely shallow due to lack of bodily energy (Williams & Bradford, 2015).

One possible likely intervention could be a diet that reduces the sodium (salt) level retained in the patient’s system.  The reason for this is that high salt levels can increase the risk of cardiac events such as MI.  It has been known for quite some time that high salt intake leads to high blood pressure that in turn is a major direct cause of coronary heart disease, (Strazullo, D’Elia, Kandale & Cappuccio, 2009).   Recent studies have indicated that high salt intake contributes to the development of left ventricular hypotrophy (LVH) , a thickening of the muscle wall of the heart’s left ventricle, independently of blood pressure

( Du Calair, Ribstein & Mimran, 2002 ;cited in Strazulla et al, 2009)

.  In turn LVH can contribute to coronary heart disease and its events, including MI.  George Orwell has a medical history of hypertension and obesity and hence may have had diety high in salt intake in past.  Though his admission blood pressure may be normal it could have resulted from a hypertensive state and a possible serious heart condition to yet be diagnosed. It is likely that a low salt diet will aid his hypertension and lower his risk of developing LVH and in turn lower his risk of short and longer term MI ( Du Calair, Ribstein & Mimran, 2002 ;cited in Strazulla et al, 2009).  Since George is of significant risk of MI, he is likely prescribed a blood thinning medication such as aspirin.  Management of correct dosage and timing of dosage and its correct ingestion by the patient is of primary responsibility of the RN who should also monitor the patient for the onset of potential side affects of this medication such as gastrointestinal bleeding, headache and constipation.  In the case of significant side-effects apparent the medication and/or its dosage may need to be changes.

Another nursing problem is fluid overload. Some patients with the pulmonary congestion develop this  rapidly because of a sudden increase in left ventricular (LV) filling pressures caused by conditions such as acute myocardial ischaemia or uncontrolled hypertension

(Pellicori, 2015).

(‘flash’ pulmonary oedema).

Pulmonary oedema

, (PO) the build up of fluid on the lungs is associated with coronary heart disease.  Conditions such a LVH, congestive heart disease or a MI could lower the ability of the ventricles of the heart to circulate blood through the blood capillary network in the lungs.  The stagnation of blood in this network causes build up of pressure that forced blood fluid into the interstitial tissue of lungs (Pellicori, 2015).

A possible nursing intervention associated with onset of PO is to supply

adequate oxygen to the patient, usually by an appropriate mask

.  This will improve the supply of oxygen to the heart and assist in gas exchange affected by the presence of fluid in the lungs

(Pellicori, 2015).

The nurse needs to monitor the supply of oxygen at an appropriate continuous rate and that the patient is fitted correctly with the mask (Pellicori, 2015). A medication such as frusemide may be prescribed as this not only treats the pulmonary oedema build up directly but also acts to relieve hypertension.  This could be given by injection or possibly as an IV.  Nursing staff could be responsible for the administration of injections at the right times with correct dosage or set up and monitoring of the IV drip, replacing bags as needed.  Nurses also should be vigilant as to the possibility of side affects such as ringing in the ear, loss of hearing and light headiness known to be associated with frusemide (Sanmuganathan, 2001).

Discharge planning is a process in which a patient is educated to help care for themselves at home safely and also address any questions or concerns to them. It also assists patients with communication with any caregivers and primary care providers about how best to manage their chronic needs once they have left hospital, (Mennuni at el 2017).

Generally discharge planning has a multidisciplinary approach when several different specialist health industry professionals collaborate together. For a cardiac patient like Mr. Orwell the specialists may comprise of the GP, cardiologist, heart failure nurse, home carer, internist, dietician, pharmacist, social worker, psychologist, physical therapist and geriatrician but its composition is ultimately dependent on the local health care system, (Jaarsma, 2005).

The role of the RN for a coronary disease outpatient includes essential monitoring of vital signs so that they remain normal to allow settling back into an at home life., they can also play a large role in informing a heart disease patient how to manage their condition in a home life, using various techniques such as discussion and repetition of facts to assist them remember important details for management (Riley, 2015).. With respect to sufferers of acute PO, helping them with medication such as spinoralactone dosage and reasons they must take once in home life as well as key monitoring of blood pressure and renal function could directly involve the nurse or assigned as part of the patient education (Sanmuganathan, 2001).

A patient presents to the hospital with a history of coronary heart disease and risk factors for worsening of this condition.  The pathology of this condition is associated with blockage of vessels supplying arterial blood the vital heart muscles responsible for passage of circulating blood in a health patient. Nursing problems of this condition are MI and PO, ischemia and build-up of fluid in lungs respectively. The RN is directly responsible in these events.  An intervention for MI is vital sign monitoring as declining quality of vital signs is associated with MI, including low pulse and blood pressure and shallow short breathlessness.  Key medication may be the effective blood thinning aspirin and the monitoring of occurrence of any of the undesirable side-effects of its use.  Similarly, oxygen supplied by a mask could be a suitable intervention of someone with acute PO.  Follow up medication could be frusemide.  Discharge is multiteam process where careful planning occurs for successful return of patient to home life.   The RN on this team could be responsible to successfully educating the patient for home life adaptability with medication and any caring regimes required.

References list

• Cardiovascular System Function, Assessment, And Therapeutic Measures 2015, F.A.Davis Company,
• Cassar, Holmes, Rihal & Gersh 2009, ‘Chronic Coronary Artery Disease: Diagnosis and Management’, Mayo Clinic Proceedings, vol. 84, no. 12, pp. 1130–1146.
• 
  deWit, SC 2013
  
  , Medical-Surgical Nursing : Concepts & Practice., 2nd ed., Elsevier Health Sciences, Philadelphia.
• Hung, S, Kuo, K, Peng, C, Wu, C, Lien, Y, Wang, Y & Tarng, D 2014, ‘Volume overload correlates with cardiovascular risk factors in patients with chronic kidney disease’, Kidney International, vol. 85, no. 3, pp. 703–9.
• Fladseth, K, Kristensen, A, Mannsverk, J, Trovik, T & Schirmer, H 2018, ‘Pre-test characteristics of unstable angina patients with obstructive coronary artery disease confirmed by coronary angiography’, Open Heart, vol. 5, no. 2, p. e000888.
• Jaarsma, T 2005, ‘Inter-professional team approach to patients with heart failure.’, Heart (British Cardiac Society), vol. 91, no. 6, pp. 832–838.
• Kreimeier, U 2000, ‘Pathophysiology of fluid imbalance’, Critical Care, vol. 4, no. Suppl 2, pp. S3–S7.
• Nursing Care Of Patients With Occlusive Cardiovascular Disorders 2015, F.A.Davis Company, .
• 
  Maagaard, M, Nielsen, E, Gluud, C & Jakobsen, J 2019, ‘Ivabradine for coronary artery disease and/or heart failure—a protocol for a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis’, Systematic Reviews, vol. 8, no. 1, pp. 1–13.
  
• M. S. Siti Maryati & R. P. Dioso 2017, ‘Nursing Care for a Patient with NSTEMI Admitted to the Coronary Care Unit for Percutaneous Coronary Intervention — A Case Study’, ASEAN Journal on Science and Technology for Development, vol. 34, no. 1.
• Mennuni, Massimo Gulizia, Alunni, Francesco Amico, Maria Bovenzi, Caporale, Colivicchi, Di Lenarda, Di Tano, Egman, Fattirolli, Gabrielli, Geraci, Gregorio, Francesco Mureddu, Nardi, Radini, Riccio, Rigo, Sicuro, Urbinati & Zuin 2017, ‘ANMCO Position Paper: hospital discharge planning: recommendations and standards’, European Heart Journal Supplements, vol. 19, no. supplD, pp. D244–D255.
• Park, Hyukjin, Hong, Young Joon, Cho, Jae Yeong, Sim, Doo Sun, Yoon, Hyun Ju, Kim, Kye Hun, Kim, Ju Han, Ahn, Youngkeun, Jeong, Myung Ho, Cho, Jeong Gwan & Park, Jong Chun 2017, ‘Blood Pressure Targets and Clinical Outcomes in Patients with Acute Myocardial Infarction’, Korean Circulation Journal, vol. 47, no. 4, pp. 446–454.
• Pellicori, P, Kaur, K & Clark, AL 2015, ‘Fluid Management in Patients with Chronic Heart Failure.’, Cardiac Failure Review, vol. 1, no. 2, pp. 90–95.
• Riley, J 2015, ‘The Key Roles for the Nurse in Acute Heart Failure Management.’, Cardiac Failure Review, vol. 1, no. 2, pp. 123–127
• Singh, Nakra, Shankar K & Jacob 2014, ‘Recurrent negative pressure pulmonary oedema after tracheal extubation’, Medical Journal Armed Forces India, vol. 70, no. 4, pp. 383–385.
• Taylor, J 2015, ‘Primary prevention of coronary artery disease by aspirin’, European Heart Journal, vol. 36, no. 8, pp. 467–8.
• Tunbridge & Jardine 2019, ‘Cardiovascular complications of chronic kidney disease’, Medicine.
• Ying Shen, Songqi Guo, Yingli Hou 2018, ‘Application effect of high-quality nursing on patients with coronary heart disease’, Biomedical Research, vol. 29, no. 6, pp.1205-1208

Outcome 1 – Understand the causes of infection

1:1




Identify the differences between bacteria, viruses, fungi and parasites

The differences between bacteria, viruses, fungi and parasites are;

• 
  
  Fungi
  
  
  have cell walls made up of chitin (found in outer skeleton of insects, shrimps and lobsters – also used in healing agents). Fungi and parasites are multi cellular (Ref:
  
  www.euchis.org
  
  )
• 
  
  Viruses
  
  
  are not living, they are only made of complex proteins and nuclear acids
• 
  
  Bacteria
  
  
  are unicellular micro-organisms
• 
  
  Parasites
  
  
  and bacteria are animals

(Bacteria, fungi and parasites are living organisms)

(Dundas & Welsby 2002, pp99-106)

1:2




Identify common illnesses and infections caused by bacteria, viruses, fungi and parasites

Common illnesses and infections caused by bacteria, viruses, fungi and parasites are;

Viruses…

• Chicken pox
• Shingles
• Laryngitis
• Pneumonia
• Mumps
• Common cold
• Aids
• Whooping cough
• Measles

Parasites…

• Malaria
• Intestinal
• Scabies
• Ringworm
• Tapeworm
• Crab louse

Fungi…

• Conjunctivitis
• Athletes foot
• Ringworm
• Thrush
• Fungal nail
• Intertrigo (yeast)

Bacteria…

• Colds
• Flu
• Fevers
• Meningitis
• Pneumonia
• Gastroenteritis
• Impetigo
• MRSA
• Severe gastrointestinal (caused by E-coli)
• Acne

(Brooker &Nicol 2003, pp254-255)

1:3




Describe what is meant by “infection” and “colonisation”

The meaning of colonisation occurs when micro-organisms inhabit on a part of the body for example, skin but don’t cause signs and symptoms of infection colonised pathogens have the potential to cause infection if spread to a different parts of the body depending on the micro-organism colonised pathogens which can be passed on from person to person from touching objects or not washing hands. This is a major route of colonisation within the health care facilities. Colonisation of micro-organisms can inhabit the host by being in or being on, they don’t cause damage or invade the tissue, yet if they do invade tissue this can make the person sick, which in turn will turn into an infection.

Even though the host may not show signs of illness, they can still pass it on to others.

(Lister & Dougherty 2008, pp1112-1113)

1:4




Describe what is meant by “systemic infection” and “localised infection”

The skins function is to protect the body from infectious organisms, but when there has been a break in the skin infections can pose a threat. The meaning of localised infection is an infection that is limited to a specific body region. The meaning of systemic infection is when the pathogen is distributed throughout the whole body by the bloodstream.

Systemic infection:

• Conjunctiva infection can cause lasting damage if not treated in time
• Low immune systems due to diabetes, kidney failure etc.
• The elderly or children may cause complications with infection due to their age

Localised infection:

• Swelling
• Redness
• Temperature changes in infected area

1:5




Identify poor practices that may lead to the spread of infection

Covered on ECA course Training centre

Outcome 2 – Understand the transmission of infection

2:1




Explain the conditions needed for the growth of micro-organisms

The conditions needed for the growth of micro-organisms are nutrients for them to reproduce. It also requires warmth and moisture. They are not visible with the naked eye. The factor that encourages the growth of micro-organisms is


nutrition, oxygen, temperature, PH and moisture


. The PH and temperature determines the rate of growth. The moisture carry’s foods into the cell, and carry’s the waste away from the cell to maintain the content of


cytoplasm


(ground substance in where different components are found). All micro-organisms have a PH at which they can grow.

(Brooker & Nicol 2003, pp.254-255)

2:2




Explain the ways an infective agent might enter the body

An infective agent might enter the body through the mouth, stomach, intestines. The digestive tract. It can also be through broken skin.

Areas of infection:

The respiratory system – nose, lungs, windpipe.

The digestive system – spoiled food, unclean hands or objects.

The urinary tract – urethra, bladder, kidneys.

Wounds on the skin – cuts, grazes, trauma to the skin.

There is also secondary infective agent:

Genital – sexually transmitted, non-sexual PH imbalance (soaps, sprays, creams).

Conjunctival – to the eye (dust, viruses, bacteria, contact lenses)

The ways that gains entry to the person is by infecting the cells:

Trauma bite – infected animal, human, insect

Congenital – unborn baby (developed through pregnancy. Rubella, chickenpox, herpes, syphilis)

2:3




Identify common sources of infection

The best source for infection is poorly chilled, heated or contaminated food. Contaminated laundry on a low heat setting, clinical waste, and contaminated equipment, others that may be infected. Unclean work surfaces in kitchens. We all come into contact with hands, some just don’t take hand hygiene seriously and will spread the infection further afield.

2:4




Explain how infective agents can be transmitted to a person

Airborne –

inhalation of pathogens (microorganism disease producing agent such as bacteria, virus). The common cold and flu spread the infection to another person, either sneezing into the air, nasal droplets; this may be from a nebuliser. Infected dust particles containing skin scales may cause a respiratory virus.

Direct contact –

this would be person to person contact, such as dirty hands upon a patient or other way around. Sexual intercourse, chicken pox/shingles (herpes zoster) with the rash and until the last blister has dried up. Impetigo (staphylococcus aureus) which mainly affects children and immune suppressed people.

Hands –

are the main part of cross-infection. This can be transferred by microbes to other body areas, for example: hand to face to phone (communal), to shared computers, to person with a handshake. They in turn have now picked up everything you have touched. If they don’t wash their hands, the cycle of cross infection will multiply too many others. With the ambulance cross contamination can be spread from person to equipment including steering wheels, radios, door handles. Your body’s blueprint may have a good resistance to bacteria in your genes, but others you treat or touch may not and could potentially make them very ill.

Indirect contact –

can be spread by


fomites –


an inanimate object that becomes contaminated with infectious organisms and then transports those organisms to another person. This can include children’s toys, chopping boards, baby’s nappies, oxygen masks, Entonox breathing adaptors. They can live for a few minutes or a few hours. Indirect contact can also be spread by crawling or flying insects these are examples of


vectors


these are organisms that transmits pathogens and parasites (person, insect, animal)


.


Insect bites may cause a variety of infections, one being malaria.

Ingestion

– the organisms that infect the gastro-intestinal tract are ingested through the mouth by objects such as the hands, in drink, uncooked food, faecal/oral spread, eating food with unclean hands. Cross infecting would be to eat food while sharing communual keyboards/laptops who would in turn pass on to others by contracting sickness and diarrhoea and by not following hand washing techniques, this will continue until the cycle is broken.

Inoculations

– there may be a chance of a “needle stick” injury caused by infected needles that may contain Hepatitis B virus, and as the inoculation has been put directly into the blood stream of the patient, an infection is high.

2:5




Identify the key factors that will make it more likely that infection will occur

The key factors that will make it more likely that infection will occur are individuals susceptible to infection; these would include older people with lowered immunity due to other illnesses or conditions, children or babies. Compromised circulation secondly to peripheral vascular disease. People with diabetes have a risk of developing infections if their blood sugar is lower than normal. Urinary catheters or percutaneous endoscopic gastrostomy tubes (PEGS). IV lines if kept in too long (when a paramedic inserts a needle to administer drugs, you should note the time and date it was inserted and place on the surrounding site of the needle, this keeps hospital staff aware the length of time it has been in). Poor personal hygiene can be a factor and open to infections. Areas around skin folds due to obesity, as infections build up in moist areas such as the groin, stomach and under the breasts, infections can multiply rapidly in these areas. Young and premature babies with under developed lungs and heart, this is due to the lungs not being fully developed affecting the oxygen levels in the cells. Infection may be more if the patient or person is contact with contagious agents.

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  Sharon H Ferguson-Guy