NCLEX-PN Preventive Health — Screenings, Immunisations, and Health Education

ORTHOSTATIC HYPOTENSION is defined as a drop in systolic blood pressure of 20 mmHg or more (or diastolic 10 mmHg or more) within 3 minutes of standing from a sitting or lying position. OLDER ADULTS ARE AT HIGHER RISK because: baroreceptors (pressure sensors in blood vessels) become less sensitive with age — the reflex to increase heart rate and vasoconstriction when standing is slower; reduced cardiovascular reserve means the body compensates less effectively; many older adults are dehydrated due to reduced thirst sensation; polypharmacy compounds the risk (multiple antihypertensives, diuretics, alpha-blockers, beta-blockers). PATIENT TEACHING — ORTHOSTATIC PRECAUTIONS: Sit on the edge of the bed for 1-2 minutes before standing; stand slowly; hold onto a support rail or sturdy piece of furniture when first standing; wait until any dizziness passes before walking; if dizzy, sit or lie back down immediately; report persistent dizziness to provider. CONSEQUENCES OF ORTHOSTATIC HYPOTENSION: Falls — the most serious consequence; head injuries, hip fractures, subdural hematomas; syncope (fainting). PN ROLE: Teach safety; measure orthostatic blood pressure (lying, sitting, standing) when antihypertensives are initiated or dosage changes; document and report positive orthostatic changes to RN/provider.

PNEUMOCOCCAL VACCINATION protects against Streptococcus pneumoniae, which causes pneumonia, meningitis, and bacteremia — conditions with high mortality especially in elderly and immunocompromised individuals. CURRENT CDC RECOMMENDATIONS (as of most recent guidelines): Adults 65 and older: pneumococcal vaccination recommended for all; Adults 19-64 with HIGH-RISK CONDITIONS: Immunocompromising conditions (HIV, transplant, cancer treatment, asplenia); Chronic conditions: heart disease, lung disease, liver disease, kidney disease, diabetes mellitus, CSF leaks, cochlear implants; Cigarette smoking (increases pneumococcal pneumonia risk). VACCINE FORMULATIONS: PCV15 (Prevnar 15) and PCV20 (Prevnar 20) are CONJUGATE vaccines — provide better immune memory; PPSV23 (Pneumovax 23) is a POLYSACCHARIDE vaccine — recommended as additional coverage after conjugate vaccine in some high-risk patients; SCHEDULE COMPLEXITY: The schedule depends on prior vaccination history; for naive adults 65+, current guidelines generally recommend PCV20 alone OR PCV15 followed by PPSV23 — consult current CDC schedule; PN ROLE: Assess vaccination history; administer per schedule; document; educate client that protection is not immediate (takes ~2 weeks); common side effects include injection site soreness, mild fever.

MMR VACCINE SCHEDULE (CDC ACIP recommended): FIRST DOSE: 12-15 months of age; SECOND DOSE: 4-6 years of age (school entry); CATCH-UP: Children who did not receive MMR on schedule should be vaccinated as soon as possible; adults born after 1957 who lack evidence of immunity should receive 1-2 doses. WHY NOT BEFORE 12 MONTHS: Maternal antibodies (IgG passed to the baby across the placenta) interfere with the baby's immune response to live vaccines; these antibodies decline over the first year; by 12 months, most infants have sufficiently low maternal antibody levels for the vaccine to generate an effective immune response; some outbreak situations (international travel, exposure risk) may prompt vaccination at 6-11 months — but this early dose does NOT count toward the series and must be repeated at 12-15 months. MMR PRECAUTIONS (live vaccine): Do NOT administer to immunocompromised individuals (HIV with low CD4 count, cancer treatment, corticosteroid use); do NOT administer during pregnancy (teratogenic risk); avoid pregnancy for 4 weeks after vaccination; may cause fever and mild rash 7-12 days post-injection (expected immune response); egg allergy is not a contraindication unless severe anaphylaxis to egg — consult allergist; TST (tuberculin test) if needed should be done on the same day as MMR or 4-6 weeks later (MMR can suppress tuberculin reaction temporarily).

HYPERTENSION DIETARY MANAGEMENT evidence supports sodium reduction and the DASH (Dietary Approaches to Stop Hypertension) pattern as primary dietary interventions. SODIUM: Sodium causes water retention, increasing blood volume and blood pressure; the current recommendation is <2,300 mg/day for most adults, and the JNC guideline and AHA recommend <1,500 mg/day for those with hypertension; most Americans consume 3,400 mg/day — primarily from processed foods, restaurant meals, and canned goods; DASH DIET COMPONENTS: High: fruits and vegetables (8-10 servings/day); whole grains; low-fat dairy; nuts, seeds, legumes; lean poultry and fish; Low: red meat; sweets and sugar-sweetened beverages; saturated fats; sodium; EVIDENCE: The DASH diet reduces systolic BP by 8-14 mmHg — comparable to starting a single antihypertensive medication; sodium reduction by 1,000 mg/day reduces systolic BP by approximately 5-6 mmHg; ADDITIONAL LIFESTYLE MEASURES: Weight loss (each kg lost reduces BP ~1 mmHg); aerobic exercise (150+ min/week reduces BP 5-8 mmHg); moderate alcohol (<1 drink/day women, <2/day men); smoking cessation; PN TEACHING: Use MyPlate; read nutrition labels for sodium (aim <600 mg per serving for pre-packaged foods); choose fresh over canned; rinse canned foods; minimize restaurant and fast food; cook at home with herbs and spices instead of salt.

PREECLAMPSIA is a serious obstetric emergency defined as: new onset hypertension (BP ≥140/90 mmHg on two separate occasions 4 hours apart) after 20 weeks gestation PLUS one of: proteinuria; other severe features. SEVERE FEATURES (indicating severe preeclampsia): BP ≥160/110 mmHg; severe headache unrelieved by medication; visual disturbances (blurred vision, scotoma, photophobia); right upper quadrant or epigastric pain (liver distension); thrombocytopenia (platelets <100,000); renal insufficiency (creatinine >1.1); pulmonary edema. The client in this question has MULTIPLE severe features: BP 158/104 (approaching severe threshold); severe headache; visual disturbances — this is URGENT. PROGRESSION RISKS: ECLAMPSIA — grand mal seizures in a pregnant or postpartum woman without other cause; highly dangerous for mother and fetus; HELLP SYNDROME — Hemolysis, Elevated Liver enzymes, Low Platelets — can occur with or without hypertension; STROKE — from sudden severe hypertension; PLACENTAL ABRUPTION — increased risk. NURSING PRIORITY: Notify RN/provider IMMEDIATELY; this is not a 'watch and wait' situation; place on continuous fetal monitoring; prepare for possible magnesium sulfate (seizure prophylaxis) and antihypertensive treatment; prepare for possible delivery. MAGNESIUM SULFATE: Drug of choice for seizure prevention in preeclampsia; loading dose then continuous infusion; monitor for toxicity (loss of patellar reflex, respiratory depression, oliguria); antidote is calcium gluconate.