NURSE-UN 240 A&E I– FINAL EXAM STUDY GUIDE WEEK 9 – HYPERTENSION & STROKE HYPERTENSION,100% CORRECT

NURSE-UN 240 A&E I– FINAL EXAM STUDY GUIDE WEEK 9 – HYPERTENSION & STROKE HYPERTENSION - Hypertension – o Some Disparities: ▪ Incidence is highest among African-Americans ▪ Incidence is higher among men compared to women until age 45 ▪ Incidence is higher among women compared to men after age 45, especially after age 54 (cause unknown) ▪ 1 in every 3 Americans has HTN • 46% do not have it under control • 2 out of 3 have HTN after 65 years old ▪ Uncontrolled BP increases the risk of co-morbidities: • A 20mmHg (systolic)/10 mmHg diastolic increase in BP doubles the risk of cardiovascular disease (CVD) o For example, a person with BP of 140/90 mmHg has twice the risk as a person with BP of 120/80 mmHg o BP = CO x PVR (systemic arterial blood pressure is a product of cardiac output and total peripheral vascular resistance). o CO – determined by the stroke volume (SV) multiplied by the heart rate (HR); SV is influenced by preload, afterload, and contractility: ▪ The greater the preload  the greater the SV, the greater the CO, the greater the BP • Diuretics – decreases preload ▪ The greater the afterload  the greater the SV, the greater the CO, the greater the BP. • Vasodilators – decreases afterload ▪ The greater the contractility  the greater the SV, the greater the CO, the greater the BP • Calcium channel blockers – decreases contractility o PVR – influenced by sympathetic nervous system activity and angiotensin II. ▪ In the renin-angiotensin-aldosterone system (RAAS), the kidney produces renin (an enzyme that acts on angiotensinogen to split off angiotensin I)  angiotensin I converted by enzyme in lung to angiotensin II • Angiotensin II – strong vasoconstrictor action on blood vessels and is the controlling mechanism for aldosterone release • Aldosterone then works on the collecting tubules in the kidneys to reabsorb sodium, which will inhibit fluid loss, thus increasing blood volume and subsequent blood pressure. Hypertension can be classified as essential (primary) or secondary: - Essential hypertension is the most common type (approximately 95% of cases) and is not caused by an existing health problem. However, a number of risk factors can increase a person’s likelihood of becoming hypertensive: o Family history of hypertension o African-American ethnicity o Hyperlipidemia o Smoker o Older than 60 years old or postmenopausal o Excessive sodium and caffeine intake o Overweight/obesity o Physical inactivity o Excessive alcohol intake o Low potassium, calcium, or magnesium intake o Excessive and continuous stress - Specific disease states and drugs can increase a person’s susceptibility to secondary hypertension: o Kidney disease o Primary aldosteronism o Pheochromocytoma (tumor in the adrenal cortex) o Cushing’s disease o Brain tumor o Encephalitis o Pregnancy o Drugs: estrogen (birth control pills), steroids (glucocorticoids, mineralocorticoids), NSAIDs, and cold and flu medications Systolic BP Diastolic BP Normal 120 and 80 Elevated 120-129 and 80 Stage I hypertension 130-139 or 80-89 Stage II hypertension 140 or 90 Hypertensive crisis 180 and/o r 120 Nursing Assessment: subjective data, risk factors, objective data Subjective PMHx, meds, SHx, FHx, ROS Risk factors Objective data Clinical Manifestations PMHx/Meds: HTN, CV (PAD, PVD), cerebrovascular, renal, thyroid dx, DM, pituitary disorders, obesity, dyslipidemia, menopause or hormone replacement - FHX of HTN - Ethnicity (African-American) - Hyperlipidemia - Smoking - Age 60 yo or post-menopausal - Excessive Na and caffeine intake - Overweight/obesity - Sedentary lifestyle (physical - BP readings - Heart sounds - Pulses - Edema - Body measurements (waist and air circumference - Essential/Primary HTN: Usually asymptomatic (“Silent Killer”), idiopathic - Secondary HTN: resulting from renal diseases, sleep ROS: salt & fat intake, wt loss or gain, nocturia, fatigue, DOE, palpitations, pain, dizziness, blurred vision, erectile dysfunction, stressful events inactivity) - ETOH - Stress - DM - Gender - SES - Metabolic syndrome (increase glc, triglycerides, BP, waist circumference, decreased HDL) ) - Mental status changes apnea, thyroid problems (hyper), adrenal gland tumors, meds or illicit drugs, primary aldosteronism, Pheochromocytoma, and Cushing’s syndrome Medications that can contribute to HTN - Cold and flu medications - Steroids (how to manager HTN caused by steroids that are needed) - Birth control pills - NSAIDs (to not be on it long term) Effects of HTN - Hemorrhage, stroke, dementia - Retinopathy - PVD - Renal failure - LVH, CHD, HF Diagnostic Tests - Must have elevated BP that is confirmed on at least 2 separate occasions for diagnosis of HTN - Diagnostic tests: o Kidney Disease: urinalysis, BUN/Creatinine, Glomerular Filtration Rate o Pheochromocytoma: presence of catecholamines in the urine o Cushing’s Disease: elevated cortisol levels in the blood and presence of 17-ketosteroids in the urine o Routine chest radiography to recognize cardiomegaly o ECG to show increased QRS voltage – indicative of LVH o Echocardiogram – can show LVH and decreased ejection fraction (55%) o 20/10 increase in BP doubles the risk of cardiovascular disease Nursing diagnosis - Ineffective health mgmt - Anxiety - Sexual dysfunction - Risk for decreased cardiac perfusion - Risk for ineffective cerebral and renal perfusion - Potential complications (stroke, MI) Planning - Achieve and maintain goal BP - Follow the therapeutic plan (lifestyle changes) – including HCP appointment - Experience minimal side effects of therapy - Manage and cope with this condition Implementation - Measures to enhance compliance o Individualize plan o Active patient participation (involved in decision making, planning) o Select affordable drugs o Involve caregivers o Combination drugs helps with compliance (take 1 combined than diff one) o Patient teaching Managing HTN - Moderation of alcohol intake: o No more than 2 drinks of ethanol (24 oz. beer, 10 oz. wine, 3 oz. 80-proof whiskey) per day in men and 1 drink for women or lighter weight person - Exercise: o 30 minutes of moderate activity 5 days/week o Divide 30 minutes into shorter period of at least 10 minutes each - DASH (Dietary Approaches to Stopping Hypertension) o Plant-based o Increased in dietary K+ is recommended for adults with HTN o A diet low in fat and sodium significantly lowers BP (lean meats, cut down on dairy) o Effect is seen in one week after starting the diet - Medications: o BP = CO X PVR o Examples: ▪ Diuretics • Thiazide (Hydrochlorothiazide) – inhibit sodium, chloride and water reabsorption in distal tubules while promoting potassium, bicarbonate and magnesium excretion • Loop diuretics (Lasix) – inhibit sodium, chloride, water reabsorption in the ascending loop of Henle and promote potassium secretion • Potassium sparing (spironalactone) – act on distal renal tubule to inhibit reabsorption of sodium ions in exchange for potassium, usually used in conjunction w/ another diuretic or antihypertensive drug to conserve potassium ▪ Beta Blockers (metoprolol, atenolol, carvedilol) – block beta-receptors in the heart and peripheral vessels  decreases HR and myocardial contractility ▪ Angiotensin-Converting Enzyme (ACE) Inhibitors (lisinopril, enalapril) – block action of angiotensin-converting enzyme as it attempts to convert angiotensin I to angiotensin II (one of the most powerful vasoconstrictors in the body), also decreases sodium and water retention and lower PVR  lowers BP ▪ Angiotensin Receptor Blockers (ARBs) drugs (losartan, valsartan) – selectively block binding of angiotensin II to receptor sites in vascular smooth muscle and adrenal tissues by competing directly w/ angiotensin II but not inhibiting ACE ▪ Ca Channel Blockers (amlodipine) – interfere w/ transmembrane flux of calcium, resulting in vasodilation and decreased BP; also blocks SA and AV node conduction  decreased HR Anti-hypertension treatment for Older Adults - “Start low, and go slow” - Compliance may be low - Medication education is very important - Older adults more sensitive to volume depletion HTN treatment goals (JNC 8) - 60 yo and older w/o DM or CKD, treatment started when: o Systolic blood pressure (SBP) reaches 150 mmHg or higher OR o Diastolic blood pressure (DBP) reaches 90 mmHg or higher - 60 yo OR those who have DM and CKD, treatment started when: o SBP of 140 mmHg or higher OR o DBP of 90 mmHg or higher o Treat to goals below these respective thresholds. Why patients stop taking medication: - BP reaches target - Side effects of meds - Forgetting to take meds - Fear of mixing meds with alcohol - Cost of meds - Ignoring need for treatment - Using alternative treatment - Fear of BP going to low - Fear of mixing meds with other drugs Evaluation - Pt will achieve and maintain goal BP; understand, accept & implement treatment plan; report minimal side effects of therapy STROKE - 5th most common cause of death in the US - Leading cause of serious, long-term disability o About 795,000 people have a stroke each year ▪ 15-30% with permanent disability ▪ Lifelong change for survivor and family - Risk factors: o Age (risk doubles each decade after 55) o Gender (more common in men, more women die) o Ethnicity/race (higher incidence in African American) o Family history o Modifiable: HTN, heart dz, serum cholesterol, smoking, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, drug & ETOH abuse Transient Ischemic Attack - Sx last 1 hr - 1/3 do not experience another event - 1/3 have additional TIA - 1/3 progress to stroke - “not good blood flow”, small microblock for a sec (can be full obstruction for a sec and alleviated or partial obstruction) Types of Strokes - Ischemic – inadequate blood supply o Thrombotic – occurs from injury to a blood vessel wall and formation of a blood clot  narrowing of blood vessel ▪ Most common cause of stroke ▪ Often a/w HTN, DM, often preceded by TIA ▪ Extent of stroke depends on rapidity of onset, size of damaged area, presence of collateral circulation o Embolic – embolus lodges (breaks off) and occludes a cerebral artery resulting in infarction and edema of area supplied by involved vessel ▪ 2nd most common cause of stroke ▪ Sudden onset with severe clinical manifestations: warning signs are less common, usually remains conscious, commonly recurs - Hemorrhagic – bleeding o Intracerebral – into brain tissue itself – caused by rupture of vessel ▪ HTN is the most common cause ▪ Sudden onset with progression over minutes to hours ▪ Extent of sx caries and depends on amount, location, and duration of bleeding ▪ Manifestation: neurologic deficits, HA, n/v (projectile), decreased LOC and HTN ▪ Can also be intraparenchymal hemorrhage (bleeding into brain parenchyma) o Subarachnoid – into subarachnoid space or ventricles (intraventricular hemorrhage) Assessment - Primary assessment focused on cardiac status, respiratory status, neurologic assessment - If patient is stable, obtain o Description of current illness: pay special attention to sx onset and duration, nature and changes o Hx of similar sx previously experienced o Current meds o History of risk factor and other illnesses o FHx of stroke, aneurysm or CV dx - FAST – face (uneven?), arm (unilateral deficit?), speech (slurred speech?), time (call emergency assistant immediately if any signs present) - Secondary assessment include a comprehension neurologic examination: LOC (A&O x4), cognition, motor abilities, cranial nerve fxn, sensation, proprioception, cerebellar fxn, deep tendon reflexes Diagnosis - Increased intracranial adaptive capacity - Risk for aspiration - Impaired physical mobility - Impaired verbal communication - Unilateral neglect - Impaired swallowing - Situational low self-esteem Planning - Goals include: maintaining stable or improved LOC, ABCs, attain max physical fxn, maximize self-care abilities & skills, maintain stable body fxns, maximize communication abilities, avoid complications of stroke, maintain effective personal and family coping Implementation - Health promotion: promotion of healthy lifestyle, reduce incidence of stroke – focus on stroke prevention and teach how to reduce modifiable risk factors - Acute care: o Respiratory system (ABCs) – risk for atelectasis, risk for aspiration pna, risk for airway obstruction – may require endotracheal intubation and mechanical ventilation o Cardiovascular (ABCs) – goal aimed at maintaining homeostasis – many stroke pts may have decreased cardiac reserves from secondary dx of cardiac dz  cardiac efficiency may be compromised ▪ Adjusting fluid intake ▪ Monitoring lung sounds for cracks and wheezes (pulmonary congestion) ▪ Monitoring heart sounds for murmur ▪ Watch for orthostatic hypotension before ambulating patient for the first time ▪ Interventions: monitor VS, cardiac rhythms, calculate I&Os, regulate IV infusions ▪ After stroke, risk for venous thromboembolism (VTE): weak or paralyzed lower extremities are particularly vulnerable, related to immobility, loss of venous tone and decreased muscle pumping in the leg, most effective prevention is to keep moving o Neurologic system – monitor closely to detect changes suggesting extension of stroke (until after 48 hours), increased ICP (probably from bleeding or swelling), vasospasm (d/t traumatized BV), recovery from stroke sx o Musculoskeletal – maintain optimal fxn, prevent atrophy and contractures o Integumentary – prevent skin breakdown through pressure relief & early mobility o GI – constipation o Urinary – incontinence, bladder retaining, catheterization o Nutrition – IV infusions to maintain fluid & electrolyte balance, many require nutritional support ▪ 1st feeding should be approached carefully, feedings must be followed by scrupulous oral hygiene o Communication – assess for ability to speak and understand  speech therapists can help assess by assessing and formulating a plan to support communication o Sensory-perception alterations – r/t hemisphere of brain in which stroke occurred ▪ Visual problems may include diplopia, loss of corneal reflex, ptosis, homonymous hemianopsia ▪ R sided stroke – may have spatial deficits (difficulty judging position, distance, movement), may have behavioral changes (impulsive, impatient, deny problems r/t stroke) – responds best to directions given verbally ▪ L sided stroke – cognitive defects (slower in organization and performance of tasks; impaired spatial discrimination), may be fearful or anxious – responds well to nonverbal cues o Coping – affects family emotionally, socially, financially, changing roles and responsibilities, explain diagnosis and therapeutic procedures, social services for pt and caregiver are helpful - Ambulatory care/rehabilitation o Rehab – process of maximizing pt’s capabilities and resources to promote optimal fxn ▪ Physical, mental & social well-being o ADLs: walking, eating, toileting, transferring, bathing o Emotional responses/coping – distract, calm environment; grief responses; communication Evaluation - Return to baseline fxn or as close to it as possible (mobility, ADLs, communication, sensory, sexual health, coping) WEEK 10 DOCUMENTATION & INFORMATICS - Health informatics – uses info and tech to communicate and coordinate pt care, manage knowledge, reduce error - Nursing informatics (NI) is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. o Informatics are used to: ▪ Communicate and coordinate patient care, manage knowledge, reduce error and support decision making o Why do we need informatics? To err is human  medical errors deadly!! (3rd leading cause of death in the US) ▪ Medical errors due to communication breakdowns, diagnostic errors, poor judgement - The American Recovery and Investment Act of 2009: $19 billion dollars for providers to integrate EHR into their systems. - Need to document appropriately and in a timely manner Electronic Medical Record (EMR) – institution based - An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization - EMR info can be part of the EHR Electronic Health Record (EHR) – can compare current clinical data w/ data from previous encounters – ongoing record – national (work in progress) – future cornerstone of health information systems, essential to improve pt safety and quality of care – REAL TIME PATIENT INFORMATION NECESSARY TO PROVIDE TIMELY & EFFECTIVE CARE - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization. - Integrated EHR systems provide: o Alerts about abnormal test results or other findings that need to come to the attention of a provider o Clinical decision support tools such as linkage to protocols related to patient problems o A centralized mechanism for access from different locations and institutions o Efficient use of storage space for patient data o Aggregation of data to assess quality measures Barriers to EHR o Implementation costs o Training of large numbers of health care professionals o Organizational culture o Systems funding o Lack of planning o Not wanting to lose patient eye contact o Slow computers o Inability to type quickly o Feeling that using the computer in front of the patient is rude o Fear of decreased critical thinking - Information commonly entered by nurses: o Physical assessment o Admission nursing role o Nursing care plan & nursing dx o Present complaint o PMHx o Tests/procedures/treatment o Discharge o Medication administration o Daily documentation Personal Health Record (PHR) - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual. - The IOM estimated that 72% of patient care errors were related to communication failures. - Errors often occur at the time of a “hand off” during a shift change, transfer of a patient from one unit to another within the same institution, or between institutions. DIKW Pathway (Data, Information, Knowledge, Wisdom) - Process of converting raw data into wisdom - Data – the smallest components of the DIKW pathway. Discrete or raw facts, products of observation with little interpretation, factors describing a patient, a datum with little meaning in isolation or without context - Information – Information = data + meaning, processed to have meaning, constructed by combining different data points into a meaningful picture, giving context, answering questions of “who”, “what”, “where,” and “when”. - Knowledge – information that has been synthesized so that relations and interactions are formalized, built meaningful information, affected by assumptions and theories, derived from discovering patterns, relationships - Wisdom – appropriate use of knowledge to manage and solve human problems, implies ethics, knowing why and why not, clinical judgment Documentation – 5 characteristics of quality documentation – stick to facts, avoid jargon & abbreviations, be SUCCINCT – avoid fluff, include only essential – date & time entry - Factual – descriptive, objective information – avoid vague terms; only subjective data included is what pt states - Accurate - Complete - Current - Organized Notetaking Methods for Nurses - SBAR-R (Identify yourself, Situation, Background, Assessment, Recommendations, Readback and Document the Response) - SOAP(IE) (Subjective, Objective, Assessment, Plan, Interventions, Evaluation) - DAR (Data, Action, Response) - ADPIE (Assessment, Diagnosis, Plan, Intervention, Evaluation) - Focus Note- Organized narrative - Narrative- Just writing the note o In a narrative note, nurses often chart by exception, meaning they only document positive results (so readers can assume everything else was negative). - When documenting, it’s important that nurses do: o Confirm correct chart o Reflect nursing process o Write legibly and watch grammar, spelling, and punctuation o Converse with health care provider o Record time patient was provided care o Tell the whole story without garnishing it o Properly note a late entry - When documenting, it’s important that nurses don’t: o Alter patient’s record o Write unacceptable abbreviations o Write imprecise descriptions o Chart ahead of time o Include opinions Computerized Physician Order Entry (CPOE) • Computer program that allows practitioners to input patient orders in the hospital or the long term care setting. • Most health care facilities are beginning to use computer provider order-entry (CPOE) systems. • CPOE systems allow the prescribing provider to enter medication orders in a standard format. • CPOE systems guide the prescriber in complete, accurate, and appropriate prescribing. The computer sends the prescription directly to the pharmacy and enters the prescription into the patient’s permanent record. This prevents any guessing when handwriting is illegible or drug names are similar • Safe practice dictates that a nurse follows only a written or typed order, or an order entered into a computer order- entry system because these types of orders are less likely to result in error or misunderstanding. Verbal Orders • The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency. • Ex.- When the physician or nurse practitioner is present but finds it impossible, owing to the emergency situation, to write the order. • The order must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist, who receives, reads back, documents, and executes the order. • In “read-back,” the recipient reads back the message as he or she heard and interpreted it. • The person giving the order then confirms that such recording and interpretation of the order is correct. Privacy and Confidentiality • Discussing patient information in any public area where those who have no need to know the information can overhear • Leaving patient medical information in a public area • Leaving a computer unattended in an accessible area with medical record information unsecured • Failing to log off a computer terminal • Sharing or exposing passwords • Copying or providing data, either on paper or in machine-readable form, for yourself, coworkers, or any other party, except as required to fulfill job responsibilities • Improperly accessing, reviewing, or releasing birth dates and addresses of friends or relatives, or requesting another person to do so • Improperly accessing, reviewing, or releasing the record of a patient out of concern or curiosity, or requesting another person to do so HIPAA (1996) • Health Insurance Portability and Accountability Act (HIPAA): a patient's private health information is any information that relates to the person's past, present, or future physical or mental health. • HIPAA is part of federal legislation that addresses actions for how PHI is used and disclosed. • Protecting and maintaining patient privacy and confidentiality are basic obligations • Includes not only specific details such as a patient's name or picture but also information that gives enough details that someone may be able to identify that person. • If a health institution wants to release a patient’s health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. Communication • The Joint Commission included “managing handoff communications” among its 2009 National Patient Safety Goals. • The Institute for Healthcare Improvement () is promoting the ISBAR communication technique as a framework for communication between members of the health care team about a patient’s condition: • Identity/Introduction: Communicate who you are, where you are, and why you are communicating. • Situation: Communicate what is occurring and why the patient is being handed off to another department or unit. • Background: Explain what led up to the current situation and put in context if necessary. • Assessment: Give your impression of the problem. • Recommendation: Explain what you would do to correct the problem. Shift Change Communication • The IOM estimated that 72% of patient care errors were related to communication failures. • Errors often occur at the time of a “hand off” during a shift change, transfer of a patient from one unit to another within the same institution, or between institutions. Bedside Nursing Care Rounds: Two Advantages 1. Nursing personnel can actually see the patient as a report of care is given, and the patient and family can participate in discussions of patient-centered care. 2. Nurses should use language the patient can understand when holding discussions at the bedside. Purposeful Rounding (every hour) • A proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs • Address four Ps: pain, personal needs (toileting), positioning, fall prevention. • Ask “Is there anything else I can do for you before I go? I have time.” • Promotes patient safety, encourages team communication, and improves staff ability to provide efficient patient care. • Reduces anxiety, contributes to efficiency to accomplish scheduled tasks. Interdisciplinary Rounds (IDR) • Each discipline plays a vital role in the management of the patient. • Participation in IDRs demonstrate taking a step toward inter-professional collaboration Nursing Informatics • Informatics drives innovation that is defining future approaches to information and knowledge management in biomedical research, clinical care, and public health. • informatics has been around for centuries. • Many have documented that the first informatics nurse (IN) was Florence • Nursing informatics (NI) is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. • NI supports consumers, patients, nurses, and other providers in their decision making in all roles and settings. (ANA, 2015) • FN compiled and processed data to improve sanitation conditions in military hospitals during the Crimean War in the 1850s • This is brought about because you need to communicate and coordinate patient care in the digital age • We’re hoping that we will be able to manage the knowledge and reduce error as well as support your decision making in the field HITECH (Health Information Technology) • Health Information Technology for Economic and Clinical Health (HITECH) Act, has allocated billions of dollars to stimulate the adoption of quality health information technology (IT) systems or EHRs that demonstrate meaningful use • Meaningful Use - the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid to – Improve quality, safety, efficiency, and reduce health disparities – Engage patients and family – Improve care coordination and population and public health – Maintain privacy and information • It is hoped that the meaningful use compliance will result in: – Better clinical outcomes – Improved population health outcomes – Increased transparency and efficiency – Empowered people – More robust research data on health – Systems security of patient health • Ultimately, it is hoped that the meaningful use compliance will result in: Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered people More robust research data on health systems Security and Privacy of Electronic Data • The term used to describe the ability to share patient data across health care systems is interoperability • This means that all individuals, their families and health care providers should be able to send, receive, find and use electronic health information KEEP DATA SAFE: • Never give your personal password or computer signature to anyone, including another nurse in the unit, a float nurse, or a doctor. • Don’t leave a computer terminal unattended after you have logged on. Know and follow the correct protocol for correcting errors. • Don’t leave information about a patient displayed on a monitor where others may see it. • Keep a log that accounts for every printout of a computerized file that you’ve generated from the system. • Never use e-mail to send protected health information unless it has been encrypted to protect it from unauthorized access. • Follow the facility’s confidentiality procedures for documenting sensitive material, such as a diagnosis of acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection. • In the paper-and-pen era, the chart was in only one physical location; a limited number of people had access to the chart, and you typically needed to fill out a request form to access it from Medical Records for review. Today, with data residing in electronic systems connected to networks, available from virtually anywhere with an Internet connection, the patient’s data now becomes much easier to access by many more people—some without a justified need TeleHealth • Telemedicine-the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. • Examples include: conducting diagnostic tests, monitoring a patient’s progress after treatment or therapy, and facilitating access to specialists that are not located in the same place as the patient. • Telemedicine involves only remote clinical services • Telehealth is being used to improve care within all health care settings. • Simple technologies, such as videoconferencing equipment, provide patients with a live, real-time interaction with a specialist across town or across the country. • Telepsychiatry- being explored within skilled nursing facilities located in communities where psychiatrists and other mental health providers are limited.