NR 601Comprehensive Final exam study guide and practice questions (Final review)

NR 601 final review.docx NR 601 Comprehensive Final exam study guide and practice questions DISCLAIMER- None of this is my original work. The first 11 pages are the completed study guide from a previous class. Pages ...

NR 601 final review.docx NR 601 Comprehensive Final exam study guide and practice questions DISCLAIMER- None of this is my original work. The first 11 pages are the completed study guide from a previous class. Pages 11 through 13 are the NR 601 course final exam review topics in outline form (Thanks Lisa Trevino!). Page 13-46 includes my notes from class and YouTube videos, Kennedy-Malone text (minimal), lessons, and some external research. When the information came from an external article, I included a link so that you do not use it as a test resource. Hopefully this is helpful for us as both a test and boards review. I kinda sorta (but not really because I’m over it) apologize for any typos. How to conduct Mini-Cog-  The Mini-Cog has been demonstrated to have comparable psychometric properties to the MMSE  The primary advantage of the Mini-Cog is that it is shorter than the MMSE and measures executive function.  It is composed of a three-item recall and the Clock Drawing Test (CDT) and takes about 3 minutes to administer  The Mini-Cog is a short dementia assessment that combines three-word recall with clock-drawing capability.  Patients are given a total score reflecting accuracy in clock drawing and recollection of the given three words.  A score of 0 to 2 is a positive screen for dementia Causes of delirium in elderly-  Causes of delirium are numerous and in elderly hospitalized patients there are often multiple etiologies, including metabolic, infection, cardiac, neurological, pulmonary, sensory impairments, medications, and toxins.  Regardless of cause, a consistent finding is significant reduction in regional cerebral perfusion during periods of delirium in comparison with blood flow patterns after recovery.  A possible neurological common pathway may involve acetylcholine and dopamine, and the disruption in the sleep-wake cycle in delirium indicates melatonin as a possible factor. (Kennedy-Malone 59) Agnosia  Loss of ability to identify objects ADA criteria for diagnosing DM-  FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*  2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*  A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*  In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L). • Urinary incontinence-  Involuntary loss of urine from the bladder ▪ So common in women many consider it normal ▪ Common in older men w/ enlarged prostate o Can affect quality of life o Significance-One of the most common complains w/ older adults, Distress & embarrassment, Cost burden to pt & society as a whole, Not life-threatening, may effect QOL, PCP essential to educating individuals o Epidemiology- Increased prevalence w/ age in men & women, Nursing home population – 40-70%, Often a factor in placement ▪ URGENCY UI is greater in men ▪ STRESS UI is greater in women o Terminology ▪ UI- Unintentional voiding, loss or leakage of urine ▪ Continuous incontinence-Continuous loss or leak of urine ▪ Increased daytime frequency-More frequent during day than considered normal ▪ Nocturia-Interruption of sleep one or more times due to the need to urinate – increases in frequency after age 50 ▪ Urgency-Sudden, compelling desire to pass urine that’s difficult to prevent ▪ Overactive bladder syndrome- Urgency, frequency, nocturia w/ or w/o incontinence o Risk Factors-Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diuretics o Risk Factors by gender-Women:Aging, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen deficiency, hx of pelvic surgery, diuretics Men:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diuretics o Physical changes w/ aging that contribute to UI ▪ Lower urinary tract-Detrusor muscle over activity,Decrease in detrusor contractility, Increase in post void residual,Decrease in urethral blood flow ▪ Women – decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral mucosal epithelium & increase in urethral sensation ▪ Men can experience constriction of urethra due to BPH which may result in bladder outlet obstructing symptoms - Initial clinical workup for UI in Men o PMH, PE, UA, DRE: Eval of prostate,PSA w/ new onset in men - UI workup in women:Exclude underlying causes,PMH, PE, UA, Pelvic exam, vaginal exam, perineal, Identify estrogen status of pt, Pelvic prolapse, fistula, -Cough test, Integrity of pelvic musculature, leaking of urine ▪ Full bladder ▪ Standing position ▪ Asked to cough ▪ If urine leak is observed, stress incontinence is confirmed - Red flags in males o Higher level of suspicion for serious diseases, Refer to urology if Previous pelvic surgery, Pelvic radiation, Pelvic pain, Severe incontinence, Severe UTI symptoms, Recurrent urologic infection,Abnl Prostate exam,Elevated PSA o Be alert to these with NEW ONSET UI- Hematuria,Pelvic pain,Abdominal mass, Dysuria, Proteinuria, Glucosuria, CVA tenderness,Nodular prostate,Any new neuro symptoms - Goals of treatment: Reduce symptoms, Improve QOL, Increase social activity, Reduce leakage volumes, increase dryness, use less protection; Increase independence in incontinence management; Decrease caregiver burden - 1st line management guidelines o AHRQ guidelines for management of UI in women ▪ Behavioral therapy ▪ Lifestyle modification ▪ Try for 3 months before pharm management o Weight loss, Smoking cessation(Tobacco is a bladder irritant),Less coughing o Dietary changes-Alcohol, soda, coffee with or without caffeine, acidic foods and spicy foods o Maintain adequate fluid balance to reduce constipation, provide adequate flow to kidneys - Behavioral strategies:Bladder training, Bladder control strategies,Timed voiding,Kegels, Pelvic floor training - 2nd line management - Medication o Antimuscarinic medication: 1st line for women ▪ Block the parasympathetic muscarinic receptors ▪ Inhibit involuntary detrusor contractions ▪ Side effects due to the effects on other muscarinic receptors o Outcomes unpredictable and side effects common o Common s/e: Dry mouth**, Blurred vision, Constipation,Nausea,Dizziness, Headache o AntimuscarinicsMechanism of action ● Blocks acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detrusor contractions (anticholinergic) ● CYP3A4 substrates ▪ Indications: UI and OAB ▪ Contraindications: Untreated/uncontrolled narrow angle glaucoma,Gastric retention, Urinary retention ▪ Precautions:CNS depression,Caution in elderly ● Renal dosing o CrCl <30 o Beta 3 Adrenergic Agonist – Mirabegron (Myrbetriq) ▪ Also approved for UI and OAB ▪ Clinical trials – significant reduction in incontinence and micturations ● No anticholinergic s/e ▪ Mech of action ● Selectively stimulates beta-3 adrenergic receptors ● Relaxes smooth muscle – bladder ▪ Contraindications/caution: HTN- Do not use if SBP >180, DBP >100 ▪ Avoid severe renal/liver disease ▪ Dose – 25-50mg PO QD ▪ CrCl <30 – max 25mg - 2nd line of UI in Males – Alpha 1 blockers o Men, not women! o Alpha 1 blockers antagonize peripheral alpha 1 adrenergic receptors o Used in men d/t high incidence of BPH in aging men o Alpha antagonists ▪ Alpha 1A – prostatic smooth muscle relaxation ▪ 1B – vascular smooth muscle contraction ▪ 1D – bladder muscle contraction and sacral spinal cord innervation o Meds ▪ Doxazosin SE: Dizziness, dyspnea, edema, fatigue, somnolence ▪ Terazosin SE: Asthenia, dizziness, postural hypotension ▪ Tamsulosin SE:Abnormal ejaculation, asthenia, back pain, dizziness, increased cough ▪ Alfuzosin- CrCl <30 use with caution, SE: Dizziness, URI ▪ Silodosin SE- Retrograde ejaculation Differentials as cause for erectile dysfunction-  Differential diagnosis: o Vascular, Endocrine, Neurological, Neurovascular, Substance abuse, End-organ disease, Psychogenic, Social causes (Kennedy-Malone 376) Elder abuse  Types- o Physical, Emotional, Sexual, Neglect, Exploitation, Abandonment, Self-Neglect  Risk Factors- o Age, Gender, Cognitive Impairment, Living Arrangement, Social Isolation  Signs of abuse- o bruises, slap marks, unexplained burns, increased accidents, lack of hygiene, failure to meet medical needs, weight loss, decubiti, changes in personality, decreased interaction, unexplained STD  Provider responsibility in reporting abuse o If you suspect elder abuse perform a physical exam and order any necessary tests. o Include a cognitive screen. o Document your findings. This includes what the patient says and your objective findings. o You may need to interview your patient and the caregiver separately to see if the stories are the same. o Be aware of your state laws regarding mandatory reporting of suspected abuse. Differentials as cause for hematuria- Differentials per class notes  Dietary substances o Caffeine, spices, Tomatoes, chocolate, alcohol, Citrus, soy sauce, & some herbal meds  Medication o Beta-lactam antibiotics, sulfonamide, NSAIDs, Cipro, allopurinol, Tagamet, & dilantin  Anticoagulation and papillary necrosis o Coumadin, Heparin, aspirin, & NSAIDs  Glomerular nephritis  Hydrocarbons (glue, paint) NSAIDs  Urolithiasis  menses Terazosin use(s)-  Alpha blocker for BPH. 1-10 mg P.O. nightly.  Caution in those with cataracts and in elderly.  Side effects o hypotension, priapism, dizziness, dyspnea, tachycardia.  2nd Line Management of UI in males ***Alpha 1 Blockers  Pharmacologic agents for men with urinary incontinence differ from women;  Alpha 1 blocker antagonize peripheral alpha-1 adrenergic receptors and commonly referred to as alpha 1 blockers *Lifestyle changes and Behavioral Management are first-line but when not effective alpha 1 blocker is initiated; *This difference in choice of medication for men is due to the high incidence of BPH associated with aging men  Alpha 1 Adrenergic Receptor antagonists  Alpha 1A- Prosthetic smooth muscle relaxation  Alpha 1B- Vascular smooth muscle contraction  Alpha 1D -Bladder muscle contraction and sacral spinal cord innervation UTIs in men and women UTI treatment guidelines BPH-  Progressive, benign hyperplasia of prostate gland tissue  Etiology/incidence- o Cause is uncertain, About 50% of men have it by 60, By age 85, 90% have it o Most common cause of bladder outlet obstruction in men over 50  Symptoms are attributed to mechanical obstruction of the urethra by the enlarged prostate gland  Signs/Symptoms- o Gradual worsening of the following, Frequency, urgency, urge incontinence, Nocturia, dysuria, Weak urinary stream, dribbling, hesitancy, Sensation of full bladder even after voiding, Retention  Diff Dx- o Urethral stricture, Prostate or bladder cancer, Neurogenic bladder, Bladder calculus, Acute or chronic prostatitis, Bladder neck contractor, Medications that affect micturition  Physical findings- o Abdomen,May have distended bladder secondary to retention; Prostate,Nontender w/ asymmetric or symmetrical enlargement, gross enlargement atypical, Consistency is smooth, rubbery (eraser), Nodules may be present  Differentiation from BPH and CA needs biopsy  Tests/Findings o UA-No hematuria or UTI, Urinary flow rate, Voided volume and peak urinary flow rate (uroflowmetry) may detect obstruction flow, Abdominal US – rules out upper tract patho, PSA, Consider PVR urine volume, Cr to assess renal function, elevated levels suggest urinary retention or underlying renal disease – refer this patient  Treatment/Management- o Refer men who have the following,  Refractory urinary retention who have failed one attempt at cath removal,  Recurrent infection, recurrent retention, refractory hematuria, bladder stone, large bladder, diverticula, or renal insufficiency related to BPH,  Consider referral if complications exist or if patients have severe symptoms  Management- o Men who have no indications for surgery,  Discuss risks/benefits of all options, Watchful waiting (observation), Behavioral techniques to reduce symptoms, Limit fluid after dinner,  Avoid medications such as Antidepressants, Antiparkinson drugs, Antipsychotics, Antispasmodics, Cold meds, Diuretics  Medication Treatments o Alpha adrenergic blocker – for smaller prostates o 5-alpha adrenergic blocker – larger prostates o Combo therapy is an alpha-adrenergic blocker and finasteride is used now for men w/ large prostates  Surgery has the best chance for relief of symptoms, but greater risks  Follow up: o Teach signs/symptoms of retention and obstruction, o If observing for now, recheck every 6-12 months, o In use of meds, recheck in 4-6 weeks, o If post surgery follow up is at the discretion of the urologist Acanthosis nigricans  A sign of insulin resistance that can be seen in African Americans  associated with colon cancer, obesity and DM Delirium treatment- (Kennedy p. 560).  Identify causes, prevent delirium though complications of identified disorders. \  Focus on safety.  Frequent reassurance and re-orientation.  First generation --haloperidol.  Second generation (olanazapine, risperidone, ziprasidone and quitiapine) antipsychotics to control behavioral symptoms. Essential tremor vs. Parkinson’s Disease  Essential tremor is an action tremor 6 to 8 Hz, Parkinson’s tremor is a resting tremor which is 3 to 6 Hz. (Kennedy p. 425) Seizure causes  In older adults stroke is the most common underlying cause of seizures.  Other causes include neurodegenerative disorders, brain tumors and head injuries. (Kennedy p 438) Hospice & palliative care-  Hospice: o Last 6 mos of life. Uses palliative care principles to support pt and family. Includes bereavement services. Covered by Medicare/Medicaid, most private insurance. Interdisciplinary care, medical service, supplies, drugs  Palliative Care: o To relieve pain and improve QOL. Used early in dz process. Interdisciplinary Care. Provides care for the entire dz process, from diagnosis to death, including bereavement services. Pain-  Pain assessment tools: o Visual Analogue Scale o Numerical Analogue Scale o Wong Baker FACES o Pain Assessment in Advanced Dementia scale  Types of pain: o Somatic, o Visceral, o Neuropathic  Framework for pharmacological interventions for pain:  The WHO Step Ladder o 1st step: NSAIDs and Tylenol for mild pain o 2nd step: Opioids added, usually with APAP for moderate to severe pain with functional impairment and or decreased QOL o 3rd step: Opioid pain meds, sometimes around the clock for severe pain  Adjuvant meds: o Tricyclic antidepressants, Nortriptyline, Desipramine, Duloxetine, Gabapentin, Pregabalin, Lidocaine 5% patch, Capsaicin cream, Corticosteroids, Calcitonin, Baclofen Pain management in elderly Delirium vs. dementia-  Delirium- o rapid onset (hours to days). o Poor memory, disorientation, speech disturbance, perceptual disturbance. o Typically fluctuates over course of day.