CNS Boards Review Flashcards
This theory focuses on the quality of nurse-client interaction
Peplau - Interpersonal relations model of nursing - 1952
This theory centers on self care, self care deficity, and nursing systems
Orem - General Theory of nursing - 1959
This theory focuses on behavior of the patient, the nurses’ reaction to the pt’s behavior, and the nurses’ subsequent actions
Orlando - Nursing process theory - 1950s
This theory has concentric circles of variables including physiological, psychological, sociocultural, spiritual, and developmental and interventions should be primary, secondary and tertiary
Neuman - Total-person systems model of nursing - 1972
This theory considers those stress-related events that are turning points in a person’s life and can lead to dander or to opportunity.
Hoff - Crisis Theory of nursing
This theory considers cultural issues as central to providing care and promotes study of cultural differences in r/t people’s beliefs about illness, behavioral patterns and caring as well as nrsg behavior.
Leininger - Transcultural theory of nursing 1974
This theory views the individual holistically from the perspective of health, sickness, and behavior with a nrsg goal to promote health and prevent illness.
Watson - Philosophy of Human Caring
Stages of Clinical Competence for nurses
Novice, advanced beginner, competent, proficient, expert - Benner
This model is used to predict health behavior with the understanding that people take a health action to avoid negative consequences if the person expects that the negative outcomes can be avoided and that he is able to do the action
Health Belief Model
Threat. Benefit. Intervening Factors.
Nursing process steps
assessment, diagnosis, planning, implementation, evaluation
Goal HR % of cardiovascular conditioning after illness/injury
60-90% of max HR
70% of cases of nocturia are r/t what?
over production of urine at night - nocturia > 2x nightly is linked with depression - treated with desmopressin
Treatment for overactive bladder (drug class)
Anticholinergics - Detrol, Ditropan
How much fiber is recommended daily to prevent constipation?
20-35 grams per day
CAGE stands for what?
Cutting down, Annoyed by Criticism, Guilty feelings, Eye opener
Moderate drinking is considered how many drinks per day for males and females?
2 per day (14/wk) for men, 1 per day (11/wk)for women
How many stages of Alzheimer’s classification are there?
Seven 1. pre clinical, no evidence of impairment, 2. mild cognitive decline 3. ST memory loss 4. moderate cognitive decline 5. confusion 6. profound confusion 7. severe
Barthel Index of ADL’s assessment of older adults includes what?
feeding, mobility, personal grooming, toileting, urinary ctrl, fecal ctrl, stairs, ambulatory status, transferring, bathing
Instrumental ADLs (IADLs) are what?
Telephone use, shopping, food preparation, housekeeping, laundry, transportation, medication, and financial responsibility
Confusion Assessment Method for delirium includes what criteria?
fluctuating inattention, disorganized thinking, and altered LOC
What are the recommendations to prevent renal complications of DM?
annual urine albumin and Cr, reduce protein intake to 0.8-1.0/kg body weight per day in early CKD stages, nl glucose level
What are the screening recommendations to prevent retinal complications in diabetics?
yearly exams - treat with laser photocoagulation
What are the recommendations to prevent neuropathic complications of diabetes?
screen yearly with pinprick, vibration sensation, monofilament test - screen for autonomic neuropathy at 5 yrs for DM1 and at 2 for DM2 - ankle brachial index - CV autonomic neuropathy tachy >100 at rest and orthostatic hypotension
What are the recommendations to prevent CV complications in diabetics?
ctrl HTN (130/80), lipid management statin if LDL >100mg/dL, ASA daily
What is JNCs preHTN classification?
120-130/80-89
What is JNC stage 1 HTN?
140-159/90-99
What is JNC stage 2 HTN?
greater than or equal to 160/100
What are JNC recommendations for screening for HTN?
recheck 2 years if normal, annually for pre HTN, every 2 mos for stage 1, and every month for stage 2
At what age should cholesterol be checked every 5 years?
after age 20
What what age should screening be done for osteoporosis if risk factors are present?
age 60, otherwise age 65
What does the pneumonic ‘fractured’ stand for in osteoporosis risk?
Family/personal hx; Race (asians/Caucasians increased risk); Age and gender (F > 65 high risk), Chronic disease/meds (DM, hyperparathyroid, corticosteroids); Thin Bones/low wt; Under Active; Reduced estrogen (postmenopausal); Excessive ETOH/smoking (ETOH disrupts Ca balance & impairs Vit D metabolism); Diet (deficient in VitD/Ca)
What is normal DEXA scan range?
0-10 T score
What are the 6 signs of malignant melanoma?
Asymmetry, Border is irregular, Color is mottled, Diameter is >6mm, Elevation is almost always present, Enlargement or a h/o an increase in size (most important sign)
Which level of prevention is screening?
secondary
Which model includes pre contemplation, contemplation, preparation, action, and maintenance?
Transtheoretical model (Prochaska & DiClemente)
Explain Systems Theory
See parts in r/t the whole
Which type of social support is the strongest?
emotional - as opposed to instrumental ($, time), information (advice, info), appraisal (feedback, affirmation)
Explain habituation as a stress reduction technique.
incorporate routine into daily activities during stressful situations
Explain time blocking as a stress reduction technique
set aside time to adapt to change and incorporate it into daily routine
Explain change avoidance as a stress reduction technique
avoid unnecessary change if able to during increased change times
What is the recommended cholesterol limit per day?
300mg/d
How many daily calories should be from carbs
carbs: 55-60%,
How much calcium is recommended daily?
600 IU/day up to age 70, then 800 IU/day
What does spirometry measure?
Forced Expiratory volume (FEV1) which is volume expelled in 1st second of Forced Vital Capacity (FVC) which is volume of air expelled forcefully after max inhalation -
What are Kubler-Ross’ 5 stages of grief?
Denial, Anger, Bargaining, Depression, Acceptance
What is the most common type of glaucoma?
chronic open angle (wide angle)
What does percussion over an organ sound like?
dull
What does percussion over a fluid filled area sound like?
flat
What does percussion over an air-filled area sound like?
resonant
What should nl bone conduction vs air conduction be in a Rinne test?
AC 2x> BC. Behind mastoid bone and then in front of ear
What does the Weber test measure?
Conductive loss (lateralize to affected ear), Sensorineural loss (lateralize to normal ear). On top of head.
Conductive hearing loss results in difficult hearing what sounds?
low tones and vowels
What tones does sensorineural hearing loss affect?
high tones, difficult with background noise
What are characteristic signs of breast cancer lumps?
single, non-tender, firm, ill defined margins
Which side has 3 lung lobes?
right
Which kind of breath sounds are normal?
Vesicular (low pitch, soft intensity)
What is a normal ankle brachial index?
1-1.4
What are Boutennier’s nodes a cardinal sign of?
Rheumatoid arthritis
The individual is viewed as a unitary energy source within the larger universe constantly interacting with the environment
Science of Unitary Human Beings - Rogers - 1980s
What are acrochordons?
Skin tags - benign, often found in older adults
What are lentigines?
Liver spots - benign, found in older adults
Why are actinic keratoses concerning?
They are precancerous lesions and should be examined carefully as they may become squamous cell or basal cell carcinoma. As opposed to seborrheic keratoses which are benign skin lesions.
JNC 8 recommended goat for treating those > 60 years
150/90
JNC 8 goal for treating HTN in those
140/90
A 10kg weight loss can result in what amount of reduced systolic bp? (#mmHg)
20mmHG
In HTN, what should the dietary sodium restriction be?
2,000 mg or 2grams. (CHF 2-3 grams)
Which heart medications reduce myocardial oxygen demand and induce coronary vasodilation?
Calcium Channel Blockers: Nifedipine, Verapamil, Diltiazem
Which heart sound is commonly heard in heart failure?
S3 gallop
Which class of heart medications are the mainstays of chronic HF management)
ACE inhibitors: Captopril, Enalapril, Lisinopril. Reduce afterload and prevent ventricular remodeling. Also BB
Virchow’s Triad (thrombophlebitis)
Vessel injury, venous stasis, hyper coagulation states
What is % of caucasian adults afflicted w/ HTN?
10-15%
Pharmacologic management of CHF includes 4 classes of agents:
1st line: ACE inhibitors (decrease afterload and prevent ventricular remodeling), then ARBs (inhibit RAAS) Diuretics (decrease preload), nitrates (decrease afterload), digoxin (contractility). BETA BLOCKERS
What does DMAIC stand for?
(define, measure, analyze, improve, control)
4 things that motivate employees the most include:
autonomy, salary, recognition, respect
Transtheoretical model describes stages of change. What are they?
pre contemplation, contemplation, preparation, action, and maintenance. There are 2 temporal dimensions to this process: distance of the behavior and duration of the behavior
This is the ratio of incidence of infection/disease among those who have been exposed compared to the incidence among those who have not been exposed:
Risk ratio. A risk ratio of 1.0 suggests the probability that those exposed will have higher rates. A risk ratio of 1.5 shows that the exposed group is 1.5 times more likely to become infection or diseased than the group not exposed. A lower number suggests exposure brings less risk of infection/disease.
This sampling occurs when there is an equal chance for any member of a group to be a part of the sample, allowing generalization of results
Probability sampling. Subtypes: cluster, multi-stage, simple random
What are the different types of non-probability sampling?
convenience, quota, and purpose
Authoritative statements by which the quality of practice, service or education can be judged.
Standards of practice
Selye’s General Adaptation Syndrome has (how many) phases:
3: alarm, resistance, exhaustion
this includes efforts to control the underlying cause or condition that results in disability
Primary prevention
This aims at preventing an existing illness or injury from progressing to long term disability
Secondary prevention
This refers to rehabilitation and special educational services to mitigate disability and improve function and participatory or social outcomes once disability has occured
Tertiary prevention
Maslow’s Hierarchy of Needs
Basic needs: food, shelter; Safety/Security: locks, lighting; Belonging: love, comfort, favorite surroundings; Trust: control over lifestyle, pain, choices; Self-esteem: status, pride, confidence; Self actualization: satisfying relationships, values, creativity, self direction.
Eric Erikson Pertinent Developmental States
Adolescent: Identity vs. Role Confusion; Young Adult: Intimacy vs. Isolation; Middle-age adult: Generativity vs. stagnation; Older Adult: integrity vs. Despair
Steps in a needs assessment
- Determine target population 2. Review or collect data (subjective/objective) 3. Conduct RCA to determine opportunities for improvement
SWOT
Strengths, Weaknesses, Opportunities and Threats
Closure of mitral valve
S1; ventricular systole [SIMS]
Closure of aortic/pumonic valves
S2, ventricular diastole [SZAPD}
The ability to understand a different culture and provide individualized, appropriate care
Cultural competence
Characteristics of delirium
Rapid onset, altered levels of consciousness, usually r/t a specific cause, usually reversible.
Characteristics of dementia
Gradual onset, clear consciousness, multiple cognitive impairments, memory impairments, disorientation, hallucinations, delusions,
What percent of dementia is due to Alzheimer’s disease?
60-80%
A diagnosis of dementia is based on:
Memory loss (both short and long term) plus one of the following: aphasia, apraxia, agnosia, disturbed executive function
Pharmacological Treatment for Early Dementia
Cholinestrerase Inhibitors: donepezil (Aricept).
Pharmacological Treatment for Middle-Late Dementia
Memantine (Namenda) (plus cholinesterease inhibitor)
Pharmacological Treatment for Delirium
Neuroleptics for hallucinations; haloperiodl or risperdone, benzos if induced by benzo withdrawl or alcohol
Hospital insurance covers acute hospital, limited nursing home care and/or home health care as well as hospice care for the terminally ill. No premiumPayed for by Social Security Taxes
Medicare A.
Medical insurance covers physicians, APRNs, lab work, PT & OT. Patients must pay an annual deductible in addition to monthly payments
Medicare B.
A prescription drug plan covers part of the costs of prescription drugs at participating pharmacies. IT is administered by private insurance companies, so monthly costs and benefits vary
Medicare D
A combined federal and state welfare program authorized by Title XIX of the Social Security Act to assist people with low income with payment for medical care. Eligibility and reimbursement guidelines vary by state.
Medicaid
A federal health insurance program for those who have Social Security or those who have bought in that provides payment to private healthcare providers but limits reimbursement.
Medicare
A HMO receives payment for services (vs. pay for service). A PCP serves as a gatekeeper to determine what other services the patient needs and patient must stay within HMO network.
Medicare managed Care
Health care program serving active military and their spouses/ dependents. All other insurances (including medicare) must pay before this kicks in
Tricare
Having a patient draw the face of a clock with all 12 numbers and the hands indicating a specific time is on which assessment tool?
Mini-Cog
Normal aging on the renal system
30-40% of nephrons are lost, kidney size decreases resulting in inability to concentrate urine. Filtration rate decreases. Excess potassium may be secreted.
Normal aging on the neurological system
Breaks in neural pathways interfere with sensory input (ex. full bladder).
Difficulty understanding and producing language in speaking, reading, and writing although patient may understand gestures and pictures/diagrams
Global aphasia
Clear understanding but difficulty producing language. Picture charts are helpful for the patient
Broca’s aphasia (expressive)
Difficulty understanding language but can understand gestures and are able to produce language, albeit sometimes incorrectly. May be able to write or use letter boards for communication.
Wernicke’s aphasia (receptive)
This type of incontinence is caused during events such as laughing, sneezing, coughing etc.
Stress incontinence
This type of incontinence is caused by overactive bladder
Urge incontinence
What are the 5 steps of CNS consultation (according to Norwood)
1.gaining entry 2. problem identification 3. action planning 4. evaluation 5. disengagement
This type of incontinence is caused by an inability to fully empty the bladder.
Overflow incontinence
This type of incontinence is caused by an inability to make it to the toilet in adequate time.
Functional incontinence
The indirect provision of care through helping others’ implement change
Consultation
The capacity to perform based on knowledge
competence
Actual performance (of a skill)
competency
What are the three determinants of learning?
Learning needs, readiness to learn, and learning style
What are the four categories of readiness to learn?
PEEK. Physical, emotional, experiential, knowledge
What are the four learning styles?
VARK. Visual, Auditory, Reading/Writing, Kinesthetic
What are the four components of the complex adaptive systems model?
Assessment, Diagnosis, Intervention, Evaluation
What are the 5 steps of the planned change and innovation model?
Needs Assessment, Identify appropriate interventions to achieve outcomes, Analyze research evidence, Implement EBP, Evaluate (modify PRN)
Lewin’s 3 step change theory
- Unfreezing of the existing situation 2. Movement 3. Refreezing.
What are the 5 basic principles of motivational interviewing?
- Empathy 2. Argument Avoidance 3. Self-efficacy support 4. Resistance reframing 5. Discrepancy awareness
What is OARS?
Used in Motivational Interviewing. Open-ended questions, Affirmations, Reflective Listening, Summaries. Helps individuals explore and resolve ambivalence
Behavioral Theories in Teaching/Learning Theories have these characteristics
Behavior is learned, can be shaped. Faculty-led, tightly structured learning environment. Positive/Negative Reinforcement.
Cognitive Theories in Teaching/learning Theories have these characteristics
Learning is individualized. Faculty relinquish some control thus students have active roles and responsibilities for learning.
Humanism
Goal is self actualization (do what is best), learning can be formal or informal. Self evals.
Malcolm Knowles Adult Learning Principles (6)
Autonomy, Life experience/knowledge, Goal-oriented learning, applicability, usefulness, respect
What are the four types of evaluation?
Process, Content, Outcome, Impact
The ability to decode instructions, charts and diagrams; analyze risks to benefits; and make decisions that lead to actions
Health Literacy (definition from NIH)
A formal, time-limited arrangement (usually short term) that includes teaching, support, counseling, coaching, evaluation etc.
Precepting
A formal or informal long term personal relationship btwn and experienced person and less experienced person that provides advice/support, wisdom, guidance and counseling for professional development.
Mentoring.
8 ethical principles relevant to nursing practice
Autonomy, non-maleficence, beneficence, justice, veracity, fidelity, confidentiality, privacy
Conduct (of professionals) that falls below professional standards of care or standard minimum knowledge/ability
Negligence
Approximately how many Americans are believed to be below basic levels of literacy?
93 million
Etiology/ Pathophysiology of CHF
(Positive Feedback Loop); Always secondary to something else. Weak/Thick, Less Compliant ventricles lead to reduced cardiac output which leads to decreased organ perfusion. This stimulates the RAAS
What happens when the RAAS is triggered?
Alodterone is released which causes compensatory Na and H20 retention. Excess fluid leaks into interstitial tissue causing pedal edema and weight gain. Norepi is also released which causes compensatory tachycardia and vasoconstriction.
Formula for Cardiac Output
CO=HR x SV
NYHA CHF Classification
Class I: No limitations; Class II: slight limitation, ADL’s may product SOB, fatigue; Class III: marked limitation; Class IV: inability to carry out any activity without discomfort. SOB @ rest.
An ABI under 1 is indicative of what?
PVD
The pathogenesis of arrhythmias falls into 1 of these 3 categories:
- Enhanced or suppressed automaticity (heart cells are all pacemaker cells) 2. Trigger activity (depolarization) 3. Re-entry (most common)
why are ACE inhibitors or ARBs used for treatment in an acute MI?
the prevent ventricular remodeling and decreased development of heart failure
How many people in the U.S. have HTN?
1 in 5. 50 million people. More than 30% are undiagnosed. Murica.
What is first line pharmacological treatment for Stage I HTN?
Thiazide diuretic (HCTZ). Use cautiously in those with hx of gout or significant hyponatremia. Avoid concomitant NSAID use.
When should Beta Blockers be avoided?
Asthma, reactive airway disease, 2nd/3rd degree heart block. NSAIDs decrease effectiveness
What is first line pharmacological treatment for Stage II HTN?
2 drug combination. Thiazide diuretic + ACEI or ARB
Calf pain produced by passive dorsiflexion of the foot
Homan’s sign. Possibly indicative of VTE. Lacks sensitivity and specificity.
What are the three etiological categories of Anemia?
- Decreased RBC production 2. Increased RBC destruction 3. Blood loss
How is sickle cell anemia diagnosed?
Hemoglobin electrophoresis
Clinical manifestations of anemia are usually the result of reduced oxygen carrying capacity and include
pallor, dizziness, fatigue, weakness, constipation, headaches, irritability. etc. When untreated, leads to compensatory mechanisms that manifest with tachycardia then resulting hemodynamic instability and organ failure.
This type of anemia is the most common
Iron-deficiency. Affects 1 in 5 U.S. adults. Especially the elderly
Anemia of chronic disease is most commons these types of diseases:
Cancers, Auto-immune diseases and chronic iflammatory conditions (RA, ESRD, SLE, Hepatitis, CHF)
Pharmacogenetics
how genetics affects drug transport and metabolism
Pharmacogenomics
Looks at genetic variations when developing a new drug
Pharmcodynamics
Drug effect and mechanism of action (what a drug does to the body)
Pharmacokinectics
Movement of the drug. Absorption, distribution, metabolism and elimination (what the body does to the drug)
The most common cancer in the U.S is
breast cancer, followed by prostate and lung, then colorectal
TNM Cancer staging
T: size of primary tumor N: lymph node involvement M: malignant/metastasis
Which neurotransmitters are implicated in depression?
Serotonin and norepi and dopamine
A diagnosis of depression is considered when
There is a change from previous (normal) functioning, for at least 2 weeks, with at least 5 key indicators (ex: anhedonia, weight loss/gain, fatigue, insomnia, etc).
Common pharmacological interventions for depression include:
SSRIs, MAOIs, Tricylcic antidepressants
Common pharmacological interventions for bipolar disorders include:
Mania: Mood stabilizers (lithium); Depression: Antidepressants; Psychotic: Antipsychotics
Inflammatory condition of the parenchyma of the lung with abnormal alveolar fluid retention
Pneumonia
If a patient has pneumonia, you would expect to find this upon auscultation and percussion:
Crackles; Dullness (maybe flat if very fluid filled)
Inability of respiratory system to maintain normal state of gas exchange to meet cellular requirements
Respiratory Failure. Dyspnea is classic symptom.
Airflow limitation that is not fully reversible, usually progressive and associated with inflammation
COPD (emphysema and/or chronic bronchitis)
What is the most common cause of pneumonia?
Aspiration, then droplet inhalation
Characteristics of emphysema
alveolar damage. Destruction or enlargement.
Characteristics of chronic bronchitis
Inflammation. Increased mucous production. Chronic cough.
What is a normal FEV1/FVC ratio?
75-80% All stages of COPD will less than 70%
COPD staging by FEV1
Stage 1 (Mild): FEV1>80%; Stage 2 (Moderate): FEV1 btwn 50-80%; Stage 3 (Severe) FEV1 btwn 30-50%; Stage 4 (Very Severe) FEV1
Airflow limitation as a result of inflammatory obstruction that is reversible either spontaneously or with treatment.
Asthma
What does the acronym COPDER stand for?
Corticosteriods/Co-morbidities; Oxygen; Preventative steps (no smoking/vaccines); Dilators; Education/action plan; Rehab.
What does the acronym AIRESMOG stand for?
R/t Asthma: Allergy/Adherence to therapy; Infection/Inflmmation; Rhinitis/sinusitis; Exercise; Smoking; Medications; Occupational exposure/OSA; Gerd.
Examples of Metabolic Acidosis
DKA, diarrhea, renal failure, shock, heart failure
Examples of Metabolic Alkalosis
K+ wasting diuretics, overuse of antacids, loss of gastric secretions, massive blood transfusions, corticosteroid therapy
Examples of Respiratory Acidosis
(Not moving air well) COPD, Oversedation, Neuromuscular disease, CNS depression, pulmonary edema
Examples of Respiratory Alkalosis
(Rapid breathing) Pain, anxiety, PE, pneumothorax, fever
Risk factors for fluid and electrolyte disorders
age extremes, gender, body size, environmental temperature, diet, exercise, stress, heavy alcohol conconsumption, fever. (Decreased total body water in elderly and obese)
Clinical picture of hyponatremia
Most are neurological and vary. Can progress from cognitive impairment, seizure activity, coma. Muscle weakness and cramping. Potential Rhabdomyolysis (leads to acute tubular necrosis)
Clinical picture of hypernatermia
Non-specific. Neurological in nature
Clinical picture of hypokalemia
signs of ileus, hypotension, arrhythmias, cardiac arrest, respiratory distress, lethargy, fasciculations or tetany, cushingoid appearance.
Clinical picture of hyperkalemia
decreased cell excitability, peaked t waves, decreased HR, twitching, tingling, numbness, look for signs of renal failure and cardiac disturbances
An adaptive response to severe volume depletion and hypotension with structurally intact nephrons
Prerenal acute kidney injury. Can lead to intrinsic AKI if not promptly corrected.
Causes of AKI
Volume loss from GI, renal, burns, or internal/external hemorrhage. Decreased renal perfusion in heart failure or sepsis. Some medications in volume-depleted states: ACEIs, ARBs
Acute tubular necrosis (ATN)
structural injury in the kidney, either ischemic of cytotoxic, patchy necrosis. Distal nephron death. May not be reversible and may progress to CRF or death.
Caused by mechanical obstruction of the urinary collecting system
Postrenal acute kidney injury. Includes renal pelvis, ureters, bladder, urethra.
Signs/Symptoms of ARF
can be asymptomatic. mental status changes, n/v, seizures, SOB, peripheral edema, pulmonary rales,
Prerenal ARF
impaired flow (ACEI, NSAIDs), intravascular depletion, kidneys resorb Na, CHF, azotemia, trace-2+ urine protein; BUN to serum Creatinine ratio >20:1
Intrinistic ARF
Impaired sodium resorption, 3-4+ urine protein. #1 cause of ATN due to structural kidney damage. hypoperfusion, cytotoxic agents, acute glomerular nephritis
4 categories of Intrinsic ARF
tubular, glomerular, vascular, interstitial
Postrenal ARF
obstruction. Stones, tumors, enlarged prostate.
which diagnostics are best to detect postrenal ARF (obstruction)
renal ultrasound, CT. Avoid pyelogram (contrast dye)
Which medications might be given for ARF?
Diuretics. Dopamine (increase CO and GFR), CaChB (minimize nephrotoxcity in ATN, prevents Ca from going into kidney cells); N-acetylcysteine (Mucomist) ( prevention of contrast medium nephrotoxicity)
The gradual loss of kidney function, that, if not stabilized, will result in ESRD.
CRF. ESRD is fatal without dialysis or kidney transplant
Common causes of CRF
irreversible ARF, DM, HTN, GU cancer, BPH, glomerulonephritis
In ESRD, kidneys are functioning at what capacity?
Less than 15% of normal
Sepsis continuum
infection + SIRS= sepsis (“simple”), then severe sepsis, then septic shock
What is one of the most common causes of sepsis?
Urosepsis. 25% of all sepsis cases. E Coli is responsible for over 50% of cases.
What are the two types of strokes?
hemorrhagic and ischemic
Which type of stroke is most common?
ischemic (90%). emboli, thrombus (hypercoagulability or vessel abnormality)
5 risk factors for stroke account for over 80% of risk
HTN (#1), smoking, Abdominal obesity, diet, physical inactivity
Management of acute ischemic CVA
Emergent CT, angiography, TPA, Do not treat HTN aggressively or fast (can cause rebound hypotension),
Exclusion criteria for TPA
Greater than 3 hours since symptom onset; neurological deficits improving; CT scan shows hemorrhage; PTT>15 seconds or INR > 1.5; severe hypo or hyperglycemia; thrombocytopenia; severe HTN, patient with recent hx of CVA or head trauma, recent hx of major surgery, patient with seizure at onset of CVA
What is the proper administration of TPA?
10% of total dose (0.9mg/kg) given as bolus over 1 minute, then remainder infused over 1 hour. No additional anticoags x 24 hours
What is used if TPA is contraindicated?
IV heparin drip and ASA
Common clinical presentation for subacachnoid hemorrhage (SAH)?
worst headache of life, nuchal rigidity, n/v. Usually related to aneurysm rupture.
What are the three stages of alcohol abuse treatment
Detoxification (can be a medical emergency), Rehabilitation, Maintence
Degenerative Joint Disease is primarily a disease of
cartilage. Affects weight bearing joints. Degrading enzymes are increased resulting in degradation vs. remodeling seen in healthy cartilage.
What are the 5 medically accepted treatments for obesity?
Diet modification, exercise, behavior modification, drug therapy (appetite suppressants), surgery (BMI>40)
What components are part of metabolic syndrome?
HTN, hyperglycemia, truncal obesity, dyslipidemia (increased triglycerides, decreased HDL)
Symptoms of hepatitis
nonspecific flu-like (malaise, body aches, fever, n/v, diarrhea, headache, loss of appetite,); dark urine, jaundice, hepatomegaly, splenomegaly.
Viral liver infection lasting at least one month. Short incubation period (15-50days). Transmitted through fecal/oral route. Vaccine available.
Hepatitis A
Viral liver infection that can be acute or chronic with an incubation period of 60-90 days (or longer). Transmitted parenterally, sexually, perinatally or with close household contact. Vaccine available.
Hepatitis B
Viral liver infection causing inflammation. normally short incubation period (2 wks-6months) but can persist up to 20 years before onset of cirrhosis or hepatoma. Spread by direct blood contact, usually IV drug use. No vaccine.
Hepatitis C (responds aggressively to interferon; primary cause of liver cancer)
Cranial Nerve #1
Olfactory
Cranial Nerve #2
Optic
Cranial Nerve #3
Oculomotor
Cranial Nerve #4
Trochlear
Cranial Nerve #5
Trigeminal
Cranial Nerve #6
Abducens
Cranial Nerve #7
Facial
Cranial Nerve #8
Vestibulococlear
Cranial Nerve #9
Glossopharyngeal
Cranial Nerve #10
Vagus
Cranial nerve #11
Spinal Accessory
Cranial Nerve #12
Hypoglossal
What is first line drug therapy for status epilepticus?
Lorazepam
Herbedens or Bouchards nodes are a signs of what?
Osteoarthritis
An autoimmune catabolic disorder resulting in low or absent circulating insulin, elevated plasma glucagon levels and failure of pancreatic beta cells to respond to all insulin-secretory stimuli
Type 1 DM
pathophysiology of DKA
dehydration due to insulin deficiency results in high blood glucose levels and ketone formation
Common causes of DKA
infection, missed or inadequate insulin, MI, CVA, new diagnosis of DM
Treatment for DKA
fluid replacement, IV insulin, potassium replacement
Early morning rebound hyperglycemia due to nocturnal hypoglycemia
Somogyi effect. Need to adjust evening snacks or insulin dose.
Hyperglycemia due to hepatic gluconeogenesis in early morning
Dawn phenomenon. Related to hormones. No bedtime snack or ensure high protein.
Insulin resistance in target tissues, decreased insulin receptors and/or impairment of insulin secretion.
Type 2 DM
What are DM screening recommendations?
Any age if obesity and additional risk factors are present otherwise age 45. If normal, repeat every 3 years.
what percent of the U.S. population has DM?
9.3% [about 29.1 million people] (38% of patients admitted to the hospital have hyperglycemia
What is the #1 cause of renal failure and blindness?
DM
In which type of DM are insulin doses smaller?
Type 1 (patients are very sensitive. A little bit goes a long way)
What medications are recommended for HTN in diabetics and why?
ACE/ARB (renal protective effects)
When is metformin contraindicated?
Decreased kidney function, recent use of IV contrast, decreased liver function, age>80, infection, cardiopulmonary insufficiency, alcoholism, surgery
What are the three categories of insulin and when are they given
basal: long acting; not eating. overnight/btwn meals
nutrition/bolus: covers carbd eaten during meals
correction/rescue: corrects a high level and brings back to goal
What are the normal basal insulins?
NPH, Glargine, Detemir. NPH has peak effects. Others’ do not
Graves disease, mulinodular goiters and follicular thyroid cancer are results of
hyperthyroidism. 60-80% of ppl with hyperthyroidism have graves disease
Hashimoto’s thyroiditis and iodine deficiency are indicative of:
hypothyroidism
a low TSH and high T4 is indicative of
hyperthyroidism
a high TSH and a low t4 is indicative of
hypothyroidism
S/Sx of hyperthyroidism
fast: tachycardia, palpitations, a fib, fine tremor, weight loss, sweating, fatigue, heat intolerance, diarrhea, bulging eyes, absence of menses.
S/Sx of hypothyroidism
slow/sluggish: weight gain, feeling cold, dry hair, skin, nails, hair loss, constipation, bradycardia, hypotension, heavier/longer menses
Treatment for hyperthyroidism includes
anti-thyroid medications (MMI, PTU [first choice in thyroid storm]), Radioactive iodine 131 (most common in U.S.), thyroidectomy. + symptom management (htn: beta blockers (or CCB if BB contraindicated)
Treatment for hypothyroidism includes
levothyroxine (take in morning 60-90 minutes prior to breakfast)
Inflammatory bowel disease that causes long lasting inflammation and ulcers (unknown cause)
ulcerative colitis
inflammatory bowel disease that can spread deep into bowel tissue; cause unknown
Crohn’s
Functional bowel disorder characterized by abdominal pain/discomfort and altered bowel habits. cause unknown
IBS
Principles of consultation
initiated by the consultee, nonhierarchial and collaborative relationship exists, consultant recommends changes that may be accepted or rejected.
Family caregiving statistics
> 65 million people (29%) of the U.S. population provide care. $375 billion/year is the estimated value of care. Average is at least 20 hours/week with 13% of family caregivers providing 40+ hours/week.
Caregiver burnout
Decreased energy, constant illness (increase from previous, sometimes due to neglect of personal health), persistent exhaustion. Feels of being overwelmed, helplessness and hopelessness.
Nursing Moral Distress
r/t unhealthy work environment. Know right thing to do but are prevented from doing it. Discrepancies btwn education and practice. ineffective communication. lack of teamwork, futile care, gap btwn managed care services and evidence based practice
Six standards to a healthy work environment
communication, collaboration, shared decision making, adequate staffing, nurse recognition, administrative support
This type of public health insurance provides publicly funded care to elders, regardless of income
Medicare
This type of public health insurance provides care for eligible poor
Medicaid
Goals of care are to rule out the underlying disease, restore homeostatis and return the patient to the peak of health (or as close as possible). Self-limiting conditions that are expected to respond to some form of medical intervention
Acute Illness
Uncertainty in outcomes or treatment required. Affects multiple systems and conditions, changes a persons’ lifestyle and relationships within it. Requires ongoing adjustments and is over a long period of time.
Chronic Illness
The ability to perform specific daily living tasks which are normally expected of an individual within a social environement
Functional Capacity. Assessed by ADL; IADL
Considerations with gerontological pharmacokinetics: Absorption
Slows. Increased gastric pH, slower emptying.
Considerations with gerontological pharmacokinetics: Distribution
Altered. Decreased total water. Increased body fat, Decreased cardiac output, consider protein status
Considerations with gerontological pharmacokinetics :Metabolism
Decrease in liver size and blood flow to liver. Increases half life of some drugs
Considerations with gerontological pharmacokinetics: Elimination
Declining renal function necessitates lower doses
Considerations with gerontological pharmacodynatics
Central nervous system changes (receptor sensitivity, receptor sites) can result in increased side effects and behavioral changes. decrease in baroreceptor function can lead to orthostatic hypotension, increased risk of hypoglycemia in DM.
Anticholinergics agents
Cumulative effects including urinary retention, dry mouth, dry eyes, constipation, sedation, confusion, hallucinations. Results from antihistamines, antidepressants, antipsychotics, cimetidine/ranitidine, antispasmodics, antidiarrheals, antiemetics, and anti-Parkinson’s drugs.
Food/Drug Interactions: ACE inhibitors
Avoid potassium supplements & poassium-rich foods
Food/Drug Interactions: Anticoagulants
Avoid foods high in Vitamin K (broccoli, spinach, burssel sprouts, cauliflower, kale)
Common causes of hypernatremia
renal disease, diabetes insipidus, dehydration. Treatment includes treating underlying cause + IV fluid replacement
Common causes of hypokalemia
diarrhea, vomiting, gastric suctioning. potassium replacement
Common causes of hyperkalemia
renal disease, adrenal insufficiency, metabolic acidosis, dehydration. May be induced by NSAIDs and potassium sparing diuretics. Tx: underlying cause + one of the following: calcium gluconate, sodium bicarbonate, insulin and hypertonic dextrose
Common causes of hypocalcemia
hypoparathyroidism, pancreatitis, renal failure, inadequate Vit D intake. S/Sx: tetany, tingling, seizures. Replace calcium and Vit. D
Common causes of hypercalemia
Acidosis, kidney disease, hyperparathyroidsim. prolonged immobilization. S/Sx: muscle weakness, nausea, vomiting, cardiac issues (including arrest). Tx with loop diuretics and Iv fluids
Rapidly progressing dementia causing memory impairments, behavioral changes and loss of coordination. Caused by a prion disease
Creutzfeldt-Jakob Disease
A cognitive and functional decline similar to Alzheimer’s but symptoms fluctuate frequently. May involve visual hallucinations, muscle rigidity, and tremors
Dementia with Lewy bodies
Symptoms similar to Alzheimer’s disease but memory loss may be less pronounced
Vascular dementia
Opacity of the lens of the eye(s) that interferes with vision. Slow progression. Very common in older adults
Cataracts. Tx: surgery
Group of eye conditions characterized by damage to the optic nerve and vision impairment. Involves an increase of intraocular pressure from inadequate drainage of aqueous fluid. S/Sx: blurred vision, halos around lights, lack of focus, headache
Glaucoma. Tx: topical beta blockers, miotics, potential surgery.
Systolic CHF is characterized by
low EF, hypotension, S3. most common. Ventricles don’t squeeze well. Usually accompanied by valvular regurgitation
Diastolic CHF is characterized by
normal EF, ventricles don’t relax well.
What is the diagnostic test that will differentiate btwn systolic and diastolic CHF?
Echocardiogram
S/Sx of CHF
SOB, periph edema, weakness, dizziness, arrhythmias, crackles, elevated JVP, S3
What heart medication should be avoided in diastolic dysfunction?
Digoxin. Dig promotes contractility but in diastolic heart failure, relaxation (not contraction) is the issue, BB, CCB and nitrates are ok
Examples of “rate control” A Fib medications include
CCB, BB, Digoxin, (+ AV node ablation)
Examples of “rhythm control” A Fib medications include
anti-Arrhythmics (amniodorone), + ablation/ MAZE
What are the components of the CHADSII score?
CHF +1; HTN+1; Age>75 +1; DM+1; Stroke hx +2. Score 0-6. 0: no tx; maybe aspirin; 1: aspirin, maybe warfarin; 2+: warfarin.
Cushing triad
Htn, increased pulse pressure, bradycardia. Late sign of brain stem dysfunction
4 clincal signs of Parkinsons disease
Tremor, muscle rigidity, dyskinesia, postural instability
