Exam 2: Gero Lecture 6 Flashcards

1
Q

Describe acute illness.

A

Occurs suddenly and often without warning
Stroke, myocardial infarction, hip fracture, infection

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2
Q

Describe chronic illness.

A

Managed rather than cured
Always present but not always visible
Most common chronic condition in persons over 65 is arthritis, followed by hypertension

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3
Q

What is the preventive phase, definitive phase, crisis phase, and acute phase of chronic illness trajectory?

A

Preventive phase (pre-trajectory)
No S/Sx

Definitive phase (trajectory onset)
S/Sx & diagnosis PRESENT

Crisis phase
Life-threatening situation

Acute phase
Active illness requiring hospitalization

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4
Q

what is the stable, unstable, downward, and dying phase of chronic illness trajectory?

A

Stable phase
Controlled illness course/symptoms

Unstable phase
Not controlled but not requiring/desiring hospitalization

Downward phase
Progressive decline

Dying phase
Immediate weeks/days/hours before death

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5
Q

what are the key points of chronic illness trajectory framework?

A

Majority of health problems in late life are chronic
Chronic illnesses
Acute phase of illness management
Other phases of management
Maintaining stable phases is central in managing chronic illness
Primary care nurse is the coordinator of multiple resources needed to promote quality of life along the trajector

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6
Q

What is frailty?

A

Incidence increases with age
Normal age-related decreases in reserve capacity are depleted and not able to compensate
Combination of geriatric syndromes

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7
Q

regarding frailty: The formal diagnosis is made in the presence of at least three of the following:

A

Unintentional weight loss
Self-reported exhaustion
Weak grip strength
Slow walking speed
Low activity

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8
Q

What are CV diseases?

A

HTN
HF

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9
Q

what is HTN?

A

HTN is a complex disease with a core defect of vascular dysfunction that leads to target organ damage.

HTN is the MOST COMMON chronic condition in people > 65 yo.

In short: 60 yrs or older
BP is OK if LESS THAN 150 SBP OR 90 DBP

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10
Q

what are the HTN interventions?

A

Weight reduction (5-20 mmHg reduction)
DASH diet (8-14 mmHg reduction)
Lower sodium intake (2-8 mmHg reduction)
Increase physical activity (4-9 mmHg reduction)
EtOH in moderation (2-4 mmHg reduction)

LOSE WEIGHT!

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11
Q

what is HF?

A

Most common cause for hospitalization, re-hospitalization, and disability for those over 65 yo
Heart cannot keep up with workload of the heart
Results in insufficient oxygen delivery to body

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12
Q

what is the HF etiology?

A

Results from damage from hypertension and CHD
Ventricles ENLARGE and DILATE  Results in weaker muscle

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13
Q

what is HF also related to?

A

(weakens the heart muscles)
EtOH abuse
Drug abuse
Chronic hyperthyroidism
Valvular disease
Some chemotherapy medications
Radiation therapy near heart (breast cancer, for example)

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14
Q

What happens with LHF?

A

pump failure to body
SBP –> decreased contractility can’t squeeze
DBP –> decreased filling can’t relax
think DYSPNEA

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15
Q

What happens with RHF?

A

pump failure to lungs
results from left side failure
think EDEMA – but also ascites

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16
Q

what happens with congestive HF? (acute decompensated)

A

swelling, edema, fluid in lungs (pulmonary edema)
must remove fluid

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17
Q

what are the CV interventions?

A

Complete assessment of all risk factors and existing disease
lifestyle changes
Medication regimen tailored to specific disease process and patient needs
Focus on symptom management and prevention of exacerbations of disease

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18
Q

What are the CV drugs?

A

ACE (captopril, etc.)
ARB (losartan, etc.)
Diuretics (loop and K+ diuretics, thiazide)
B-Blocker (-lol, etc.)

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19
Q

What is the action for ACE’s and ARB’s?

A

vasodilation –> reduces the cardiac preload and post load improving

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20
Q

What is the action of diuretics?

A

reduce fluid retention

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21
Q

what is the action of B-Blockers?

A

improve contractility of heart muscles

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22
Q

What is neuro-Parkinson’s disease?

A

Progressive disease – over 10-20 yrs
Think DOPAMINE – Dopamine is lost or inhibited
Dopamine regulates nerve impulses for MOTOR function
More common (slightly) in men than women
Onset approximately 60 years
Considered a terminal diagnosis

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23
Q

What is the classic TRIAD for PD? (motor dysfunction)

A
  1. cogwheel rigidity
  2. bradykinesia/dyskinesia –> ALL skeletal muscles are affected
  3. resting/non-intention tremors
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24
Q

what is associated with cogwheel rigidity?

A

Cogwheel Rigidity
Small jerking movements when affected muscles stretched
Muscle rigidity

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25
what is associated with Bradykinesia/Dyskinesia?
Bradykinesia/Dyskinesia  ALL skeletal muscles are affected Difficulty starting, continuing, and or coordinating movements Shuffling May become frozen (Akinesia)  absence of movement Lip, jaw, tongue, etc. when asleep  you won’t see these
26
what is associated with resting/non-intention tremors?
Fine, rhythmic, purposeless tremors Disappear with sleep and purposeful movements Pills rolling, small handwriting, low monotone voice
27
what are the PD clinical signs for autonomic dysfunction?
Seborrhea (seb-o-REE-ik) dermatitis Hyperhydrosis of face and neck Heat intolerance Postural hypotension Constipation
28
what are the PD clinical signs for cog and psychologic dysfunction?
Dementia  dopamine not produced Memory loss, lack of problem solving, decreased intellect Anxiety  don’t understand what is going on Depression Sleep/wake reversal Visual disturbances Psychosis
29
what are some PD clinical signs?
Postural abnormalities (stooped posture) Altered gait (slow start, short steps, “shuffle”)
30
What are the PD complications in late stages?
Complications in late stages can be fatal Pressure ulcers Pneumonia Aspiration Falls
31
what are the PD complications in PD crisis?
Parkinsonian Crisis – Major complication Precipitated by emotional stress or sudden withdrawal of meds
32
What are the PD complications CMs?
Severe exacerbation of tremors, rigidity, and bradykinesia Anxiety Sweating Tachycardia Hyperpnea
33
what are the treatments and interventions for PD complications?
Treatment and interventions Respiratory/cardiac support prn Non-stimulating environment Psychological supports Restarting medications
34
what are the PD interventions?
Early assessment and symptom management Surgical procedures Ablation Deep brain stimulation Stem Cell transplantation (experimental phase) Drug therapy focuses on mimicking or slowing dopamine breakdown
35
what is the PD nursing care: teach exercises?
lift toes when walking widen legs while walking small steps while looking forward tight corner manipulation swing arms with walking to improve balance and ROM cary bag to counterbalance is necessary facial exercises read aloud speak loudly with purpose and concentrated articulation --> watching your movement
36
what are the PD nursing interventions?
preservation of functional ability and quality of life increase independence and ADLs prevent complications and excess disability coping mechanisms increased socialization support groups for pt and fam physical therapy and balance training increase strength and ROM occupational therapy with adaptive equipment
37
What are the dopamine precursors and glutamine antagonist regarding PD meds?
Levodopa (Lardopa), carbidopa-levodopa (Sinemet), amantadine (Symmetrel)
38
what does Levodopa (Lardopa), carbidopa-levodopa (Sinemet), amantadine (Symmetrel) improve in PD?
Improves manifestations of motor dysfunction Levodopa converted to dopamine in brain Carbidopa prevents conversion of dopamine in peripheral tissues = Synergistic effect Amantadine increases CNS response to dopamine
39
what are the SE for Levodopa (Lardopa), carbidopa-levodopa (Sinemet), amantadine (Symmetrel) for PD?
N/V/D, arrhythmias, blurred vision, darkening of sweat and urine, dyskinesias, postural hypotension, hallucinations and vivid dreams
40
who should be avoided with levodopa?
Levodopa avoided in those with h/o TIA, angina, melanoma, Narrow Angle glaucoma
41
what is the client education for levodopa in PD?
Weeks to months to take effect Decrease protein intake Avoid foods with pyridoxine Pork, beef, avocado, beans, oatmeal Antiemetics and PPIs/H2RA prn Interventions to decrease postural hypotension Teach to report increases symptoms and cardiac SEs
42
what are the PD monoamine oxidase B inhibitors (MAOB inhibitors)?
Selegiline (Eldepryl), rasagiline (Azilect)
43
what does Selegiline (Eldepryl), rasagiline (Azilect) do in PD?
Inhibits enzymes that inhibit and/or breakdown dopamine Often used synergistically with Levodopa
44
what are the SE with selegiline and rasagiline for PD?
N/V, dizziness, insomnia, postural hypotension, HTN at high doses
45
what is contraindicated with selegiline and rasagiline for PD?
Contraindicated with Prozac and Demerol
46
what is the client education for selegiline and rasagiline for PD?
Take at same time each day Report insomnia Interventions to prevent postural hypotension Skin exams – risk of melanoma Avoid foods containing Tyramine
47
What is the dopamine agonists for PD?
Bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip)
48
what does Bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip) do for PD?
mimic effects of dopamine in brain
49
what is Bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip) often used synergistically with in PD?
levodopa
50
what are the SE of Bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip) for PD?
N/V/D, arrhythmias, blurred vision, darkening of sweat and urine, dyskinesias, postural hypotension, hallucinations and vivid dreams
51
what is the client edu. for Bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip) in PD?
Same teaching as Levodopa: Weeks to months to take effect Decrease protein intake Avoid foods with pyridoxine Pork, beef, avocado, beans, oatmeal Antiemetics and PPIs/H2RA prn Interventions to decrease postural hypotension Teach to report increases symptoms and cardiac SEs Don’t stop abruptly May cause compulsive behavior
52
what is the catechol-o-methyltransferase inhibitors for PD?
Tolcapone (Tasmar), entacapone (Comtan) “The Capones”
53
what does Tolcapone (Tasmar), entacapone (Comtan) inhibit in PD and what is it used synergistically with?
Inhibit COMT, which breaks down dopamine Used synergistically with Levodopa/Sinemet
54
what does Tolcapone (Tasmar), entacapone (Comtan) interact with, what do you need to monitor, and what should not be used with it for PD?
Monitor LFTs Interacts with warfarin, so monitor INR closely Not to be used with MAOBIs
55
what is the client education for Tolcapone (Tasmar), entacapone (Comtan) in PD?
Take with food No ETOH or sedatives Interventions to prevent postural hypotension Don’t stop abruptly Report muscle control changes, jaundice, dark urine, hallucinations
56
what are the anticholinergics for PD?
Benztropine (Cogentin), trihexyphenidyl (Artane)
57
what do Benztropine (Cogentin), trihexyphenidyl (Artane) do in PD?
Block the excitatory action of acetylcholine May be used synergistically with Levodopa/Sinemet Used early in disease or when Levodopa not tolerated Help prevent PD symptoms of drooling, tremors, rigidity
58
what should benztropine for PD not be used with?
Not used with any other meds with anticholinergic effects (antihistamines, TCAs, etc.)
59
what are the S/S for anticholinergics for PD?
Assess for glaucoma S/S and photophobia dry mouth blurry vision constipation drowsiness sedation hallucinations memory problems trouble urinating confusion delirium decreased sweating decreased saliva Long-term useTrusted Source of anticholinergics, as well as use of these drugs in older peopleTrusted Source, has been linked with an increased risk of dementia. If you’ve been prescribed one of these drugs and have concerns about this risk, be sure to talk to your doctor.
60
what is the client education for anticholinergics for PD?
Avoid activity which promotes fluid loss Don’t stop abruptly
61
What is GERD?
Gastroesophageal reflux disease (GERD) Goal of therapy is to prevent exacerbation of symptoms Lifestyle and diet changes Medication management – PPI’s Most serious complication – Aspiration Pneumonia
62
what are the symp found in elders with GERD?
Persistent cough, Asthma exacerbations, Laryngitis, Intermittent chest pain
63
What is non-modifiable with OP?
female gender northern european ancestry advanced age fam history of OP
64
what is modifiable with OP?
Low birth/body weight (underweight) Low calcium intake Estrogen deficiency Low testosterone Inadequate exercise or activity Use of steroids or anticonvulsants Excess coffee or alcohol intake Current cigarette smoking
65
what is associated with OP stature?
For women, fastest overall loss of bone mineral density is 5 to 7 years immediately after menopause
66
what are the OP complications?
Most serious health consequence of osteoporosis is morbidity and mortality resulting from falls 20-24% of adults with hip fractures die within one year One in five will require long term care Only 15% will be able to walk unassisted six months post fracture Women with osteoporotic fractures have increased incidence of other major complications Vertebral fractures often not recognized - Silent Several new treatment options available – kyphoplasty/vertebroplasty
67
what is the OP diagnosis and treatments?
Diagnosis DEXA scan – dual energy-ray absorptiometry (most common) Put feet in a “feet massager” looking machine T-Score: Osteopenia – diagnosis -1 to -2.5 Osteoporosis – diagnosis if greater than -2.5 USPSTF Currently (but under review): Recommends screening women 65 and older for OP
68
what are the OP interventions?
Weight bearing and resistance training Adequate calcium and vitamin D intake Education about fall prevention Pharmacological therapy to prevent bone loss Bisphosphonates – Teaching!! Upright for 30 min!
69
what is osteoarthritis (OA)?
Normal soft and resilient cartilaginous lining in joint becomes thin and damaged Joint space narrows and bones of joint rub together, causing joint destruction Diagnosis is made clinically Most common symptoms are stiffness with activity and pain with activity relieved by rest
70
what are the most common locations for OA?
Neck – cervical spine Lower back – lumbar spine Hips Hands Fingers Thumbs Knees
71
what are the OA deformities?
Heberden’s node – DIP – Distal Interphalangeal Joint Only in OA Bouchard’s node – PIP – Proximal Interphalangeal Joint In OA and RA
72
what are the OA interventions?
Goals of therapy are to control pain and minimize disability Non-pharmacological therapy Weight loss can help – 1 lb of weight places 4 lb of pressure on knees Exercise - “Motion is the Lotion” Strength and flexibility – support the joints Water exercise Physical therapy Hot/Cold therapy – patient preference Adaptive devices Cane – Relieves hip pressure by 60% Shoe lift for back pain Knee brace for stability
73
what are more OA interventions (pharm therapy)?
Pharmacological therapy Acetaminophen – 4 Gram MAX/day NSAIDs - COX2 (selective NSAID) Joint injections – Intra-articular Steroids - Inflammation Hyaluronic Acid - Lubrication Acupuncture Surgical intervention – Knee/Hip  make sure the surgeon is using visualization Arthroscopy Total Joint Replacement  take everything out
74
what is rheumatoid arthritis (RA)?
Chronic, progressive, systemic inflammatory autoimmune disease Primarily synovial joints Inflammation destroys surrounding cartilage & eventually bone Systemic can affect any organ system i.e. vasculitis, anemia, splenomegaly, pulmonary nodules, pericarditis
75
what is the RA focus of research?
Focus of research includes Genetic factors Environmental triggers in genetically vulnerable population Hormonal triggers
76
what are the RA interventions?
Complete physical and laboratory assessment Pharmacological therapy Pain management DMARDs (disease-modifying anti-rheumatic drugs) - methotrexate Biological response modifier - “-mab” Exercise and physical therapy Environmental modifications Assistive devices
77
Osteoarthritis vs. RA?
OA: older adults may be unilateral (knew, hip, spine, hand DIP AND PIP usually NO MCP shorter period of morning stiffness pain with activity RA: women> men symmetrical -- hands and feet common MCP and PIP usually NO DIP prolonged morning stiffness > 30 M pain > with inactivity
78
What is DMT1?
Disorder of glucose metabolism Type I Absolute deficiency of insulin production due to autoimmune destruction of pancreatic β cells
79
what is DMT2?
Disorder of glucose metabolism Type II Combination of relative insulin deficiency and insulin resistance Genetics, lifestyle, and aging influence development of diabetes
80
what are the DM - Presentation in Older Adults?
dehydration confusion, delirium decrease visual acuity incontinence weight loss and anorexia (polyphagia in younger) fatigue, nausea delayed wound healing parenthesis
81
DM increased risk for...
Amputation Peripheral neuropathy with loss of sensation Evidence of increased pressure (redness, bony deformity) Peripheral vascular disease (diminished or absent pedal pulses) History of ulcers History of amputation Severe nail pathology
82
what are the DM interventions?
Screening and early identification of diabetes Prevent complications Assessment of end organ status Medication management Oral agents Insulin therapy Assessment of self-care ability Nutrition Exercise Close monitoring of residents in long-term care environment
83
What are the thyroid hormones?
Thyrocalcitonin (calcitonin) Tetraiodothyronine or Thyroxine (T4) Triiodothyronine (T3) Thyroid Stimulating Hormone (TSH) Thyrotropin Releasing hormone (TRH) T3 and T4 are call the “thyroid hormones”. Abnormalities of these lead to hyper and hypothyroidism
84
What is associated with calcitonin?
Decreases calcium loss from bone Balances Parathyroid hormone (PTH)
85
what is associated with T4?
Produced by follicular cells if thyroid gland T4 converted to T3 in peripheral tissues
86
what is associated with T3?
4-5 times stronger than T4 - more potent
87
what is associated with TSH?
Produced by pituitary gland
88
what is associated with TRH?
Produced by hypothalmus
89
what are the diagnostic studies for thyroid function?
Thyrotropin-releasing hormone stimulation test (TRH) Radioactive Iodine uptake (RAI) Thyroid scan T3 and T4 lab values Hormones, steroids, ASA, foods containing iodine should be avoided for 7 days before testing.
90
what does the diagnostic study for TRH look like?
TRH injected and TSH measured to assess thyroid function
91
what does the diagnostic study for RAI look like?
Direct test of thyroid function Radioactive iodine absorbed by thyroid and thyroid can be visualized assessing for nodules
92
what is done in a thyroid scan?
Similar to RAI, but iodine not used. Radioactive isotopes given orally and taken up by thyroid and visualized on scan
93
what is hyperthyroidism?
Most severe form thyrotoxicosis Causes Autoimmune disorder (Grave’s disease) *most common Multinodular goiter (Toxic goiter) Women affected more often, 5-7:1
94
what is hyperthyroidism in elders?
Graves disease most common form in older adults Also caused by toxic goiter, iodine ingestion or iodine-containing foods, contrast agents, & medications Onset often abrupt Thyroxine increases myocardial oxygen consumption Increases risk for Afib and angina in person with CHD Can cause heart failure Most common complication – AFIB – 27% of older adults with hyperthyroidism
95
what hyperthyroid symp are not seen in elders?
Many symptoms non-specific in older adults Unexplained Afib Heart failure Constipation Anorexia Muscle weakness
96
what hyperthyroid symp are seen in elders?
older adults often present w: tachycardia tremors weight loss apathetic thyrotoxicosis -- slowed movement and depressed effect
97
what are the hyperthyroidism meds?
Anti-thyroid agents – blocks thyroid hormone production Iodides – inhibit thyroid hormone secretion Beta Blockers – manage tachycardia, anxiety, & tremors Radioactive Iodine (RAI) – shrinks thyroid gland
98
what is associated with the anti thyroid agent?
Methimazole (Tapazole), Propylthiouracil (PTU)
99
what is associated with iodides?
Saturated solution of potassium iodide (SSKI)
100
what is associated with RAIs?
Most common for Graves disease Can be used alone or prior to surgery Absorbed by thyroid and radiation destroys tissue Teach radiation precautions
101
what is a thyroidectomy?
Surgical removal of part or all of thyroid Reserved for severe case or large goiters Review Pre-op & Post-op care
102
what is a thyrotoxicosis?
Life-threatening Exaggeration of hypertyroid symptoms Treatment: Cool with ice, ↓ levels of TH, replace fluids & electrolytes, give O2, stabilize cardiac function. Avoid ASA (increases TH)
103
what is hypothyroidism?
Women affected more often 5:1 Ages 30-60 Slow onset Causes: Primary & Secondary S/S: Think SLOW Metabolic
104
what is hypothyroidism in elders?
Most frequent cause chronic autoimmune thyroiditis Also radioiodine treatment, surgery, medications (Amiodarone), pituitary/hypothalamic abnormality
105
what are the vague S/S for hypothyroidism?
Vague S/S – often subtle Slowed mentation Gait disturbances Fatigue Weakness Heat intolerance
106
what are the treatment and diagnosis for hypothyroidism?
Diagnosis TSH, T3, T4, FT4 PE and hx; Cardiac studies to assess for complications Treatment Thyroid replacement therapy Review: Levothyroxine (Synthroid)
107
what is the nursing care for hypothyroidism?
Prevent: chilling, constipation, skin breakdown, infection Assess: cardiac complications, edema, tachycardia, skin Lifelong levothyroxine therapy Warning: levothyroxine can cause digoxin toxicity
108
Hypothyroidism- Myxedema Coma?
Rare & Life-threatening complication with HIGH mortality rate
109
Hypothyroidism- Myxedema Coma causes?
Untreated or uncontrolled hypothyroidism External stressors including surgery, trauma, infection, excessive exposure to cold temps
110
Hypothyroidism- Myxedema Coma cms?
Hypothermia, Mental function ranges from depression to unconscious, Respiratory depression (hypoventilation), Hypotension, Bradycardia
111
Hypothyroidism- Myxedema Coma treatment?
Supportive measures and stabilization of vitals Treat underlying cause Thyroid hormone replacement – must be slow r/t toxicity with rapid replacement
112
what is prostate cancer (PC)?
Most common non-skin cancer in men 1 in 5 (black) & 1 in 6 (white) chance of developing Usually detected by screening
113
what are the cms of PC?
General urinary complaints, retention, hematuria, back pain Cachexia, bone tenderness, lower lymphedema, adenopathy
114
what are the screening for PC?
Screening when asymptomatic should be individualized based on personal and family history Uncertainties, Risks, Benefits Screening methods Digital Rectal Exam Prostate-Specific Antigen (PSA) American Cancer Society 50 y/o for men at average risk who have at least a 10-year life expectancy 40 or 45 y/o for African Americans and men who have had a first-degree relative diagnosed with prostate cancer before age 65 40 y/o for men with several first-degree relatives who had prostate cancer at an early age USPSTF Men aged 55 to 69 years Recommends against PSA screening in men aged 70 and older
115
What are the PC diagnosis?
PSA No PSA level guarantees the absence of prostate cancer. The risk of disease increases as the PSA level increases, from about 8% with PSA levels of ≤1.0 ng/mL to about 25% with PSA levels of 4-10 ng/mL and over 50% for levels over 10 ng/mL Digital Rectal Exam (DRE) Examiner-dependent; serial examinations over time are best Most patients diagnosed with prostate cancer have normal DRE results but abnormal PSA readings Biopsy Biopsy establishes the diagnosis False-negative results often occur, so multiple biopsies may be needed before prostate cancer is detected
116
what is the PC care?
Active surveillance Watchful waiting Radical prostatectomy (surgical removal)  will go home with a foley (teach foley care) Radiation therapy Hormone therapy  don’t normally have to replace male hormones