NURS 6550 Acute Care Study Guide for Midterm Exams

NURS 6550 Acute Care Study Guide for Midterm Exams Psychosocial WEEK 2 Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2018). Current medical diagnosis & treatment (57th ed.). New York, NY: McGraw Hill. Chapter 25, “Psychiatric Disorders” (pp. ) • Evaluate patients with psychosocial health conditions • Develop differential diagnoses for patients with psychosocial health conditions • Develop treatment plans for patients with psychosocial health conditions Generalized anxiety disorder diagnosis criteria- Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. (1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3) difficulty concentrating or mind going blank (4) irritability (5) muscle tension (6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Primary neurotransmitter in PTSD- Due to the traumatic stress of PTSD victims, the neurotransmitters that fuel the sympathetic versus parasympathetic system get out of balance. As a Yale University journal review states, “It has been suggested that alterations in NE [norepinephrine], E [epinephrine], and 5-HT [5HTP] may have relevance for symptoms commonly seen in survivors with PTSD * PTSD diagnosis and treatment-assessing history of exposure to a perceived or actual life threatening event, serious injury or sexual violence, symptoms lasting more than 1 month. Disturbance causes clinically significant distress or impairment in functioning H) The disturbance is not attributable to the physiological effects of a substance or other medical condition DSM-5 recognizes a “with dissociative symptom” specifier when the PTSD symptoms are accompanied by persistent or recurrent depersonalization or derealization. The specifier “with delayed expression” should be included if the full criteria for PTSD are not met for more than 6 months following the trauma. The traumatic event is persistently re-experienced: • Nightmares • Intrusive thoughts of the traumatic event • Flashbacks • Marked emotional distress when exposed to traumatic reminders • Strong physiologic reaction when exposed to traumatic reminders Treatment psychotherapy (cognitive processing, prolonged exposure therapy, eye- movement desensitizing) . SSRIs (sertraline, paroxetine) clonidine 0.1mg at bed time, prazosin 2-10mg for nightmare, antiseizure meds for anger management (carbamazepine 400-800mg daily), clonazepam 1-4mg daily for anxiety, Trazodone 25-100mg for sleep. Treatment of acute panic attacks- What are the medications for initial/first line therapy- SL 0.5-1 mg alprazolam, clonazepam 0.5-1mg, antidepressants, SSRIs (sertraline 25mg/day for 1 week, then 50mg) Inpatient treatment of depression- ECT o What are the therapies for patient’s that won’t eat, take meds, etc. When is serotonin norepinephrine reuptake inhibitor indicated, when is it contraindicated? For pain neuropathy/fibromyalgia Venlafaxine dosing, when is follow up? What are you monitoring? - Blood pressure monitoring, arrhythmias DOSE is 150-225 mg daily. Patients should be cautioned about the concomitant use of Venlafaxine tabletsand NSAIDs, aspirin, warfarin, or other drugs that affect coagulation since combined use of psychotropic drugs that interfere with serotonin reuptake and these agents has been associated with an increased risk of bleeding (see PRECAUTIONS,Abnormal Bleeding). Usual Adult Dose for Anxiety Extended release: Initial dose: 75 mg orally once a day Maintenance dose: May increase in daily increments of 75 mg orally at intervals of no less than 4 days Maximum dose: 225 mg orally per day Usual Adult Dose for Panic Disorder Extended release: Initial dose: 37.5 mg orally once a day Maintenance dose: May increase dose in daily increments of 75 mg orally at intervals of no less than 7 days Maximum dose: 225 mg orally per day Usual Adult Dose for Depression Immediate release: Initial dose: 37.5 mg orally twice a day or 25 mg orally 3 times a day Maintenance dose: May increase in daily increments of up to 75 mg orally at intervals of no less than 4 days Maximum dose: (moderately depressed outpatients): 225 mg orally per day Maximum dose (severely depressed inpatients): 375 mg orally per day Comments: -Daily dosage may be divided in 2 or 3 doses/day Endogenous depression pathophysiology is best described as? Endogenous depression. Endogenous depression (melancholia) is an atypical sub-class of the mood disorder, major depressive disorder (clinical depression). Endogenous depression occurs due to the presence of an internal (cognitive, biological) stressor instead of an external (social, environmental) stressor. No apparent outside cause. Exogenous is caused by something (stress, some event) Differences between panic attacks and panic disorder? Panic attacks are recurrent, unpredicted episodes of intense surges of anxiety accompanied by marked physical manifestations. Panic Disorder Someone with generalized anxiety disorder (GAD) has chronic anxiety, and a tendency to become over- anxious about issues which would not normally cause concern. Panic disorder is characterized by repeated episodes of panic attacks, in which the individual is overcome by feelings of fear and dread. What are Major Depressive disorder symptoms?- physical & cognitive symptoms, loss of interest and pleasure(anhedonia) withdrawal from activities and guilt, poor concentration, worthlessness, fatigue Identify the primary neurotransmitter in PTSD • PTSD diagnosis and treatment, meds (families/common meds)? Familiarize yourself with the side effects of Lithium- GI, tremors-treat with propranolol 20- 60mg a day, weakness, somnolence, polyuria (reduced renal response ADH) , polydipsia (increased plasma renin concentration), thyroid, EKG changes, long term effects cogwheel rigidity, affect Common adverse effects of atypical antipsychotics- anticholinergic side effects dry mouth which can cause increases caloric liquid intake (wt gain & hyponatremia) blurred vision, urinary retention, delayed gastric emptying, esophageal reflux, ileus, delirium, acute glaucoma, sexual disturbances, and orthostatic hypotension, EKG changes prolonged QT Mental status changes in elderly… how do you evaluate? Mental status changes related to UTI in elderly Assessment of Delirium in geriatric patients- Acute onset, fluctuating course, deficits in attention not memory. Elders with dementia and driving – there is no gold standard assessment, consider the severity of the dementia ( severe should not drive), consider comorbidities and medications, ability to do IADLS, , may need to be assessed by a driver rehab specialist. Short Confusion Assessment Method (Short CAM): what things are assessed? Acute onset and fluctuating course, inattention and either disorganized thinking or ALOC. Types of dementia, know differences? Alzheimer's disease- Alzheimer's disease Most common type of dementia; accounts for an estimated 60 to 80 percent of cases. Symptoms: Difficulty remembering recent conversations, names or events is often an early clinical symptom; apathy and depression are also often early symptoms. Later symptoms include impaired communication, poor judgment, disorientation, confusion, behavior changes and difficulty speaking, swallowing and walking. Revised guidelines for diagnosing Alzheimer’s were published in 2011 recommending that Alzheimer’s be considered a slowly progressive brain disease that begins well before symptoms emerge. Brain changes: Hallmark abnormalities are deposits of the protein fragment beta-amyloid (plaques) and twisted strands of the protein tau (tangles) as well as evidence of nerve cell damage and death in the brain Vascular dementia- Vascular dementia Previously known as multi-infarct or post-stroke dementia, vascular dementia is less common as a sole cause of dementia than Alzheimer’s, accounting for about 10 percent of dementia cases. Symptoms: Impaired judgment or ability to make decisions, plan or organize is more likely to be the initial symptom, as opposed to the memory loss often associated with the initial symptoms of Alzheimer's. Occurs from blood vessel blockage or damage leading to infarcts (strokes) or bleeding in the brain. The location, number and size of the brain injury determines how the individual's thinking and physical functioning are affected. Brain changes: Brain imaging can often detect blood vessel problems implicated in vascular dementia. In the past, evidence for vascular dementia was used to exclude a diagnosis of Alzheimer's disease (and vice versa). That practice is no longer considered consistent with pathologic evidence, which shows that the brain changes of several types of dementia can be present simultaneously. When any two or more types of dementia are present at the same time, the individual is considered to have mixed dementia Dementia with Lewy bodies (DLB)- Dementia with Lewy bodies (DLB) back to top Symptoms: People with dementia with Lewy bodies often have memory loss and thinking problems common in Alzheimer's, but are more likely than people with Alzheimer's to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and slowness, gait imbalance or other parkinsonian movement features. Brain changes: Lewy bodies are abnormal aggregations (or clumps) of the protein alpha-synuclein. When they develop in a part of the brain called the cortex, dementia can result. Alpha-synuclein also aggregates in the brains of people with Parkinson's disease, but the aggregates may appear in a pattern that is different from dementia with Lewy bodies. The brain changes of dementia with Lewy bodies alone can cause dementia, or they can be present at the same time as the brain changes of Alzheimer's disease and/or vascular dementia, with each abnormality contributing to the development of dementia. When this happens, the individual is said to have mixed dementia. Mixed dementia- Mixed dementia In mixed dementia abnormalities linked to more than one cause of dementia occur simultaneously in the brain. Recent studies suggest that mixed dementia is more common than previously thought. Brain changes: Characterized by the hallmark abnormalities of more than one cause of dementia — most commonly, Alzheimer's and vascular dementia, but also other types, such as dementia with Lewy bodies. Parkinson's disease- Parkinson's disease As Parkinson's disease progresses, it often results in a progressive dementia similar to dementia with Lewy bodies or Alzheimer's. Symptoms: Problems with movement are common symptoms of the disease. If dementia develops, symptoms are often similar to dementia with Lewy bodies. Brain changes: Alpha-synuclein clumps are likely to begin in an area deep in the brain called the substantia nigra. These clumps are thought to cause degeneration of the nerve cells that produce dopamine. Frontotemporal dementia- Frontotemporal dementia Includes dementias such as behavioral variant FTD (bvFTD), primary progressive aphasia, Pick's disease, corticobasal degeneration and progressive supranuclear palsy. Symptoms: Typical symptoms include changes in personality and behavior and difficulty with language. Nerve cells in the front and side regions of the brain are especially affected. Brain changes: No distinguishing microscopic abnormality is linked to all cases. People with FTD generally develop symptoms at a younger age (at about age 60) and survive for fewer years than those with Alzheimer's. Creutzfeldt-Jakob disease- CJD is the most common human form of a group of rare, fatal brain disorders affecting people and certain other mammals. Variant CJD (“mad cow disease”) occurs in cattle, and has been transmitted to people under certain circumstances. Symptoms: Rapidly fatal disorder that impairs memory and coordination and causes behavior changes. Brain changes: Results from misfolded prion protein that causes a "domino effect" in which prion protein throughout the brain misfolds and thus malfunctions. Normal pressure hydrocephalus-Normal pressure hydrocephalus Symptoms: Symptoms include difficulty walking, memory loss and inability to control urination. Brain changes: Caused by the buildup of fluid in the brain. Can sometimes be corrected with surgical installation of a shunt in the brain to drain excess fluid. Huntington's Disease back to top Huntington’s disease is a progressive brain disorder caused by a single defective gene on chromosome 4. Symptoms: Include abnormal involuntary movements, a severe decline in thinking and reasoning skills, and irritability, depression and other mood changes. Brain changes: The gene defect causes abnormalities in a brain protein that, over time, lead to worsening symptoms Wernicke-Korsakoff Syndromeback to top Korsakoff syndrome is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). The most common cause is alcohol misuse. Symptoms: Memory problems may be strikingly severe while other thinking and social skills seem relatively unaffected. Brain changes: Thiamine helps brain cells produce energy from sugar. When thiamine levels fall too low, brain cells cannot generate enough energy to function properly Aricept and dosing and patient teaching? Donepezil 5 mg PO once daily max dose 10mg daily, side effects diarrhea, nausea, anorexia, wt loss, syncopal. D/C med if no benefits or having side effects, or financial burdens, evaluate after 2 months of highest dose Most important fact about this drug To maintain any improvement, Aricept must be taken regularly. If the drug is stopped, its benefits will soon be lost. Patience is in order when starting the drug. It can take up to 3 weeks for any positive effects to appear. How should you take this medication? Aricept should be taken once a day just before bedtime. Be sure it's taken every day. If Aricept is not taken regularly, it won't work. It can be taken with or without food. If you miss a dose... Make it up as soon as you remember. If it is almost time for the next dose, skip the one that was missed and go back to the regular schedule. Never double the dose. Management of disinhibition in elderly- • Physical findings when death is imminent- dyspnea, nausea/vomiting. Pain, constipation, fatigue, delirium/agitation, Coolness. Hands, arms, feet, and legs may be increasingly cool to the touch. ...Confusion. ... Sleeping. ... Incontinence. ... Restlessness. ... Congestion. ... Urine decrease ................. Fluid and food decrease, Little appetite and thirst. Fewer and smaller bowel movements and less pee, More pain, Changes in blood pressure, breathing, and heart rate. Limits of pain medication on dying patient- use long acting opioids around the clock and short acting opioids for breakthrough pain , do not undertreat pain in the dying pt (in rare cases palliative sedation may be needed, use of versed or phenobarbital IV with monitoring) Theories about successful aging…familiarize yourself with them- A person was deemed to have successfully aged if the person (1) lived free of disability or disease; (2) had high cognitive and physical abilities; and (3) was interacting with others in meaningful ways Reducing risk factors for disease/disability • Genetic risks decline with age; lifestyle factors determine risk • Risk factors can be reduced/modified (e.g. weight loss program effect on cardiovascular disease) • Increased within-person variability is predictor of mortality (better than just their mean level of performance) • Maximizing cognitive and physical function • Predictors of cognitive function: education, strenuous activity around home, peak pulmonary flow rate, self-efficacy • Education: due to direct beneficial effect or leads to life-long learning? • Cognitive function can be enhanced; plasticity persists in older age • Continuing engagement with life • Social relations: Being part of social network determines longevity, esp for men • Socio-emotional (affection) vs instrumental (direct assistance) support • Productive activity predictors: functional capacity, education, and self-efficacy • Response to stress • More ‘stressful life events’ and ‘daily hassles’; need resilience to recover and meet criteria for successful aging • Activity theory • Continuity theory • Disengagement theory Activity Theory The activity theory occurs when individuals engage in a full day of activities and maintain a level of productivity to age successfully. The activity theory basically says: the more you do, the better you will age. It makes a certain kind of sense, too. People who remain active and engaged tend to be happier, healthier, and more in touch with what is going on around them. Same goes for people of any age. Often, the activity theory is dismissed to some degree because it falls a little flat. It isn't sufficient to just be busy, like the definition states. You can't wake up every day and do the same thing, like riding a stationary bike, and expect to age well. This theory was taken and used by many program designers for the elderly, who filled older folks' schedules with busy work and required them to complete tasks. A heightened level of activity is needed, but it needs to be engaging and fulfilling, rather than just busy work. The theory also fails to consider maintenance of one's mid-life or changes that are made when entering retired or older life. If I was a high-powered, high-stress executive and I retire and go into pottery making, am I going to age successfully? Not likely, particularly if I enjoyed my job as an executive. Maybe what is needed is another theory that looks at the lifespan instead of just older age. Continuity Theory The continuity theory states that individuals who age successfully continue habits, preferences, lifestyle, and relationships through midlife and later. Again, this theory makes a certain kind of intuitive sense. People who are doing well in midlife, who are happy, healthy, and just plain dandy should carry over the habits and ideals that made them that way. Basically, good stuff should be continued because it's good stuff! An easy way of thinking about how the continuity theory can demonstrate successful aging is by considering your own life. The disengagement theory of aging states that "aging is an inevitable, mutual withdrawal or disengagement, resulting in decreased interaction between the aging person and others in the social system he belongs to". The theory claims that it is natural and acceptable for older adults to withdraw from society. Psychological abuse of elders Death and the anxiety related to it, who’s at risk? Age and suicide risk in the different age groups? Geriatric Depression Screen- Geriatric Depression Scale: Short Form Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO Answers in bold indicate depression. Score 1 point for each bolded answer. A score 5 points is suggestive of depression. A score ≥ 10 points is almost always indicative of depression. A score 5 points should warrant a follow-up comprehensive assessment. Geriatric Depression Scale The Geriatric Depression Scale (GDS) was specifically developed for use in geriatric populations, originally as a 30-item scale. It was modified a 15-item scale, which has been widely used. The GDS was later reduced to 5 items, so as to be better received by elderly patients. The questions elicit only “yes” or “no” responses, making comprehension easier compared with multiple-choice answers. The 5-item scale has a sensitivity of 94%, specificity of 81%, and demonstrated a significant agreement in the clinical diagnosis of depression with the 15-item scale. The 5-item scale is scored by 1 point for a “no” answer on the first question or a “yes” answer for the remaining questions. A score of greater than or equal to 2 is a positive screen for depression Which of the following is not an indication for use of a serotonin-norepinephrine reuptake inhibitor?- Unresponsiveness to an SSRI Lucy Garcia is a 42-year-old Hispanic female with a 20-plus-year history of depression. She is currently hospitalized for treatment of progressive, acute-on-chronic depressive symptoms, including refusal to get out of bed and inattentiveness to personal hygiene --------------------------------------------- Electroconvulsive treatments Which of the following are risk factors for obesity? (Select all that apply ------------- African American and Hispanic youth are at increased risk for childhood and adolescent obesity, Skipping breakfast Frequent takeout/fast-food meals, Consumption of sugar sweetened beverages How should a physician assess the risk for suicide in a depressed adolescent? (Select all that apply.) By asking family members whether they feel that the patient is at risk for suicide By establishing a no-suicide contract with depressed adolescents Why must a physician assess the risk for suicide in a depressed adolescent? All suicide gestures should be taken seriously WEEK 3 ENT Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F.A. Davis Company. • Section 5, “Head: Eyes, Ears, Nose, and Mouth” o Chapter 68, “Audiometry Testing”- C/O tinnitus, unexplained behavior changes in geriatrics, contraindications (cerumen obstruction, otitis externa) pull the pinna up and back, normal -10-26 dB, mild 20-40 dB, mod. 56-70 dB, profound 91 + dB o Chapter 70, “Tympanometry” – test mobility of tympanic membrane, middle ear pressure, and volume of the external canal. Used to measure otitis media resolution, serous otitis media, presence of eustachian tube dysfunction problems and screen for developemental delays. The tympanometer measures the "admittance" or "compliance" of the tympanic membrane while different pressures