NR601 Final Exam Questions with Certified Solutions

NR601 Final Exam Questions with Certified Solutions Diabetes Diagnostic criteria - 2 fasting BS > 126 -Random BS >200 if sx of DM present - A1C > 6.5 x2 - 2 hour plasma glucose (OGTT) >200 - Prediabetes 5.7-6.4 A1C Initial Tx of DM - Type 1: usually need hospitalization d/t being in crisis, endocrinology, daily basal & prandial insulin -Type 2: A1C <7.5: Nutritional therapy, physical activity, weight loss, monotherapy (usually metformin). >7.5 @ diagnosis or after 3 months: add a 2nd agent >9.0 insulin (AACE) >10 insulin (ADA) DM medication side effects - Metformin: decr B12 absorption, diarrhea, nausea, anorexia, abd discomfort, *lactic acidosis* (rare), metallic taste - Sulfonylureas (glyburide, glipizide): hypoglycemia, weight gain, GI upset, skin rashes, severe anemia, headache - Acarbose & Miglitol (alpha- glucosidase inhibitors): flatulence & diarrhea -Actos & Avandia (thiazolidinones): weight gain, URI, edema, anemia, hypoglycemia, *CHF*, possible liver damage, bladder tumors - Januvia, onglyza, nesina: stevens-johnson syndrome, pancreatitis, renal failure, abd pain - Trulicity, Tanzeum, Victoza (glucagon-like peptide-1..): pancreatitis, arthralgia - Invokana, Farxiga, jardiance (NA-glucose transport..): renal failure, ketoacidosis, hypotension, genital fungal infections - Glufast, Starlix, Prandin (Meglitinides): wt gain, hypoglycemia DM Tx goals - Healthy pt, long life exp.: A1C <7.5, Fasting: 90-130, Bedtime: 90-150, BP: <140/90, - Complex/intermediate pt, interm. life exp., A1C <8.0, Fasting: 90-150, Bedtime: 100-180, BP <140/90 - Very complex/poor health, limited life exp, A1C < 8.5, Fasting: 100-180, Bedtime: 110-200, BP <150/90 *A1C < 6.5 reduces complications* DM weight loss recommendations - Wt loss not recommended in frail elderly d/t risk of sarcopenia, but even modest exercise is good. -5% weight loss recommended DM Risk factors -Type 1: Caucasians, environmental, autoimmune, and viral toxins, young age, congenital rubella, CMV, Adenovirus, Coxsackie B4, and mumps, high birth weight -Type 2: Men, native American, Alaskan, Hispanic, African American, obesity, sedentary life, family hx, BMI > 25, > 45yo, HLD, GD, having baby > 9lbs, smoking, HTN, PCOS Dm Complications Retinopathy, HLD, diabetic kidney disease, HTN, Macrovascular disease, neuropathy, impotence, blindness, CAD, stroke, slow healing wounds, GU disorder DKA, altered behavior, seizures, coma, Obesity comorbidities CAD, HTN, HLD, DM, sleep apnea, asthma, varicose veins, gout, osteoarthritis, GERD, thromboembolic disease, cancers (endometrial, breast, prostate, colon) BMI Classifications <18.5: underweight 18.5-24.9: Normal 25-29.9: Overweight 30-34.9: Class 1 obesity 35-39.9: Class 2 obesity >40: Class 3 extreme obesity Types of incontinence -Stress: sneezing, coughing, laughing, etc. Tx: Lifestyle &behavioral interventions -Urge: sudden need to void. Tx: Lifestyle interventions. &behavioral. Consider antimuscarinic -Mixed: Combo of stress and urge. Involuntary leaking. Tx: -Overflow: urine leaking when bladder is overfull & doesn't fully empty. Sx: Constant dribbling, nocturia, bladder outlet obstruction -Functional: Unable to hold urine d/t other reasons: unable to get to the bathroom, UTI, psych, delirium Therapies & Meds for incontinence - Lifestyle: Wt loss, fluid restriction, avoid ETOH, caffeine and carbonated drinks, avoid constipation - Behavioral: Pelvic floor exercise, Bladder training (void more often, scheduled toileting, double voiding) - urge incont: anticholinergics (oxybutynin/tolterodine), muscarinic- receptors (darifenacin/solifenacin/trospium). Topical estrogen x2 weeks, when d/t vaginal atrophy - Overflow: d/t prostate hypertrophy (finasteride/ dutasteride/ tamsulosin/doxazosin/terazosin) - Other: collagen (stress), botox & sacral nerve stimulation (urge) Workup for incontinence & hematuria/proteinuria - Urinalysis: Nitrates & leukocytes= infectious process, Hematuria= infection, obstruction, kidney stones, or malignancy, Proteinuria= renal disease (usually from poorly controlled DM). - BUN/Creat/ GFR UTI risk factors - Women: being sexually active, having a previous UTI, pregnancy. postmenopausal: incontinence, hx of UTI, use of spermicide - men: Urethral catheter, anatomical abnormalities of the urinary tract, unprotected anal sex or vaginal sex when woman has an infection. 20% incidence, lifetime prevelance 1% - all: DM (alkaline urine), suppressed immune system, obstruction, catheter dependency, neurogenic bladder UTI bacteria - 80-90%: gram neg e. choli (uncomplicated) -5-20%: gram + staph saprophyticus (uncomplicated) -complicated: (gram neg) proteus mirabilis, klebsiella, enterobacter, serratia, pseudomonas. (gram +) enterococcus, staph aureus. Candida UTI Tx - Due to asymptomatic bacteriuria (ASB) in institutionalized elders, you need more than bacteriuria and pyuria to treat. Need clinical symptoms. - Gu symptoms & pyuria are required for diagnosis - ASB with with foley does not need treatment - all symptoms must be new or acutely worse - Nitrofurantoin 100mg BID x 3 days OR Fosfomycin 3G one time dose (Women) - Fluoroquinolone or SMX-TMX x7 days (Men) Untreated UTI pyelonephritis, sepsis, shock, death STIs - Most common: (Bacterial) Chlamydia, then gonorrhea and syphilis. (Viral) HPV . - Most serious: HIV - older women more susceptible due to drying and thinning of vaginal and vulvar tissue GSM (Genitourinary syndrome of menopause) - incorporates VVA - caused by estrogen deficiency - S/s: painful sex, change in vaginal PH, dysuria, incr UTIs, urinary frequency, itching, bleeding after sex, dryness, pale, dry nonrugated vaginal walls, watery white discharge, retracted clitoris, loss of fat in mons pubis - Dx:pap smear, urinalysis, pelvic exam. Vaginal pH will be >5 - Tx: Pelvic PT, lubricants, low dose estrogen, sexual activity Menopause -12 months of amenorrhea (aver: 51.5 yo) -menstrual changes physiology: FSH > 40 = approach of menopause, high LH levels, levels of estradiol - symptom management: wt loss, aerobic activity, dress in layers, avoid ETOH, caffeine, stress, fans, wt loss,high complex carb & fiber, low fat diet, SSRIs, SNRIs, hormone therapy x 10 years(mod-sev sx, no breast CA), Clonidine 100-150mcg, Duavee, Black cohosh, no soy if CA hx, vaginal estrogen, Osphena (SERM, oral, non-estrogen), regular sex, Bisphosphonates (Fosamax, Boniva, Actonel) to prevent bone loss Erectile dysfunction - Dx: R/o other conditions: BS, Lipid, TSH, testosterone (if <300, serum prolactin). CBC, BMP, PSA. NPTR test to assess ability to get an erection. Doppler sonography - Tx: vacuum constriction device, penile prosthesis, penile revascularization, -Meds: Testosterone (no BPH, CVD, HTN, or Prostate CA) -Comorbid dx: DM/Htn, nerve disease, leriche syndrome, priapism, trauma, peyronie's disease, medications (CA channel blockers, etoh, spironolactone, thioridazine, heroin) ED meds - Parenteral Test- incr libido within 72 hours of injection - oral agents Test: not recommended d/t hepatotoxicity - transdermal (androderm)- dont out on scrotum - implant pellets- steady blood levels for 3-4 months - Buccal Tes- take BID, steady blood levels - Vasoactives: take 1 hour before. viagra, cialis(48 hours no nitrates), stendra, levitra- don't take nitrates or alpha blockers within 24 hours. - injectable vasoact (alprostadil)-works in 20 minutes, lasts 30-60 min. use only once in 24 hours, max of 3x per week. inject in penis. Incr bleeding with anticoagulants -urethral suppository (Alprostadil): works in 5-10 minutes, don't use with pregnant partner Elder Abuse -Types:Physical, Sexual, Neglect, Exploitation (taking funds, property without benefit to them), Emotional, Abandonment, Self- neglect -Provider responsibility: Must report to either 911 or state elder abuse hotline Alzheimer's disease - S: personality changes, psychiatric symptoms, - O: deficits in executive functioning, ADLs, behavior, learning new things, coordination, perception, neuropsychiatric symptoms, - Tx: Biological: treat underlying conditions. Psychotherapeutic: behavioral therapy. Social: functional/safety assessment and intervention. Family: caregiver education. Pharmacotherapy: ChEIs (donepezil, rivastigmine, galantamine), NMDA receptor agonist (Namenda) Dementia Meds SE - ChEIs (Donepezil, Rivastigmine, galantamine): N/V, dyspepsia, anorexia, diarrhea, insomnia, vivid dreams, fatigue, increased urination, cramps. Uncommon: syncope, bradycardia, confusion, depression, agitation. - NMDA receptor antagonist (Namenda): HA, constipation. Uncommon: confusion. Caution with renal impairment - *Black box warning* for antipsychotic medications in elderly d/t stroke and incr mortality ( Zyprexa, Haldol, Abilify, Seroquel, Risperdal, Geodon). reserve use for when behaviors interfere with care Alzheimer's staging - Preclinical: impaired memory (excused or covered), difficulty wit money handling and bills, preserved ADL's, poor judgement and decisions, loss of initiative, subtle personality changes, incr. anxiety, socially normal (2-4+ years) - Mild-Mod: obvious memory & ADL impairment, short attention span, language difficulty, supervision required, variable social skills (2-10 years) - Severe: fragmented memory, no recognition of familiar people, needs help with ADLs, wt loss, infections, seizures, incontinence, groaning, moaning, fewer troublesome behaviors, dysphagia) (1-2+ years) Types of dementia - AD- Most common! -Vascular Dementia: from TIAs/CVAs, no cortical shrinkage, losses defined by area of infarct,stepwise deterioration -Lewy Body Dementia: diffuse lewy body proteins in brain which deplete dopamine. ACTH is depleted causing disruption of perception, thinking, and behavior. results in parkinson symptoms -Frontotemporal Dementia: gradual/progressive symptoms- social inappropraite, disinhibition, easily frustrated, impulsive, compulsive behaviors. exp aphasia, difficulty reading/writing Delirium - S: confusion, attention shifting, rambling, sleep-wake cycle disturbance, daytime sleepiness, nighttime agitation, anxiety, fear - O: Rapid onset (hours to days), Fluctuates throughout the day, poor memory, disorientation, speech disturbance, perceptual disturbances, sudden significant decline - Cause: substance intoxication or withdrawal, medication induced, renal/hepatic/resp failure, hypoxia, meningitis, MI, CHF, arrhythmia, COPD, stroke, infection, seizures, cancer, AIDS, surgery, terminal s, sedative-hypnotics, opioids, anticholinergics, antihypertensives, corticosteroids, lithium - Prevention: correction of sensory deficits, promote normal sleep patterns, nutrition/hydration, stimulation of cognitive functioning, visits from family -Tx: haloperidol, olanzapine, risperidone, quetiapine. Avoid benzos Palliative care - When a pt has a life threatening illness. From the time of diagnosis to death. helps family with bereavement after death -medical, social, emotional, and spiritual services - Ok for pt to have chemo and radiation still - consultation service, but routine weekly visits & hours are not provided Hospice -Last 6 months of persons life -medical, social, emotional, and spiritual services -physician referral is necessary - covered by medicare and usually private insurance - pt chooses to receive hospice instead of curative treatment -usually provided in home Palliative/hospice symptom management - Fatigue: r/o other causes (anemia, IDA, hypoxia, hypothyroid, depression, etc), exercise, stimulants (ritalin), dexamethasone, mirtazapine to help sleep. - Insomnia: sleep hygiene (reduce caffeine, no tv/phone before bed, cool room, warm bath), meditation, zolpidem, mirtazapine, buspirone, trazodone, NO antihistamines - Constipation: goal: +3/week w/o straining&pain, first, bisacodyl 2-3 taps or fleets enema(nothing PR if pt thrombocytopenic), loperamide, lomotil, opium tincture, metamucil, octreotide, cholestyramine, pancrelipase -Dyspnea: Opioids (morphine Qhour), anxiolytics/benzo(ativan), O2 if hypoxemic -Anorexia: small, frequent meals, megestrol acetate, dexamethasone, dronabinol, mirtazapine - N/V (not chemo induced): compazine, haloperidol, zofran, olanzapine, promethazine, reglan, hyoscyamine, scopolamine, meclizine, dexamethasone, dronabinol, haldol,ativan, risperdal, seroquel - Death rattle (secretions): atropine, scopolamine, glycopyrrolate (less likely to cause confusion), levsin, lasix, no suctioning beyond oral cavity Palliative/hospice pain - Mild: NSAIDs (don't use routeinly)/APAP (max 3,000 mg in elderly) -Mod-Sev: Opioid therapy (with APAP) - Sev: Opioids. controlled release- Usually need an aggressive bowel regimen, methadone (helps with neuropathic pain also, long acting, needs careful monitoring-long QT) - TCA (desipramine, nortriptyline, amitrypt): neuropathic pain - SNRI (Duloxetine): DM neuropathy, fibromyaliga, MS pain - anticonvulsants (gabapentin, lyrica): neuropathic - Capsaicin top: neuropathic and non-neuropathic - Lidocaine top: postherpetic neuralgia - corticosteroids: pain d/t nerve compression/antiinflammation - cannabinoids: state-specific regulations Complicated Grief -prolonged, intense, disabling, troubling thoughts, dysfunctional behaviors, dysregulated emotions, serious psychological problems. shock, anger,denial, anxiety, panic, self-harm, substance abuse, difficulty regulating emotion - chronic: prolonged period of time - Delayed: normal reaction is suppressed or postponed (consciously or unconsciously) - Exaggerated: intense reactions (nightmares, delinquent behavior, phobias, suicidal thoughts) - Masked: survivor is unaware that behaviors are interfering with normal functioning are result of loss - Disenfranchised: a loss is not socially recognized ( ex-spouse, women/husband after stillbirth, partners of HIV/AIDS patients, children's stepparent) - 6+ months Uncomplicated grief - sleep/ appetite disturbances, memory loss, hard to concentrate, social withdrawal, disinterest in activities, auditory/visual hallucinations, questioning spiritual beliefs, relief, numbness, helplessness, sad, guilt, self-reproach advanced care planning - Barriers: people not thinking about ACP - POA for healthcare: the person who is consulted when a patient is unable to self=determine care. can legally receive HIPPA protected info to make healthcare decisions for the patient. POLST - pt has < 1 year life expectancy - not a living will or advanced directive - outlines appropriate care for pt- is a set of orders to be followed by emergency workers (they are not bound to a living will, but are bound to follow POLST). -