NURS 620 Adult Health Exams Prep | Comprehensive Study Materials

NURS 620 Adult Health Exams Prep | Comprehensive Study Materials Risk factors for DVT - ANS •Genetic clotting disorders •Immobility, prolonged bedrest, inactivity •Paralysis •Injury/trauma •Surgery/dehydration •Oral contraceptives/hormonal replacement therapy •Overweight and obesity states •Tobacco use •Cancer/malignancy •Prolonged sitting •Family hx of DVT or PE •Age of 60+ •Heart failure/CV conditions •Bowel diseases that have an inflammatory etiology •Pregnancy/postpartum •Varicose veins Symptoms of DVT - ANS •Sometimes asymptomatic •Swelling in affected extremity-usually unilateral •Pain in the calf •Leg cramps/tenderness/soreness •Erythema •Pallor •Cyanosis Physical assessment for DVT - ANS •Vascular assessment- palpation of peripheral pulses • Evaluation of capillary refill •Neurological exam-motor, sensory, reflex deficits may occur •Homan's sign-pain in the posterior calf or knee with forced dorsiflexion of foot What happens after DVT sometimes? - ANS PE •DVT- occurs deep in veins •Phlebitis -occurs in superficial veins •33% to 40% of individuals with Dx of DVT develop a subsequent Pulmonary Emboli (PE) •15 percent mortality rate PE symptoms/signs - ANS •SOB/DOE •HTN •Tachypneatachycardia •Diaphoresis •Hemoptysis •Low grade fever •Chest pain •Cough Diagnosis of DVT - ANS •Wells score •Compression USG • Venography- reference gold standard for dx •MRI •D-Dimer measurements-d dimer is a fragmented protein that has a negative predictive value (i.e. results of D-Dimer negative= unlikely VTE- Different for geriatric patients Treatment for PE, DVT - ANS •Anticoagulation -heparin, low molecular heparins -Fondaparinux (Arixtra) injections -Warfarin (Coumadin) INR-2.0-3.0 usual target -Enoxaparin (Lovenox) -Rivaroxaban (Xarelto) -Apixaban (Eliquis) •Thrombolytic therapy-"clot busters"-tPA •Surgical intervention •Filters-i.e. inferior vena cava filters •Compression stockings New anticoag agents - ANS •Savayse *edoxaban (approved ) Jan, 2015 •Xarelto- no monitoring (linked to internal bleeding events recently) •Pradaxa-blocks thrombin •Eliquis- used mostly for stroke prevention Patient education for DVT - ANS •Avoid prolonged immobility •Avoid as possible estrogen therapy in women •Early ambulation-post surgical •Hydration •Compression stockings •Take meds as directed •Avoid tight fitting clothing-hose, stockings •Low K diet in pts with Warfarin therapy Make sure your teaching about medications- especially anticoagulants. Symptoms to explore for respiratory - ANS •Cough •Dyspnea -On exertion -At rest -Constant or intermittent •Associated symptoms •Chest pain/pleuritic pain •Fever, chills •Sputum production -Color -Quality -Consistency •PND •Wheezing •Night sweats •Hemoptysis HPI habit questions for respiratory - ANS •Tobacco use- vaping? -Pack years •Exposure to allergens •Travel •Medications- ace inhibitors -Prescription -OTC -Herbal •Alternative therapies Cough duration: Acute- Sub-acute Chronic- - ANS acute: 0-3 weeks sub-acute: 3-8 weeks Chronic: >8 weeks diff diagnosis of cough - ANS •Postnasal drainage/sinusitis •Acute bronchitis •Medication side effect •Environmental irritants •GERD •Asthma •COPD •Pneumonia •Tuberculosis Differential diagnosis for hemoptysis - ANS •Upper respiratory tract infection •Pneumonia •Malignancy •Tuberculosis •Lung abscess •Pulmonary edema •Pulmonary embolism •Mitral stenosis •Sarcoidosis evaluation for hemoptysis - ANS •History - is key! •Physical examination •Laboratory studies -CBC -Coagulation panel •CXR •Sputum for AFB and cytology •Bronchoscopy •Chest CT Acute Bronchitis - ANS •Common clinical diagnosis usually described as an acute infection of the lower respiratory tract manifested by a cough with or without sputum production that lasts for up to 3 weeks •Subjective diagnosis - significant symptom overlap with common cold -No diagnostic test can differentiate between the two diagnoses Risk factors for acute bronchitis - ANS -Smoking -Alcohol use -Malignancy -History of splenectomy -HIV positive Causes of acute bronchitits - ANS •Caused by viruses in over 90% of cases - Influenza A and B, parainfluenza, and respiratory syncytial viruses •Bacteria responsible for infection < 10% of the time - Mycoplasma pneumoniae, Chlamydophila pneumonia , Bordetella pertussis Acute Bronchitis Treatment - ANS Supportive care only inhaled b2-agonist Cough medications Self limiting usually caused by a virus Community Acquired Pneumonia (CAP) - ANS •An acute infection of the lung parenchyma •Epidemiology - Nearly 5 million people develop pneumonia annually -Approximately 1 million of these individuals are over age 65 -7th leading cause of death in the U. S. -Rates of mortality due to pneumonia have not decreased significantly since penicillin became routinely available Symptoms of CAP - ANS -Cough - productive/nonproductive -Fever/chills -Chest discomfort -Fatigue -Dyspnea -Pleuritic pain Evaluation for pnumnoia - ANS •History •Physical examination- dull lungs to percussion, rales, wheezing. •CXR - infiltrate by CXR required for diagnosis •Laboratory studies - may include -CBC -BMP -Sputum culture indications for hospital admission for pneumonia - ANS •PORT-PSI and CURB-65 -Risk assessment tools to determine need for hospitalization •Pneumonia Outcomes Research Team-Pneumonia Severity Index (PSI) -Five separate risk categories based on age, comorbidities, physical examination, and laboratory findings -Patients scoring in classes IV and V should be hospitalized CURB-65 - ANS 1) Confusion 2) BUN>19 3) RR>30 4) BP<90/60 5) 65yo -0-1 - Low risk; consider home treatment -2 - Short inpatient hospitalization or closely supervised outpatient treatment -3-4 - Severe pneumonia; hospitalize and consider admitting to intensive care •Determination of need for admission should also include: -Patient's ability to safely and reliably take oral medications -Home environment/resources what pathogen causes CAP- Common viral and bacterial causes of pneumonia: - ANS The most common pathogens include: - Streptococcus Pneumoniae - Haemophilus influenzae - Mycoplasma Pneumoniae - Chlamydophila Pneumoniae - Viral infections • -VIRAL: INFLUENZA A AND B, RSV • -BACTERIAL: STREPTOCOCCUS PNEUMONIAE, H. INFLUENZAE, LEGIONELLA PNEUMOPHILA, STAPH AUREUS, CHLAMYDIA PNEUMONIAE, MYCOPLASMA PNEUMONIA Know treatment of CAP- First and second line therapy for community acquired pneumonia. - ANS · Levofloxacin 750 mg PO q24h or. · Moxifloxacin 400 mg PO q24h or. · Combination of a beta-lactam ( amoxicillin 1 g PO q8h or amoxicillin-clavulanate 2 g PO q12h or ceftriaxone 1g IV/IM q24h or cefuroxime 500 mg PO BID) plus a macrolide (azithromycin or clarithromycin) Lung pathologies (bronchitis, emphysema, asthma, COPD) - is disease process reversible - ANS BRONCHITIS: NONREVERSIBLE EMPHYSEMA: NONREVERSIBLE COPD: NONREVERSIBLE ASTHMA: REVERSIBLE Lung Cancer - ANS •Non-small-cell -Adenocarcinoma - most common type •Many present peripherally •Frequently arise in areas of previous pulmonary parenchymal damage •Less closely associated with smoking than other types -Squamous cell - second most common type •Strongly associated with smoking •Most occur centrally and can produce bronchial obstruction •Tend to ulcerate and cause bleeding •Non-small-cell -Undifferentiated large-cell - least common type •Likely a form of adenocarcinoma, but are found centrally •Metastasize early to bone, liver, and brain •Small-cell -Located centrally -Tumors grow rapidly - 50 - 75% of patients have metastatic disease at time of diagnosis -Untreated, the median survival is only a few months Clinical presentation of lung ca - ANS •Partially a function of tumor location •Central endobronchial lesions - may produce symptoms early -Hemoptysis -Cough -Sputum production -Localized wheeze •Symptoms of advanced disease -Anorexia -Weight loss -Nausea -Hoarseness -Bone pain OSA: Understand how to determine if someone may have it. What do you inspect when screening for it? What are some risk factors for sleep apnea? - ANS • Obesity o Nuchal obesity • Deviated septum • Nasal polyps • Enlarged uvula and soft palate • Small chin with deep overbite • Enlarged tonsils • Large tongue NASAL POLYPS, DEVIATED SPETUM, OBESITY, THICK NECK, ALCOHOL CONSUMPTION, COEXISTENCE WITH SNORING AND HYPERINSOMNIA Claudication is the classic presenting symptom associated with which of the following? - ANS arterial insufficiency Risk factors for chronic arterial insufficiency?- - ANS tobacco use You are using the CURB 65 clinical tool, for determining which patient dx with CAP should be hospitalized or treated at home. Mabel's score is 2- what should we do? - ANS Short inpatient stay; if she is relatively healthy, she could be closely supervised outpatient S/S of COPD correlate with which of the following?- - ANS Chronic bronchitis with airway obstruction Presents with history of asthma without treatment for a while. She reports daily but not continual symptoms that last longer than 1 week and present at night. She has been using her rescue inhaler. Her FEV1 is 60-80% predicted- how would you classify her asthma? - ANS moderate persistent What is the most common bacterial pathogen in CAP? - ANS Streptococcus PNA Which obstructive lung disease is reversible - ANS asthma George has COPD and a 40% FEV1. How would you classify the severity of his COPD - ANS Stage 3 Jason age 62 has Obstructive Sleep Apnea (OSA). Which of these is a contributing factor? - ANS his collar size is 17 inches A patient with CAD should be placed on which of the following as antiplatelet tx (first line) - ANS Aspirin What is the desired therapeutic action of inhaled corticosteroids? - ANS reduction in airway inflammation What is the appropriate tx for a pt dx with chronic venous insufficiency - ANS use of elastic stockings What is the most important measurement in a pulmonary function in a patient with asthma? - ANS FEV forced expiratory volume Healthy 27 yo man, dx with CAP, which one of these is the best choice of tx? - ANS azithromycin- macrolide Salmeterol (Serevent) is an example of which of the following? - ANS long acting beta agonist(LABA) fluticasone & budesonide (pulmocort) are examples of what? - ANS ICS Inhaled Corticosteroid Ipratropium (Atrovent) is an example of what? - ANS Short-acting muscarinic-antagonist (SAMA) montelukast (Singulair) is an example of what? - ANS NON STEROIDAL PREVENTERS Salbutamol (Ventolin) and Albuterol is an example of what? - ANS Short acting beta-2 andrenergic (SABA) tiotropium (Spiriva) is an example of what? - ANS (LAMA) Long-acting muscarinic-antagonist What is the most important goal of treating HTN - ANS Avoiding disease targeted organ damage indicates severe asthma attack, requiring emergent treatment? - ANS inaudible breath sounds When should a rescue course of prednisolone be issued for a asthma attack - ANS anytime its needed for symptoms What intervention would indicate a patient needs more education for her asthma? - ANS opening a window at night what is usually the earliest sign of coronary artery disease (CAD) - ANS intermittent claudication what characteristic is a risk factor for PVD? - ANS male gender An asthmatic patient comes in for a follow up, as you assess his asthma control. He uses albuterol for wheezing, cough, SOB 1 x week. He has been to the ER once for asthma symptoms and coughs 3x a month at night. He is only prescribed albuterol. What would you add? - ANS Inhaled low dose corticosteroid A patient presents with a dry cough, causing chest discomfort x 10 days. He has a runny nose and fatigue. Nurse notes late expiratory wheeze in the lower lobes and rhinitis in the nasal passages. Denies smoking, fever, wheezing. What do we expect? - ANS Acute bronchitis According to JNC 8, a 40 yo with 168/88 with CKD should have treatment with? - ANS Lisinopril (ACE inhibitors) a new 58yo pt has a BP 152/90, first time seeing this patient, what should you do? - ANS Come back for 3 more BP checks What HDL level is considered cardioprotective? - ANS >60 which of the following is the drug of choice for a African American pt with HTN and DM? - ANS HCTZ (diuretic) There are 4 stages of heart failure, classified as A-D- Describe the evolution and progression of the disease - ANS A -Asymptomatic; B -structural change; C-Fatigue, DOE, -Pulmonary congestion on CXR, Cardiomegaly; D-nocturnal dyspnea, edema, JVD, S3, crackles, Pleural effusion Patients who have symptoms of HF at rest despite medical therapy and are hospitalized or require special interventions.. which stage would it be? - ANS D Risk factors for HTN - ANS age, race (AA), gender (male), obesity, FH, ETOH, sedentary, smoking, stress, diet BP goals per JNC 8 - ANS ≤ 60 y/o or DM, CKD <140/90; ≥ 60 y/o <150/90 what are Cozaar (losartan), Benicar (olmesartan), Micardis (telmisartan), and Avapro (Irbesartan) examples of? - ANS angiotensin receptor blockers (ARBs) What would you see on EKG with ischemia? - ANS T-wave inversion Which of the following is in the heart and rapidly rises in the blood stream in heart failure? - ANS BNP James is in your office for annual exam. His cholesterol screening is 198. Which action would you take? - ANS initiate drug therapy with a statin Which diagnostic test would be used for dx of a venous embolism (gold standard)? - ANS Ascending venogram Sam age 78 presents to the clinic with respiratory symptoms. His PFT- normal, total lung capacity, decreased PaO2, increased PaCO2, on assessment crackles and forced expiratory wheezes. What is our DX? - ANS Chronic Bronchitis At what LDL level would you start a person on a statin with no risk factors regardless of comorbidities? - ANS >190 What does this CXR Show? - ANS infiltrates; pneumonia Heart Failure Classification System - ANS I - Asymptomatic; II - Symptoms only with marked exertion; III - Symptoms with moderate exertion; IV - Symptoms at rest What would a diagnosis of HTN w/o further confirmation be based on? - ANS Initial screening BP of ≥180/110 mmHg or who presents with hypertensive emergency What is the first lifestyle modification to address for someone diagnosed with HTN - ANS Weight reduction African Americans dx with HTN without chronic kidney disease should use - ANS CCBs and thiazides what 2 classes of HTN medication should not be used together? - ANS ACEIs and ARBs