NURS 6501 Final Exam with verified solutions.

What is the role of the primary care provider in mental health? - Screen for mental health issues - Improve outcomes and reduce health care costs - Assess and give care to mild-moderate disorders or patients with stable severe mental disorders - From strong links with mental health specialty care for complex cases Sharing patient info (ex: meds used) about PHQ2 - what does it screen for, what are the questions, scoring - Screens for MDD - It is the first two questions of the PHQ9 - In the last two week, have you been feeling these (not at all, several days, more than half the day, nearly everyday): - Little interest or pleasure in doing things? - Feeling down, depressed, or hopeless? Scoring: A single yes or score >3 (out of 0-6) = possible clinical depression ⇒ due the PHQ9 If the pt screens (+) ⇒ continue to eval with the PHQ9 about PHQ9 - what its used for, questions, scoring Used for screening, diagnosing, and treating - It asks about functioning impairments which is needed for the DSM-based diagnosis Includes asking about suicide or hurting self Scoring: 0-27 available 0-4: Minimal/none Monitor; may not require treatment 5-9: Mild Use clinical judgment; follow-up in one month 10-14: Moderate Use clinical judgment; may need meds if functionally impaired 15-19: Moderately Severe Warrants active treatment with psychotherapy, meds, or combo 20-27: Severe Warrants active treatment with psychotherapy, meds, or combo What is the appropriate initiation dose for fluoxetine for adults and geriatric adults? 20mg PO once daily in the AM - May ↑ daily dose after several weeks if inadequate response - Full therapeutic effect may be delayed 4 weeks or longer - Max dose: 80mg/day What labs would be appropriate to draw if you initiate fluoxetine in a geriatric patient? Sodium levels - Baseline screening & after 3-4 weeks in high-risk patients (> 65yrs, previous hx of antidepressant-induced hyponatremia, low body weight, concomitant use of thiazides or other hyponatremia-inducing agents) - monitor regularly in the elderly What are potential side effects of SSRI medications? - what are the common SSRIs, LEAP of them, and zoloft AE Common SSRIs: Lexapro, celexa, paxil, zoloft, prozac L = decreased libido and sleep E = Neutral effect on energy A = neural effect on addiction P = celexa may stop working after awhile (increase or switch) Zoloft AE: Insomnia, somnolence, fatigue, abnormal ejaculation, suicidal thoughts What are characteristics of major depressive disorder or MDD? 9 Diagnostics need 5 or more of the following: - SS occur more days than not in a 2 week period - SS cause significant impairment in any realm of functioning - Depressed mood - Loss of interest - Significant unintended ▲ in weight or appetite - Significant ▲ sleep - ▲ psychomotor activity (restlessness) - Fatigue, loss of energy - Worthlessness, guilt What is serotonin syndrome? - Increased serotonergic activity in the CNS - Can be due to therapeutic med use, inadvertent drug interactions, or self-OD Serotonin in the Body: CNS: Modulates attention, behavior, and thermoregulation PNS: Regulates GI motility, vasoconstriction, uterine contraction, and bronchoconstriction, promotes PLT aggregation PE of serotonin syndrome 11 - Hyperthermia, flushed skin, diaphoresis - Agitation - Slow, continuous, horizontal eye movements (ocular clonus) - Dilated pupils - Tremor, akathisia - Deep tendon hyperreflexia (common) - Inducible or spontaneous muscle clonus (common) - Muscle rigidity - Bilateral babinski - Dry mucus membranes - Increased bowel sounds What is discontinuation syndrome (from SSRIs)? "FINISH" 2-3 days after stopping SSRIs abruptly F: flu-like SS I: insomnia N: nausea I: imbalance S: sensory disturbances H: hyperarousal Bupropion - MOA - BENFITS AE CONTRA MOA - act to inhibit reuptake of NE, dopamine, and serotonin BENFIT - Depression - Smoking cessation - Seasonal affective disorder - Treat sexual dysfunction relative to SSRI therapy AE - weight loss - increases libido ⇒ combine with SSRI - can cause seizures by lowering the seizure threshold CONTRA - History of seizures - Do not prescribe to pts with psych disorders ⇒ ↑ risk for delusions or hallucinations RF for ETOH abuse 4 Younger adults (18-29 yrs) Men > women Native americans Genetics (low response to ETOH), environment (peer influences), specific personality traits (impulsivity, extroversion), cognitive fxn What are predisposing factors impacting the likelihood of someone developing a SA issue? Predisposing Factors: - Unhealthy use of one substance increases the likelihood of unhealthy use of other substances - Family history - Social history - Partner or friends with SA, living in a community with poverty, violence, and/or high ETOH/drug use Use of: - Caffeine, tobacco, ETOH, prescription meds, marijuana, illicit drugs - Mental health disorders - Highest in personality disorders What is withdrawal process of removal of the drug of dependence from the body SS of substance abuse withdrawal 3 Can last days to weeks - NVD - Flu-like SS: lacrimation, rhinorrhea, diaphoresis, shivering, piloerection - SNS/CNS Arousal: mydriasis, mild HTN and tachy, anxiety, irritability, insomnia, agitation, restless leg, general restlessness, tremor, low grade temp Which medications are central nervous system sedatives? Include sedatives, tranquilizers, hypnotics - Good for treating anxiety, panic, acute stress reactions, sleep disorders Examples: Benzos: - Diazepam (valium), clonazepam (klonopin), alprazolam (xanax) Non-Benzo Sedative Hypnotics - Zolpidem (ambien) Barbiturates - Mephobarbital Initiation Strategies for Antidepressants: Antidepressants are considered equivalent in efficacy for depression Decide on med by: - History of response - Family history of response - Symptoms - Medical history - Interactions - AE which antidepressant is good for smoking cessation, weight loss, and ADD? Bupropion which antidepressant is good for fibromyalgia Duloxetine which antidepressant is good for migraine prevention Amitriptyline what is grief - response to bereavement → varies over time as the person adapts to the loss - painful, impairing, should NOT be diagnosed as a mental disorder - Bereavement is a stressor ⇒ can worsen mental disorders (ex: depression) - can progress to complicated grief: intense, prolonged, and debilitating SS treatments for acute grief - Typical doesn't require treatment - For bereaved patients who don't have mental disorders, suggest not routinely administering grief counseling or other psychotherapies - Grief counseling can be helpful for bereaved patients who request it - Encourage pts to maintain regular patterns of activity, sleep, exercise, and nutrition How long is a preoperative evaluation valid? - Preop evaluation must occur 1-30 days prior to the surgery - The more time the better so that referrals and consults can be done if needed Factors that influence the testing performed for preop visit 5 Presenting diagnosis Patient's age Comorbidities Type of anesthetic agent planned Surgeon's preference American Society of Anesthesiologists Anesthesia Classification System 1-4 ASA Class 1: healthy, normal patient ASA Class 2: patient with mild systemic disease ASA Class 3: patient with severe systemic disease ASA Class 4: patient with severe systemic disease that is a threat to life major clinical predictors that increase surgical risk 7 - MI within 30 days - unstable angina - decompensated HF - High-grade AV block - symptomatic ventricular arrhythmias - supraventricular arrhythmias with uncontrolled ventricular rates - severe valvular disease intermediate risk factors that increase surgical risk 4 - mild angina - previous MI by history or pathologic Q waves, compensated or previous HF - DM (especially 1) - renal insufficiency minor risk factors that increase surgical risk 6 - advanced age - abnormal EKG - rhythm other than sinus - low functional capacity - history of stroke - uncontrolled HTN How far in advance should herbal medications be held before a planned surgery? All herbals should be stopped two weeks prior List the potential complication of spinal or regional anesthesia HA, nerve damage, infection, limb loss presurgical guidelines for metformin - take day before surgery, then resume it afterwards when patient is eating again - If procedure involves IV contrast or long surgical time ⇒ metformin is stopped when the preop fasting begins and restarted postop with normal diet resumption - If renal dysfunction found preop or postop ⇒ DC metformin until renal function normalizes SGLP2i presurgical guidelines Stop immediately if undergoing emergency procedure Hold med 24h prior to elective surgery DM2 with insulin presurgical guidelines Continue insulin therapy Hold NPH or premixed insulin the morning of surgery if DM2 and BS <120 DM1 with insulin presurgical guidelines - Will need insulin perioperative period - Stress of surgery can cause hyperglycemia or ketoacidosis - Should get 80% basal insulin dose the evening before surgery and on the morning of surgery to prevent hypoglycemia - Prandial insulin is stopped when the fasting state begins are most DM PO agents taken the day of surgery? yes What is the Duke Activity Status Index (DASI) and what does it measure? - Self-administered questionnaire that measures a patient's functional capacity - Gets a rough estimate of the patient's peak O2 uptake Questions: - Can you take care of yourself, walk around, run, climb stairs, do yard work Answer yes/no what does STOP-BANG mean S: Snoring (do you snore loud enough that it can be heard through closed doors) T: Tired (often feel tired, fatigued, sleepy) O: Observed → has anyone observed you stop breathing or choking/gasping during your sleep P: Pressure → do you have or are being treated for HTN B: BMI >35 A: Age → >50yrs N: Neck size large → measured around Adam's apple Men: shirt collar → 17 inches/43cm or larger Women: shirt collar → 16inches/41cm or larger G: Gender → male scoring for STOP BANG - Low risk: yes to 0-2 questions Intermediate risk: yes to 3-4 questions - High risk: yes to 5-8 questions OR yes to 2 or more STOP questions + male gender OR yes to 2 or more STOP questions + BMI >35 OR yes to 2 or more STOP questions + neck circumference What is your responsibility as a health care provider to do when a patient informs you that they have recently been sexually assaulted? (IF WITHIN 72H) - PCP should defer a PE and refer the pt to the ER if the sexual assault occured within the last 5 day, preferably within 72h - Ensures proper measures are taken and comply with standardized protocols - Support the patient's current or future desire for legal pursuits - PCP doesn't need to request specific info about the assault → this will be done in the ED