MIDTERM EXAM STUDY GUIDE NURS 6550 Acute Care
MIDTERM EXAM STUDY GUIDE NURS 6550
NURS 6550
MIDTERM EXAM STUDY GUIDE
NURS 6550 Acute Care
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Psychosocial
* Generalized anxiety disorder diagnosis criteria
Excessive anxiety and worry occurring more days than not for 6 months
Difficulty controlling worry
3 or more of the following: restlessness, feeling keyed up or on edge; easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; sleep disturbances
significant distress or impairment on social, occupational, or other important areas
symptoms not attributed to another medical condition or substance abuse
symptoms not explained by another medical disorder
* Treatment of acute panic attacks
• physical activity
• selective serotonin reuptake inhibitors are first line therapy
• continue medication for 12 months after symptoms improve prior to tapering
• antidepressants and benzodiazepines may speed recovery from anxiety-related symptoms but do not improve long term outcomes. Benzodiazepines are associated with tolerance and should only be used short term
• psychotherapy can be as effective for GAD and PD; cognitive behavior therapy has the best level of evidence
• tailored options to individuals have the best outcomes and may include a combination of therapies
* Inpatient treatment of depression
reasons for inpatient: suicidal behavior; refusal to eat; severe malnutrition; catatonia; presence of general medical or comorbid psychiatric conditions that make outpatient treatment unsafe or ineffective (Depression Mgnt Guidelines AC folder)
* When is serotonin norepinephrine reuptake inhibitor indicated
most often prescribed for anxiety/sleep disorders
influence on thalamus and prefrontal areas of the cortex
fibromyalgia
when SSRIs don’t work
side effects are worse
* Venlafaxine dosing
generalized anxiety disorder/major depressive disorder: 75-225mg qd
social anxiety disorder: 75mg qd
* Endogenous depression pathophysiology
type of MDD
biological or genetic predisposition
* Differences between panic attacks and panic disorder
panic attack: sudden, intense fear or anxiety may feel shortness of breath or dizzy or may make your heart pound. Feeling they are having a heart attack. Lasts 5-20 minutes.
panic disorder: when the panic attacks occur often
* Depressive disorder symptoms
persistent sad, anxious, or empty mood
feelings of hopelessness, or pessimism
irritability
feelings of guilt, worthlessness, or helplessness
loss of interest or pleasure in hobbies and activities
decreased energy or fatigue
moving or talking more slowly
feeling restless or having trouble sitting still
difficulty concentrating, remembering, or making decisions
difficulty sleeping, early-morning awakening, or oversleeping
appetite and or weight changes
thoughts of death or suicide, or suicide attempts
aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment
* Primary neurotransmitter in PTSD
catecholamines
serotonin
* PTSD diagnosis and treatment
history of exposure to perceived or actual life-threatening event, serious injury, or sexual violence
comorbidity depression or panic disorder
comorbidity alcohol and substance abuse
treatment: psychotherapy and SSRIs
* Lithium side effects
coma, seizures, ventricular arrhythmias, severe bradycardia, syncope, Brugada syndrome, goiter, hypothyroidism, hyperparathyroidism, pseudotumor cerebri, Raynaud phenomenon. Diabetes insipidus, tremor, polyuria, polydipsia, weight gain, diarrhea, vomiting, drowsiness, cognitive impairment, impaired coordination, muscle weakness, anorexia, nausea, blurred vision, xerostomia (dry mouth), fatigue, reversible leukocytosis, acne, edema
* Common adverse effects of atypical antipsychotics
dry mouth, dizziness, lightheadedness, weight gain, sleep problems, extreme tiredness and weakness
* Mental status changes related to UTI in elderly
confusion
* Delirium in geriatric patients
rapid onset and fluctuating course
coexists with dementia frequently
primary deficit is in attention
may be hypoactive or hyperactive
review of medications
meds that increase delirium: sedatives/hypnotics, anticholinergics, opioids, benzodiazepines, and H1 and H2 antihistamines
* Short Confusion Assessment Method (Short CAM)
algorithm for delirium assessment
* Types of dementia (Lewy body, vascular, Alzheimer’s, Parkinson’s)
Lewy body: histologically indistinguishable from Parkinson’s, alpha-synuclein-containing Lewy bodies occur in the brainstem, midbrain, olfactory bulb, and neocortex. Alzheimer pathology may coexist
o Cognitive dysfunction with prominent visuospatial and executive deficits
o Psychiatric disturbances, with anxiety, visual hallucinations and fluctuating delirium
o Parkinsonian motor deficits with or after other features
o Cholinesterase inhibitors lessen delirium; poor tolerance of neuroleptics and dopaminergics
Vascular: multifocal ischemic change
o Stepwise or progressive accumulation of cognitive deficits in association with repeated strokes
o Symptoms depend on localization of strokes
Alzheimer’s: plaques containing beta-amyloid peptide and neurofibrillary tangles containing tau protein, occur throughout the neocortex
o Most common age-related neurodegenerative disease; incidence doubles every 5 years after age 60
o Short-term memory impairment is early and prominent in most cases
o Variable deficits of executive function, visuospatial function, and language
Parkinson’s: dementia associated with Parkinson’s
* Aricept
Donepezil
Mild Alzheimer’s dementia 5-10 mg PO qhs
Moderate-severe Alzheimer’s dementia 10-23 mg qhs
* Management of disinhibition in elderly
distraction
* Physical findings when death is imminent
nonreactive pupils
decreased response to verbal stimuli
inability to close eyelids
drooping of nasolabial fold
hyperextension of neck
grunting of vocal cords
upper GI bleed
* Limits of pain medication on dying patient
pain management is a professional, moral and legal obligation
pain should be assessed
use of pain behavioral tools such as:
o Pain Assessment in Advanced Dementia
o Behavioral Pain Scale
o Critical Care Pain Observation Tool
Use of NSAIDs as first line
Use opioids but not meperidine (it is not reversible with Naloxone)
* Theories about successful aging…(Erikson’s, Levinson’s, Peck’s, Butler’s)
see Successful Aging Theories in AC folder
* Psychological abuse of elders
Most common abuse
Threatens of physical punishment or withholding basic needs
Deprives elderly of healthy mental well being
Prolonged periods of solitude
Can be inflicted by spouses, children, or siblings
Domestic violence within the family
Physical disability increases risk
Women who provide more than 65% of the household income are more likely to be abused
Caregiver strain increases abuse
passivity, withdrawal, or increasing depression;
evasiveness or reluctance to talk openly;
avoidance of eye contact or verbal contact with a caregiver;
cowering in the presence of the abuser;
hopelessness, helplessness, anxiety, or feelings of powerlessness (Anxiety and powerlessness are the most commonly expressed warning signs in grandfathers in the custodial role.);
fear;
confusion that is unrelated to any medical condition;
change in sleeping or eating habits;
contradictory statements;
missing appointments; and
isolation from friends or other family.
* Transtheoretical model of change
focuses on intentional behavior change
o Precontemplation (not ready)
o Contemplation (getting ready)
o Preparation (ready)
o Action
o Maintenance
* Death anxiety
Thanatophobia
Fear of death or the dying process
Is not recognized by APA: considered GAD
SS: anxiety, dread, and distress
Tx: learning to refocus fears and talking about your feelings
* Assessing driver safety in elderly
Assessment of Driving-Related Skills (ADReS)
Use direct language
Reassurance of safety in mind
If fear is expressed emphasize that you do not have the power to take the license away
Encouragement of taking a self-exam
Vision, cognition, and motor function
* Geriatric Depression Screen
GDS
15 question quiz
a score of >5 suggestive of depression
as score of greater than or equal to 10 indicative of depression
as score of >5 should warrant a follow-up comprehensive assessment
EENT
* Eye pain from medications
Bisphosphonates: meds used to increase bone density
Fosamax, Aredia, Actonel, Skelid, Zometa, Didronel
Topamax: used to treat migraines
* Cataracts
Cloudy or opaque area in the lens
Can interfere with vision
Usually in pts over 55
Blurry, or hazy vision
Reduction of intensity of colors
Increased sensitivity to glares
Difficulty night seeing
* Chronic uveitis
Long-standing inflammatory disease of the anterior part of the eye
Exceeds 3 months
Swelling and destruction of eye tissue
Middle layer of eye
Consists of the iris, ciliary body, and choroid
disrupts vision by primarily causing problems with the lens, retina, optic nerve, and vitreous
* Gonococcal conjunctivitis
caused by Neisseria gonorrhoeae(gonorrhea), a sexually transmitted disease that also may spread to the eye by contact with genital secretions from a person who has a gonorrheal infection.
Affects neonates
Treatment includes pre-treat the mother
include topical erythromycin ointment and an IV or IM third-generation cephalosporin
* Viral, allergic, bacterial conjunctivitis
viral
o highly contagious; starts in one eye and quickly spreads to the other
o watery discharge
o adenovirus, or herpes simplex (HSV)
o may accompany URI such as measles, the flu, or common cold
o treatments: drops to reduce the symptoms, decongestants to reduce swelling, vasoconstrictors to whiten the eye, antihistamines to reduce the itching
bacterial
o most common cause: staph aureus, Haemophilus influenza, strep pneumoniae, and pseudomonas aerugiosa
o thick discharge or pus
o can affect one or both eyes
o abx drops for one to two weeks
allergic
o caused by allergies
o itchy eyes
o antihistamine drops OTC and Rx
* Macular degeneration
leading cause of vision loss
incurable
deterioration of the central portion of the retina
central portion of retina is the macula
responsible for focus
hereditary and environmental
smoking, African American, Hispanics, Latinos, and genetics
* Dacrocystitis
infection of the lacrimal sac 2/2 obstruction of the nasolacrimal duct at the junction of lacrimal sac. It causes pain, redness, and swelling over the inner aspect of the lower eyelid and epiphora
* Open angle glaucoma
the angle in your eye where the iris meets the cornea is as wide and open as it should be, but the eye's drainage canals become clogged over time, causing an increase in internal eye pressure and subsequent damage to the optic nerve
* Metal FB in eye
attempt to irrigate
ophthalmology should be consulted for removal
pt with rust ring should be treat like pts with corneal abrasions
topical abx ointment is better than drops
pt that wear contact lens should have pseudomonas coverage (ciprofloxacin, ofloxacin, tobramycin, or gentamicin)
no contacts: erythromycin
pain control: varies according to size
* Penetrating eye injury
do not force eyelids open (pressure can cause extrusion of ocular contents)
do not attempt to remove
NPO
Analgesia (If opiates are required consider concurrent antiemetic as vomiting increases intraocular pressure and may cause expulsion of ocular contents. Use ondansetron rather than agents which may precipitate dystonic reactions.)
Notify ophthalmology
image the orbit (X-ray or CT) in cases where an intra-ocular foreign body is suspected.
* Corneal abrasions
a scratch or cut on the outermost surface of the cornea, the epithelium
painful bc of the many nerve terminations
most are superficial and heal spontaneously
larger abrasions are treated with abx drops or ointment
patches are sometimes used to decrease the pain and promote healing
do not keep patch on over 24 hours at a time
* Orbital cellulitis
infection involving the contents of the orbit (fat and ocular muscles)
most common cause bacterial rhinosinusitis
other causes: ophthalmic surgery, peribulbar anesthesia, orbital trauma, dacryocystitis, infection of the teeth, ear, or face, an infected mucocele that erodes into orbit pain with eye movements, proptosis, and ophthalmoplegia with diplopia.
causes ocular pain and eyelid swelling with erythema, and swelling and inflammation of the extraocular muscles and fatty tissues within the orbit leading to pain with eye movements, proptosis, and ophthalmoplegia with diplopia.
Ddx: Preseptal cellulitis, Mucormycosis or aspergillosis involving the orbit, Idiopathic orbital inflammatory disease, Cavernous sinus thrombosis, Herpes simplex or varicella zoster virus infections involving the eye, Tuberculosis involving the orbit, Endophthalmitis, Tumors, posterior scleritis, periocular dermoid cyst, granulomatosis with polyangiitis (Wegener’s disease), trauma, allergic response, hordeolum, severe conjunctivitis, mucocele, thrombosed orbital varix, graves disease
* Orbital fractures
Traumatic injury to the bone of the eye socket
If the fx is small it may not need to be treated with surgery
More severe when it keeps the eye from moving properly
Surgery may not be completed until swelling goes down
Decongestants and antibiotics are prescribed
* Sensorineural hearing loss
Hearing loss involving the inner ear, cochlea, or the auditory nerve
* Conductive hearing loss
Involving any cause that in some way limits the amount of external sound from gaining access to the inner ear. Ex: cerumen, impaction, middle ear fluid, or ossicular chain fixation
* Age related hearing loss
Presbycusis
* Transient hearing loss
Temporary
* Acute otitis media
Inflammation of the middle ear
* Vertigo (acute or central)
symptom of illusory movement
vestibular dysfunction
* Epistaxis
nosebleed
* Bacterial sinusitis
observation or abx on patient follow up
* Tonsillitis
group A streptococcus
bacterial pharyngitis
tx PCN
* Epiglottitis
inflammation of the epiglottitis and adjacent supraglottic structures
infectious causes
o in children H. Influenzae, and group A strep
o in adults: broad range of bacteria, viruses, combined viral-bacterial infections fungi, and noninfectious causes
o immunocompromised hosts: microbes such as pseudomonas aeruginosa, and candida species
non-infectious causes
o trauma
o thermal injury
o foreign body ingestion
o caustic ingestion
* Slit lamps, Snellen chart, Amsler grid, Wood’s lamp
slit lamp: a microscope that provides a 3 dimensional view of the eye
Snellen chart: chart to check visual acuity
Amsler grid: used for detecting macular degeneration
Wood’s lamp: used for skin examination
* Beta adrenergic antagonists
Beta-blockers
Bind to beta-adrenoceptors in cardiac nodal tissue, the conducting system, and contracting myocytes and therefore block the binding of norepinephrine and epinephrine
Sympatholytic drugs
The heart has both B1 and B2 receptors, but B1 are predominate
Able to reduce heart rate, contractility, conduction velocity, and relaxation rate
Non-selective blockers:
o Both B1 and B2
o Selective B1
Class/Drug HTN Angina Arrhy MI CHF Comments
Non-selective β1/β2
carteolol X ISA; long acting; also used for glaucoma
carvedilol X X α-blocking activity
labetalol X X ISA; α-blocking activity
nadolol X X X X long acting
penbutolol X X ISA
pindolol X X ISA; MSA
propranolol X X X X MSA; prototypical beta-blocker
sotalol X several other significant mechanisms
timolol X X X X primarily used for glaucoma
β1-selective
acebutolol X X X ISA
atenolol X X X X
betaxolol X X X MSA
bisoprolol X X X X
esmolol X X ultra short acting; intra or postoperative HTN
metoprolol X X X X X MSA
nebivolol X relatively selective in most patients; vasodilating (NO release)
Abbreviations: HTN, hypertension; Arrhy, arrhythmias; MI, myocardial infarction; CHF, congestive heart failure; ISA, intrinsic sympathomimetic activity.
* Cholinergic mimetic
Direct agonists are resistant to acetylcholinesterase
Direct Agonists Uses Mechanism of Action
Methacholine • Challenge test for bronchial airway hyperactivity/asthma
• Rapid onset of contraction of smooth muscles in the airways and increases tracheobronchial secretions
• Slightly resistant to acetylcholine-esterase (AChE)
Pilocarpine • Management of glaucoma
• Contracts the pupillary sphincter (miosis) and ciliary muscle (improved accommodation)
• Lowers intraocular pressure by reducing resistance to aqueous humor outflow
• Resistant to AChE
Bethanechol • Acute postoperative and postpartum urinary retention
• Neurogenic ileus
• Causes bladder contractions which initiates urination
• stimulates gastric motility and tone restoring peristalsis
• Resistant to AChE
Carbachol • Lowers intraocular pressure treating glaucoma
• Pupillary contraction
• Stimulates muscarinic receptors causing miosis
• Resistant to AChE
Indirect agonists inhibit acetylcholinesterase and prevent the degradation of ACH prolonging its effects
Indirect Agonist Uses Notes
Physostigmine • Glaucoma
• Atropine overdose or Atropa belladonna (deadly nightshade) ingestion
• CNS penetration
• Absorbs well on all bodily surfaces
Neostigmine • Postoperative and neurogenic ileus and urinary retention
• Myasthenia gravis
• Reversal of neuromuscular junction blockade (postoperative)
• No CNS penetration
Pyridostigmine • Myasthenia gravis
• No CNS penetration
Edrophonium • Diagnosis of myasthenia gravis
• Ileus
• Arrhythmias
• Extremely short lived (5 - 15 min)
Echothiophate • Glaucoma
• Long-lasting (100 hours)
• No CNS penetration
• Insecticides: malathion is safe in humans but parathion is harmful and both can penetrate the CNS
* Prostaglandin analogs
Eye drops that reduce intraocular pressure caused by open-angle glacoma
* Osmotic diuretics
Inhibits water reabsorption and sodium
Mainly used to reduce intracranial/intraoccular pressure
o maintol
Cardiovascular disorders
* ACS protocol: low risk vs high risk mi
algo-acs acute care folder
* Contraindications to thrombolytic therapy
prior intracranial hemorrhage
know cerebral vascular lesion
malignant intracranial neoplasm
ischemic stroke or head trauma in the last 3 months
suspected aortic dissection
active bleeding
severe uncontrolled HTN
Thrombocytopenia and Coagulopathy
If patient is taking a therapeutic dose of low-molecular weight heparin
Direct thrombin inhibitors
Factor Xa inhibitors
Hypo or hyperglycemia
Advanced age (over 75)
Recent major surgery
* MONA
Morphine
Oxygen
Nitro
ASA
* Duke criteria for infective endocarditis
Major Diagnostic Criteria
Positive blood culture for typical Infective Endocarditis organisms (strep viridins or bovis, HACEK, staph aureous without other primary site, enterococcus), from 2 separate blood cultures or 2 positive cultures from samples drawn > 12 hours apart, or 3 or a majority of 4 separate cultures of blood (first and last sample drawn 1 hour apart)
Echocardiogram with oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or abscess, or new partial dehiscence of prosthetic valve or new valvular regurgitation
Minor Diagnostic Criteria
Predisposing heart condition or intravenous drug use
Temp > 38.0° C (100.4° F)
Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Janeway lesions
Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with endocarditis (excluding coag neg staph, and other common contaminants)
Echocardiographic findings: consistent with endocarditis but do not meet a major criterion as noted above
* Heart murmurs
* Endocarditis treatment
Antimicrobial therapy: empiric Vancomycin 15-20mg/kg/dose q 8-12 hrs
Surgery
* Pericarditis s/sx and treatment: inflammation of the pericardial sac
Acute and recurrent pericarditis
Pericardial effusion without major hemodynamic compromise
Cardiac tamponade
Constrictive pericarditis
Effusive-constrictive pericarditis
Initial treatment of acute pericarditis in adults
* Treatment and findings for acute anterior wall MI
LAD occlusion
Patients presenting with an anterior wall MI usually have occlusion of the left anterior descending coronary artery (LAD). The presence of ST-elevation in lead aVR, complete right bundle branch block, ST-depression in lead V5, and/or ST elevation in V1 greater than 2.5 mm strongly predicts a LAD artery occlusion proximal to the first septal perforator
Tombstones
Relief of pain: opioids (morphine), beta-blockers or nitrates, supplemental oxygen
* Monitoring wedge pressures
Used to assess left ventricular preload
https://www.ncbi.nlm.nih.gov/books/NBK6895/
* Medications for CHF
ACE: blocks the effects of angiotensin II,
o Captopril
o Enalapril
o Lisinopril
o Benazepril
o Ramipril
ARB:
o Losartan
o Candesartan
o Telmisartan
o Valsartan
o Irbesartan
o Olmesartan
Beta-blockers in conjunction with ACE
Digoxin stimulates the heart muscle to contract more forcefully
* Aortic stenosis: narrowing of the aortic opening restricting the blood flow from the left ventricle to the aorta and may affect the pressure in the left atrium
Symptoms:
o Breathlessness
o Chest pain (angina), pressure or tightness
o Fainting, also called syncope
o Palpitations or a feeling of heavy, pounding, or noticeable heartbeats
o Decline in activity level or reduced ability to do normal activities requiring mild exertion
o Heart murmur
Can cause thickening of the left ventricle
* Diastolic failure
Associated with aging and myocardial stiffening and LVH
Associated with HTN
* Thoracic aneurysm
Leading cause of death in US in individuals over 55
* Medications for acute descending aortic aneurysm:
beta blockers: they decrease the force of contraction and minimize the rise of the aortic pressure
vasodilators: nitroprusside which reduces the systolic blood pressure and in turn decreased the aortic wall stress and possibility of rupture
* Treatment plans for PAD
* Risk factors for DVT
* PE risk factors
* Hypertensive urgency vs crisis
* Chronic venous insufficiency treatment
* Cardiac rehab
* Stroke treatment guidelines
* Coumadin guidelines
* How to read EKGs [Show Less]