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AACN Exam
Charcot's Triad - RUQ pain, fever, jaundice (indicates cholangitis) Reynold's pentad - RUQ pain, fever, jaundice, AMS, hypotension (indicates worsening cholangitis) Murphy's sign - pain with palpation of the RUQ during inspiration, indicative of cholecystitis Psoas sign - RLQ pain with extension of right thigh/hip indicative of appendicitis Kehr's sign - Left shoulder pain caused by irritation of the undersurface of the diaphragm by blood leaking from a ruptured spleen. While Kehr's sign (left shoulder pain) is commonly a symptom of splenic rupture, right shoulder pain typically signals liver or gallbladder irritation Cullen's sign - Ecchymosis in periumbilical area, seen with pancreatitis Grey Turner's sign - Atraumatic ecchymosis in the flank, typically indicating hemorrhagic pancreatitis Beck's triad - JVD, muffled heart sounds, decreased BP (indicate cardiac tamponade) Cushing's triad - bradycardia, bradypnea, hypertension (indicate increased ICP; normal ICP=5-15 mm Hg) Charcot's neurologic triad - Nystagmus, staccato speech, intentional tremor (indicate MS) Virchow's triad - Venous stasis, hypercoagulability, endothelial damage (high risk of thrombosis) Shock Triad - Hypotension, tachycardia, tachypnea Opioid Poisoning Triad - CNS depression (AMS, coma), respiratory depression, miosis (pinpoint pupils)
Wolf-Parkinson-White Syndrome: 3 signs - short PR interval, delta waves, and wide QRS complex Behcet's disease - Recurrent oral ulcers, genital ulcers, eye inflammation 3 D's of pellagra (niacin, vit B3, deficiency) - Diarrhea, dementia, dermatitis Serotonin Syndrome - Similar to NMS but caused by serotonin medications, and has HYPERreflexive muscle activity Symptoms= mental status changes and hyperthermia. Treatment=cyproheptadine Neuroleptic Malignant Syndrome - Adverse reaction to antipsychotics with severe "lead pipe" rigidty, FEVER (102-104), tachycardia, tachypnea, mental status changes lethal triad of trauma - Hypothermia, acidosis, coagulopathy Neurogenic shock: 3 symptoms - Hypothermia, hypotension, bradycardia Whipple's triad -
- Fasting hypoglycemia <
- Symptoms during hypoglycemia
- Immediate relief of symptoms after the administration of IV glucose (suggest insulinoma) Reactive arthritis rhyme - Can't see (conjunctivitis), can't pee (urethritis or cervicitis), can't climb a tree (arthritis) Murphy's Triad - RLQ pain, nausea/vomiting, fever (indicates appendicitis) Acidosis vs Alkalosis - ROME: Respiratory - Opposite Acidosis: pH is down, pCO2 is up Alkalosis: pH is up, pCO2 is down Metabolic - Equal Acidosis: pH is down, pCO2 is down Alkalosis: pH is up, pCO2 is up
4.5-11 x 10^3/uL RBC range - Male: 4.5 - 5.5 x 10^6/uL Female: 4 - 5 x 10^6/uL Hgb range - Male: 14-18 g/dL Female: 12-16 g/dL Hct range - Male: 42-52% Female: 36-46% MCV range (size of RBCs) - 80-100 fL MCH range - 28-34 pg (color) MCHC range (color, how red RBCs are) - 32 - 36% RDW range (red cell distribution width; variation in RBC size) - 12 - 14.6% Platelets range - Range: 150 - 400 x 10^3/uL aPTT (activated partial thromboplastin time) - 25-35 seconds PT (prothrombin time) - 11-16 seconds INR (international normalized ratio) - 1- sedative approved for rapid sequence intubation use and, the most appropriate choice for a patient requiring intubation in the setting of hypotension - Etomidate Preventative med for tumor lysis syndrome and gout attacks - Allopurinol Med taken to treat acute gout attacks and FMF -
Colchicine C. diff treatment - stop antibiotic Oral vancomycin or fidaxomicin Amylase range - 25-125 IU/L Lipase range - 10-180 IU/L Total protein - 6.0-8.3 g/dL Albumin - 3.5-5 g/dL Total bilirubin - 0.1-1.0 mg/dL Sodium range - 135- Potassium range - 3.5-5. Calcium range - 8.5-10. Magnesium range - 1.5-2. Phosphorus range - 2.5-4. Glucose range - 60- BUN range - 7- Creatinine range - 0.6-1. Bicarbonate -
morning glucose levels. Admin of insulin at a later time in day will coordinate insulin peak with the hormone release. Antidote for tricyclic antidepressant overdose - Sodium bicarbonate AMO therapy - Albumin, midodrine and octreotide, often referred to as AMO therapy, are used for hepatorenal syndrome. They synergistically act to increase circulating volume and improve renal perfusion by reversing sustained renal vasoconstriction hepatorenal syndrome - Progressive renal failure associated with hepatic failure characterized by a sudden decrease in urinary output, elevated BUN and creatinine levels, decreased urine sodium excretion, and increased urine osmolarity. It's the rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure. HRS is usually fatal unless a liver transplant is performed, although dialysis and AMO treatment can buy time. Two forms of hepatorenal syndrome have been defined: Type 1 HRS entails a rapidly progressive decline in kidney function, while type 2 HRS is associated with ascites that does not improve with standard diuretic medications. Dexmedetomidine hydrochloride (Precedex) - An alpha-2-adrenergic agonist for treatment of patients with delirium. It does not suppress respiratory drive. It is currently recommended by the Society of Critical Care Medicine for pharmacologic management of delirium that is not caused by alcohol or benzodiazepine withdrawal Exudative pleural effusion lab values - The pleural effusion fluid has at least one of the following:
- LDH more than 2/3 the upper limit of normal LDH (280) or
- LDH effusion / LDH serum > 0.6 or
- Total protein of effusion / Total Protein of serum > 0. Transudative pleural effusion lab values - Pleural fluid glucose equal to serum glucose, pleural fluid pH 7.40-7.55, and less than 1000 WBC/mcL Chylous effusion - Effusion with white, milky appearance that has a high triglyceride count and mature lymphocytes; caused by damage to thoracic duct Cerebroselective CCB that improves cerebral perfusion pressure (CPP) and thereby decrease morbidity and mortality in patients with SAH - Nimodipine Nitroglycerin should be used cautiously with which MI? -
Inferior wall MI First line therapy for HTN - Thiazide diuretics (hydrochlorothiazide, chlorthalidone). Then ACEI, ARBS (less effective for POC). Then CCBs. Minimum urine output per hour - 30 mL/hour (approximately 0.5 mL/kg/hr) oliguria - Decreased urine output Inotrope - substance affecting muscle contraction. Positive inotropes increase myocardial contractility, while negative inotropes decrease myocardial contractility. Chronotrope - substance that changes heart rate Preload - The amount of stretch experienced by cardiac muscle cells, called cardiomyocytes, at the end of ventricular filling during diastole. Preload is directly related to ventricular filling (think of blowing up a balloon; the more air, the more stretch). Afterload - The amount of resistance to ejection of blood from the ventricle. The pressure that the left ventricle must generate to overcome the high pressure in the aorta to get blood out of the heart. Afterload is squeeze. Right atrial pressure - 2-6 mm Hg Right ventricular pressure - Systolic 15-30 mm Hg Diastolic 2-6 mm Hg Central Venous Pressure (CVP) - 2-6 mm Hg. Reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. CVP is good approximation of RA pressure. Pulmonary Capillary Wedge Pressure (PCWP) - 8-12 mm Hg Measures left ventricular pressure when mitral valve is open. Good approximation for preload.
Inadequate circulating volume leading to multiple organ failure. Common causes: acute hemorrhage, severe dehydration, severe burns ↓ CO, ↓ PCWP, ↑ peripheral vascular resistance (PVR), ↓ CVP Obstructive shock definition and causes - Obstructed ventricular filling and/or filling of the great vessels results in inadequate cardiac output Examples: pulmonary embolus, tension pneumothorax, cardiac tamponade ↓ CO, ↓ PCWP, ↑ peripheral vascular resistance (PVR), ↑ CVP Obstructive shock treatment - Relieve obstruction. Volume replacement Distributive shock causes - Excessive vasodilation & altered distribution of blood flow. Common causes: septic shock, anaphylactic shock, neurogenic shock anaphylactic shock treatment - Volume replacement Epinephrine Glucocorticoids (IV and/or PO) Antihistamine Neurogenic shock treatment - Volume replacement followed by alpha agonists (phenylephrine, midodrine hydrochloride) Which type of shock places the patient at highest risk for DIC? - Septic shock Which type of shock will initially exhibit an increased CO followed by a decreased CO? - Septic shock Signs of left sided heart failure pertain to the: - Lungs (left=lungs) Signs of right sided heart failure pertain to the: - Ankles Peripheral vascular disease (PVD) is diagnosed using - Ankle-Brachial Index (ABI) Normal ABI = 0.8-1. Refer to specialist if ABI is <0.5 or >1. American College of Cardiology and the American Heart Association has stages of heart failure that describe: -
How bad a patient's heart disease/failure is. You can only progress in these stages, you can't go backwards: ✤Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder. ✤Stage B: a structural heart disease but no symptoms at any stage. ✤Stage C: structural heart disease with prior or current symptoms of heart failure ✤Stage D: advanced, refractory heart failure requiring hospital-based treatments The New York Heart Association has classes of heart failure that describe: - How bad a patient's symptoms of HF are. Patients can move up or down in these classes. ✤Class I: no limitation on physical activity; there are no overt symptoms ✤Class II: slight physical activity limitation; the patient is comfortable at rest or but normal physical activity causes symptoms. ✤Class III: marked limitation of physical activity; the patient is comfortable only at rest. ✤Class IV: unable to perform any physical activity without discomfort and symptoms; symptoms are present at rest. Lifestyle modifications for HTN and dyslipidemia - Weight reduction, diet rich in produce and low in saturated fat (DASH diet), reduce sodium intake, aerobic physical activity, moderation of alcohol Normal blood pressure - 90-120/60- When to start HTN medications - Systolic 140 OR diastolic 90 Hypertensive urgency/emergency BP: - Systolic 180 OR diastolic 120 HTN emergency is that blood pressure AND acute target organ ischemia/damage (ACS, pulmonary edema, encephalopathy, papilledema, proteinuria, hematuria) BP goal for hypertensive patients - 130/ For hypertensive urgency use: - Captopril 12.5-200 mg PO TID Common IV meds for hypertensive emergency - Nitroprusside 0.25-10 mcg/kg/min Labetalol 20-80 mg IV push q10min Nicardipine 5-15 mg/hour Nitroglycerin 5-1000 mcg/min Esmolol (big loading dose) Hydralazine 10-20 mg q20min
STEMI!!! not NSTEMI Goal is PCI treatment with 90-120 minutes of presentation or maybe high risk NSTEMIs? Absolute contraindications to fibrinolysis - History of any cerebrovascular event (ICH, intracranial neoplasm, aneurysm, AVM) Non-hemorrhagic stroke (4.5hrs-3months prior) Suspected aortic dissection Active bleeding (except menstruation) BP >180/110 (severe hypertension) Streptokinase 6 months prior HDL range -
50 mg/dL LDL range - <100 mg/dl in pt with moderate risk factors <70 mg/dl for high risk patients Triglycerides range - <150 mg/dL Total cholesterol levels - <200 mg/dL Vitamin given to prevent Wernicke's encephalopathy - Thiamine (vitmain B1). Should be given to all patients with alcohol use disorder Dysarthria - slurred speech dysphagia - difficulty swallowing dysphonia - difficulty producing speech sounds, usually due to hoarseness SOFA score (sequential organ failure assessment score) is used to determine the extent of a person's organ function or rate of failure (predicts sepsis mortality) based on 6 factors: -
- Respiratory: PaO2/FiO2 ratio
- Cardiovascular: level or hypotension or MAP or administration of vasopressors required
- Hepatic: bilirubin level
- Coagulation: platelet count
- Renal: creatinine level
- Neuro: GCS score qSOFA - H (100) A (15) T (22) 2 or more of: Hypotension: SBP less than or equal to 100 mmHg Altered mental status (any GCS less than 15) Tachypnoea: RR greater than or equal to 22 identified patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital Fomepizole - Antidote for ethylene glycol overdose or methanol overdose Methanol poisoning sometimes seen with homemade alcohol/moonshine Fomepizole works by inhibiting alcohol dehydrogenase (unlike disulfiram)-->decreased breakdown of ethylene glycol into toxic metabolites Synergy Model - A model of care delivery adopted by the AACN that matches the needs and characteristics of the patient with the competencies of the nurse. When the knowledge, skills, and competencies of the nurse are used to meet the complex needs of the patient and family, the care is optimal. Patient characteristics: resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, predictability Nurse competencies: clinical judgement, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, facilitation of learning, clinical inquiry ABCDEF Bundle - Evidence-based guide to help reduce delirium, improve pain management and reduce long-term consequences for adult intensive care unit (ICU) patients. It includes:
- Assess, Prevent, and Manage Pain
- Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
- Choice of analgesia and sedation
- Delirium: Assess, Prevent, and Manage
- Early mobility and Exercise
- Family engagement and empowerment Serum Osmolality (normal range) - 285-300 mOsm/kg
Urine specific gravity range - 1.01-1. What is the suppressed or deficient enzyme that causes the majority of thrombotic thrombocytopenic purpura cases? - ADAMTS Nimodipine - controls vasospasms after SAH Reversal agent for dabigatran - Idarucizumab (Praxbind) preferred energy dose given to patients by parenteral nutrition - 20-25 kcal/kg/day parts of Small intestine mnemonic - DJI-Dow Jones Inc
- Duodenum
- Jejunum
- Ileum What should you think of with emphysema in a young non-smoker? - alpha-1-antitrypsin deficiency Pneumocystis jiroveci - a fungus causing severe pneumonia Seen in patient with a history of HIV, immunocompromised or immunosuppression Complaining of gradual onset of non-productive cough Labs will show CD4 < 200, increased LDH CXR will show bilateral infiltrates (bat wing pattern) Treatment is TMP-SMX Mobitz Type I (Wenckebach) - progressive lengthening of PR interval until a beat is 'dropped' (P wave not followed by a QRS complex) usually asymptomatic Cushing's syndrome - A condition caused by prolonged exposure to high levels of cortisol d/t tumor on pituitary gland that causes pituitary to make too much ACTH, or adrenal malfunction, or prolonged use of steroids Signs and symptoms: Moon face, buffalo hump, purple striae, hypertension, hyperglycemia, poor wound healing, leukocytosis, osteoporosis, muscle wasting, thin skin, erectile dysfunction,
amenorrhea, hirsutism, hypernatremia, hypokalemia, fatigue, cardiac hypertrophy, personality changes Tested with 24 hr urine cortisol and testing ACTH levels. Also dexamethasone suppression test and testing ACTH levels Saw Palmetto uses - benign prostatic hyperplasia What complimentary therapy has demonstrated reduced length of stay in the intensive care unit when added to total parenteral nutrition? - Fish oil Braden Scale - A tool for predicting pressure ulcer risk Tinetti Assessment Tool - Measures a patient's gait and balance. -total score possible: 28 -scored on balance (X/16) and gait (X/12) 25-28 = low risk of falls <19 = high risk of falls Ranson's criteria - clinical prediction rule for predicting the prognosis and mortality risk of acute pancreatitis evoked potential studies - diagnostic tests that use an EEG to record changes in brain waves during various stimuli Acupuncture for post-op pain? - Several clinical trials have demonstrated the utility of acupuncture for post-operative pain management. Life care communities provide a continuum of care for older adults that allows for a smooth transition to more comprehensive care as the patient's abilities decline. Which of the following circumstances would most likely precipitate a transfer from assisted living to the long-term care facility? Dementia, falls, urinary and/or fecal incontinence, or depression? - Falls Generalized thinning of the hair, mild temporal wasting, scattered areas of hyperpigmentation, and dry skin - Normal age-related variants
What is the most common cause of liver failure requiring transplantation in the United States? - Hepatitis C What class of medications is used for both erectile dysfunction and pulmonary hypertension? - Phosphodiesterase inhibitors Most common complication of SAH - Vasospasm (treated with nimodipine) Treatment for Parkinson's - Levodopa...carbodopa When percussing the abdomen, what sound would suggest bowel perforation? - Diffuse tympany through the abdominal cavity, which suggests free air. Most common inherited bleeding disorder - von Willebrand disease Desmopressin as sole therapy is appropriate for treatment of minor bleeding in von Willebrand disease, type 1. Von Willebrand factor product is recommended in the treatment of minor bleeding in von Willebrand disease, type 3, and major bleeding in von Willebrand disease, types 2 and 3. Phenytoin pharmacokinetics - Metabolized by zero order kinetics (a constant amount of drug is eliminated per unit time; the rate is independent of the concentration of the drug) intraocular pressure normal range - 10-21 mm Hg Eustress - A positive stress that energizes a person and helps a person reach a goal ESR (erythrocyte sedimentation rate) - <30 mm/hr A patient is admitted for the management of hypertensive emergency with acute aortic dissection. Preferred pharmacotherapy includes: - Nitroprusside sodium and labetalol. Prolactinoma - a benign tumor of the pituitary gland that causes it to produce too much prolactin (decreases the levels of some sex hormones)
Diabetic ketoacidosis. Consistent with evidence-based standards of care, she will convert the patient from intravenous to subcutaneous insulin administration when which of the following have occurred along with a blood glucose of <200 mg/dL? - Serum bicarbonate >15 mEq/L and venous pH >7.3. The scope of practice for nurse practitioners in the acute care setting is said to encompasses three general competencies: -
- Advanced practice registered nurse (APRN) core competencies.
- Role core competencies.
- Population core competencies. Immune Reconstitution Inflammatory Syndrome (IRIS) - paradoxical worsening of pre-existing OI or malig when ART initiated due to improvement in immune function; highest risk with low CD4 and high viral load
- paradoxical worsening of preexisting infection in HIV＋patient
- days to weeks after HAART
- continue HAART Change Theory - guides the development of interventions. It spells out concepts that can be translated into program messages and strategies When coding a hospital rounding visit as evaluation and management code 99233, the AGACNP realizes that documentation must include: - High complexity-level decision making Common CPT Codes - Initial hospital care for new or established patient — CPT codes 99221-99223. Subsequent hospital care — CPT codes 99231-99233. Performance appraisals and peer review are tools that the AGACNP should use to guide: - Professional development. diabetes self-management education and support - An ongoing process of individualized education and support to facilitate the knowledge, skill, and ability necessary for prediabetes and diabetes self-care and quality of life. Self-management is a mechanism by which patients are taught to take charge of their chronic conditions. Self-management tasks include the following: - Medical management. Role management. Emotional management.
