Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) /NR601 Final Ex, Exams of Nursing

Download Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) /NR601 Final Ex and more Exams Nursing in PDF only on Docsity! Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) NR 601 FINAL EXAM STUDY GUIDE Week 5: Glucose metabolism disorders Types of DM 1. Type 1- severe insulin deficiency resulting in reduction or absence of functioning beta cells in the pancreatic islets of Langerhans. This leads to hyperglycemia due to altered metabolism of lipids, carbs, and proteins. Initial s/s of hyperglycemia. Subjective findings- polyuria, polydipsia, nocturnal enuresis and polyphagia with paradoxical weight loss, visual changes and fatigue. Objective-dehydration(poor skin turgor and dry mucous), wt loss despite normal/increase appetite, reduction in muscle mass. DKA-fatigue, cramping, abnormal breathing 2. Type 2- Type 2 DM is characterized by the abnormal secretion of insulin, resistance to the action of insulin in the target tissues, and/or an inadequate response at the level of the insulin receptor. A patient may, however, present with pruritus, fatigue, neuropathic complaints such as numbness and tingling, or blurred vision. 3. Prediabetic- fasting glucose consistently elevated above the normal range but less than 100- 125. Impaired glucose tolerance (IGT) state of hyperglycemia where 2 hr post glucose load glycemic level is 140-199 Diagnostic criteria- there are 4 lab-based criteria to confirm DM: A1C, random plasma glucose, fasting plasma glucose, and 2-hr post load plasma glucose • AIC of 6.5 or higher=diabetes • Random plasma glucose level of 200 WITH classic symptoms of hyperglycemia or a hyperglycemic crisis • Fasting plasma glucose level of 126 or higher on TWO occasions(fasting is defined as no caloric intake for at least 8 hrs • 2-hour post load plasma glucose level of 200 or higher during an OGTT, following consumption of a glucose load containing the equivalent of 75g of anhydrous glucose dissolved in water (OGTT is also used to screen for diabetes during pregnancy) *** In the absence of unequivocal hyperglycemia results should be confirmed by repeat testing on a new blood sample without delay, preferably using the same type of test.*** • *All above-but confirmation of type 2 diabetes mellitus requires: two fasting blood glucoses ≥126 mg/dL or two random blood glucoses ≥200 mg/dL. Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) • If glycemic goals are not met in 3 months, initiate triple therapy. • If after 3 additional months (or at the time of diagnosis) A1C is 9.0% or higher and the patient is symptomatic, add insulin therapy. • A1c-Gyycemic level over 2-3months and is helpful is documenting control and continuing care. • A1c less than 7% indicate strong control • 6.5%or less decrease occurrence of complications achieved w/o hypoglycemia or other adverse effect. 2 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Medication Side Effects -Type 1: Hypoglycemia is a common occurrence in patients with type 1 DM and occurs for a variety of reasons: excessive exogenous insulin, missed meals or inadequate food intake, excessive exercise, alcohol ingestion, drug interactions, or decreases in liver or kidney function. Signs and symptoms: diaphoresis, tachycardia, hunger, shakiness, altered mentation (ranging from an inability to concentrate to frank coma), slurred speech, and seizures. The ADA classifies hypoglycemia as a plasma glucose level of < 54 as serious, clinically significant hypoglycemia. A blood glucose level of 70 is considered a threshold level that requires intervention. Examples of appropriate foods: #1 choice: pure glucose, ½ cup fruit juice, 6oz regular soda (not diet or sugarless), 1 cup milk, or glucose tabs. Candy is only a last resort. Recheck glucose 15 minutes after treatment. Additional carbs can be given if glucose is still less than 70 -Type 2: Metformin can cause: hypoglycemia esp in older adults, adverse reactions such as GI disturbances and metallic taste, and is contraindicated in renal disease so assess renal function prior to prescribing. - Metformin also has a boxed warning in its FDA-approved prescribing information for lactic acidosis, although this side effect is very rare. Metformin should be discontinued 24 to 48 hours before diagnostic and surgical procedures due to the risk of decreased kidney function, and its administration should not be resumed for at least 6 hours after these procedures or until the patient is adequately hydrated. Initial dosing is 500 mg once a day with breakfast or dinner for 1 week, then twice daily with breakfast and dinner. Several weeks of therapy may be needed to achieve maximum effects of the given dose. Common adverse reactions include diarrhea, nausea, anorexia, and abdominal discomfort, which usually resolve with a gradual increase of dosage. Metformin has been shown to cause decreased vitamin B12 absorption, and patients on long-term metformin therapy should undergo periodic testing for B12 deficiency, especially if the patient complains of peripheral neuropathy. At the maximum dose, the monthly cost of metformin in the United States is approximately $4 on many generic formularies. Metformin is currently found in 20 combination formulations with other medications. *For other noninsulin agent adverse reactions see pg 929 Dunphy book* SINGLE-DOSE THERAPY Single Injection • Intermediate or long-acting insulin with or without regular insulin in the morning or Intermediate or long-acting insulin at bedtime • Recommend at a minimum SMBG in the morning and at bedtime CONVENTIONAL SPLIT-DOSE THERAPY Two Injections • Mixture of NPH and regular insulin in the morning and evening • Recommend at a minimum SMBG before each dosing and at bedtime INTENSIVE INSULIN THERAPY Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) 3 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) • African American • Latino • Native American • Asian American • Pacific Islander Complications • Type 2 DM is the leading cause of acquired blindness in adults aged 20-74 and up to 25% of newly diagnosed patient may present with retinopathy at the time of diagnosis. • Metformin is contraindicated in patients with renal insufficiency because the risk of lactic acidosis is increased in these patients and, while uncommon, has a very high mortality rate. • Acute complications requiring immediate attention include diabetic ketoacidosis, recurring fasting hyperglycemia of greater than 300 mg/dL, Hb A1c of greater than 13%, or severe hypoglycemia with changes in sensorium, altered behavior, seizures, or coma. Complications resulting from prolonged hyperglycemia include renal failure, blindness, coronary artery disease, stroke, peripheral vascular disease, slow-healing wounds, autonomic neuropathies, hypertension, sexual problems, and genitourinary system disorders. Macrovascular complications from diabetes substantially increase the risk of morbidity and death from coronary artery disease, stroke, and peripheral vascular disease. Treatment for complications - Hyperlipidemia: use of statins as antihyperlipidemia therapy is indicated with these patients with nutritional treatment (diet modification) initiated as first line therapy. (hyperlipidemia: LDL greater than 100 Referrals • Initial diagnosis: referral to dietician and a certified diabetes educator • DM patient should have annual exam of feet and eyes (funcuscopy) • Endocrinologist • Annual eye and oral examination Obesity • Comorbidities related to obesity- Obesity is considered a risk factor for the development of a Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) number of illnesses or diseases. Being overweight or obese explains almost 50% of cardiovascular outcomes (ie coronary heart disease, stroke) and contributes of blood pressure, dyslipidemia, and glucose concentration. • The obese patient is more likely to develop coronary artery disease, hypertension, and hyperlipidemia. There is an increased risk of developing type 2 diabetes mellitus, cerebrovascular disease, and CKD. The obese patient is more likely to develop physical disability, sexual dysfunction, lower UTIs, and impaired cognitive function and dementia. Certain types of cancer such as colon, breast, endometrium, liver, kidney, esophagus, gastric, pancreatic, 5 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) gallbladder, and leukemia are also associated with obesity. Obese patients are also more likely to develop obstructive sleep apnea, gallbladder disease, fatty liver disease, and osteoarthritis. They will often have symptomatic varicose veins or GERD. • Obesity is defined as a BMI >30 with morbid obesity as a BMI >40. Overweight is defined as a BMI of 25 to 29. The CDC provides a BMI calculator on their Healthy Weight Web site (CDC, 2015b). BMI DEFINITION <18.5 Underweight 18.5–24.9 Normal 25.0–29.9 Overweight 30.0–34.9 Class I obesity 35.0–39.9 Class II obesity >40.0 Class III extreme obesity Week 6: Urology and aging UTI - Urethritis and cystitis usually occur together - Infections can be acute, chronic, recurrent, complicated, or uncomplicated. - UTIs become chronic because of obstructions, antibiotic-resistant bacteria, or the presence of multiple strains of bacteria that are not susceptible to the antibiotic therapy prescribed. - A complicated UTI is either an acute or chronic infection that is accompanied by factors that predispose a patient to the infection or make treatment more difficult such as instrumentation (ie indwelling, suprapubic, or intermittent cath), underlying chronic disease, systemic symptoms, or pregnancy. Risk factors- Predisposing factors to the development of cystitis in older adults include Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) urine is not a marker of complicated infection. • Bacteriuria and pyuria are the main laboratory clinical manifestations of cystitis • older adult, the presence of localized genitourinary symptoms (see Signal Symptoms) and pyuria on urinalysis are required for diagnosis • The presence of greater than 10^ 5 colony-forming units/mL of a single bacterium in a culture of freshly voided urine is generally considered to be a significant bacteriuria Treatment 7 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) • Uncomplicated UTI in women that highlighted nitrofurantoin 100 mg twice daily for 3 days over trimethoprim-sulfamethoxazole related rising resistance rates and nitrofurantoin’ s lesser side effect profile. And Fosfomycin given in a 3 g one-time dose o However, a 3 day course of Bactrim or a longer 10 day course of ampicillin. In pts with sulfa allergy or previous abx use in last 3 months, use nitrofurantoin (Macrobid) • Uncomplicated treatment of UTI in the adult male can be treated empirically for 7 days with a fluoroquinolone or sulfamethoxazole-trimethoprim DS. • In pregnancy, fluoroquinolones should be avoided due to concern for their effects on bone and cartilage formation in developing fetus and Bactrim should be avoided in first and third trimesters of pregnancy. However, treatment is important because a UTI during pregnancy increases premature delivery . Empirical therapy may include ampicillin or Keflex • The management of asymptomatic bacteriuria deserve s special mention: o Treat pregnant individuals out of risk of premature delivery o Treat asymptomatic young children due to high rate of recurrent asymptomatic infection without obvious sequelae o Treat pts before they undergo a urological procedure to avoid operating on a contaminated field, after removal of a bladder cath in place for less than 1 week, and in any pt with an underlying structural abnormality of the urinary tract, vesicoureteral reflux, or struvite stones. o In contrast, treatment of asymptomatic bacteriuria is not warranted in: adult men, nonpregnant women, the elderly, diabetic persons, and spinal cord patients with indwelling urinary catheters • Older men may require longer therapy for 10 to 14 days • *Untreated symptomatic cystitis can lead to pyelonephritis, sepsis, shock, and death* Incontinence : involuntary loss of urine and is generally the result of illness or the effects of medications and is self-limiting when the cause is determined and addressed Different Types: - Stress: urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors increasing and pressure o Tx: lifestyle interventions, behavioral therapies, possible surgical procedures, alpha adrenergic meds, SNRI - Urge: urine leakage associated by or immediately preceded by the feeling of an urgent need to void o Tx: lifestyle interventions, behavioral therapies, consider trial of antimuscarinic Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) (anticholinergic) medications - Mixed: a combo of stress and urge incontinence, marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing o Tx: same as stress and urge incontinence - Overflow: urine leakage when the bladder is over-distended and may result in incomplete bladder emptying. Symptoms can present as constant dribbling, frequency, hesitation when initiating urination, and nocturia. Often associated with bladder outlet obstruction, such as benign prostatic hypertrophy in men and pelvic organ prolapse in women (DING: TAMSULOSIN) 8 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) - Age-related changes that may affect urological functioning are decreased bladder capacity, increased postvoid residual urine volume (>50mL), increased disinhibition of bladder contractions (overactive bladder), increased nocturnal sodium and fluid excretion (nocturia), urinary overflow phenomena resulting from increased urethral resistance in men related to BPH, and weakness of the pelvic floor in women. Postmenopausal estrogen deficiency in women can result in decreased competence of the internal and external sphincters via atrophy of the urethral mucosa epithelium resulting in atrophic urethritis, loss of compliance, and a diminished urethral mucosal seal. It is important to note that normal aging does NOT cause UI. Sexuality and aging STIs/Age related changes: - Assumptions regarding lack of sexual expression in the healthy older adult are unfounded. With the possibility of pregnancy eliminated, many mature adults feel less restraint. As a result of divorce or widowhood, they may seek satisfaction with new partners yet lack the knowledge to protect themselves from sexually transmitted diseases, especially HIV. More than 42% of those living with HIV in the United States in 2013 were in people more than 50 years old; 39% of deaths from HIV in 2014 were in adults older than 55yo. Older adults need to be taught methods for safe sex with use of a barrier to avoid sexually transmitted diseases, including HIV and hepatitis B. Using the patient’s sexual history, explore patient needs, preferences, and medical or psychological obstacles to sexual expression. This exploration facilitates counseling and interventions to promote healthy sexual behavior. - Male microabrasion in outer penis shaft serve as entry point for STI - Susceptibility is also influenced by aging and the presence of existing infection - Female pH change can disrupt the natural balance of flora and predispose the reproductive track to infection - Older women are prone to infection secondary to drying and thinning of the vaginal and vulvar tissue - Education methods of safe sex with the use of barriers to avoid STI (esp HIV and Hep B) - More than 42% living with HIV are over 50yo, 39% of deaths from HIV 55yo+ GSM: genitourinary syndrome of menopause • GSM incorporates VVA (vulvovaginal atrophy aka atrophic vaginitis). VVA really just describes estrogen deficiency changes of the vulva and vagina but GSM is a whole syndrome that involves symptoms of the vagina, the urinary tract, and sexual symptoms. • Signs and symptoms- main symptoms: pain with intercourse, vaginal dryness, postmenopausal o GSM is the #1 cause of discomfort with intercourse after menopause Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) o All symptoms: vaginal dryness, dysuria, vulvar and vaginal itching, urinary frequency, blood-tinged vaginal discharge, dyspareunia, decreased vaginal secretions ▪ Complaints of urinary frequency, urgency, and stress incontinence are common o On exam: pale, dry, nonrugated vaginal walls with patches of erythema or petechiae or both. The vaginal canal is short and narrow. A watery, white vaginal discharge without foul odor may be found. Estrogen deficiency can lead to loss of uterine support and subsequent uterine descensus. The exam may also reveal sparse vulvar hair, decreased 10 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) subcutaneous fat within the mons pubis and labia majora, volume reduction of labia minora, retracted clitoris and inadequate vaginal lubrication with pale, dry, and shiny introitus. • Diagnosis- estrogen deficiency leads to atrophy of vaginal and vulvar epithelium. o Diagnostic tests: pelvic exam with speculum and Pap smear (may do wet mount and KOH preparation if infection is suspected) : results if GSM: pale, dry, nonrugated vaginal mucosa; pap smear results should be normal, vaginal pH by litmus paper > or equal to 5. Urinalysis to rule out UTI if symptoms: results if GSM: variable, if dipstick is positive for WBCs and nitrates, a culture and sensitivity should be done. If negative, UTI is not cause of symptoms. • When to treat, common treatments – • Nonprescription therapies: FIRST LINE: over the counter moisturizers and lubricants plus regular sexual activity with a partner, device, or masturbation. Use products on a small patch of skin for 24 hrs before using intravaginally. Next step: pelvic physical therapy (PT). o Herbal alternatives (black cohosh and soy) have NO benefit on atrophic vaginitis • Prescription therapies: If these options do not work, hormonal therapy is the next option: low- dose vaginal estrogen, there's a tablet that's placed in the vagina twice weekly, creams that are placed in the vagina two or three times weekly, and it's very simple to use vaginal ring that's put the vagina for 3 months at a time. GSM often occurs in women with a history of breast cancer who reinitiate their sex lives. o Potential contraindications to vaginal estrogen are postmenopausal women with undiagnosed vaginal/uterine bleeding and controversial in women with estrogen- dependent breast or endometrial neoplasia. • Expected response is quick, with resolution of symptoms within 2-3 months. If this does not occur, the patient should be reevaluated and reexamined for other causes of symptoms. • The important message is that we have so many effective medications for general urinary syndrome of menopause (GSM) yet so many women aren’t on therapy often because we just are not asking. Every clinician needs to ask every postmenopausal patient at every well visit and every comprehensive visit if they have any vaginal dryness, discomfort with sexual activity, or any concerns about your sex life. • Education: Use water-soluble lubricants. Counsel patient regarding the benefits of regular sexual activity. Identify age-related difficulty associated with intravaginal application of creams and address these needs with sensitivity Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) supplements: isoflavonoid phytoestrogens (are similar to estradiol), soy products (have phytoestrogens) like tofu and soy milk. It should be noted however, that the use of soy- based products is controversial because of their unknown effects on estrogen receptors located in breast tissue. Due to this, they should be avoided by women with breast, ovarian, or uterine cancer, endometriosis, and uterine fibroids, black cohosh • Emotional symptoms: many women experience depression, irritability, and anxiety. • Pharmacological: SSRIs (paroxetine or venlafaxine) may relieve hot flashes as well as hormonal therapy 12 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) • Nonpharmacologic: regular aerobic exercise improves cognitive function, enhances mood, and promotes daytime alertness and nocturnal sleepiness. Recent studies have shown that a brisk daily walk enhances wellness and promotes a sense of well-being • Hormone Therapy (HT): useful for prevention of osteoporosis, relief of vasomotor symptoms, and the treatment of vulvovaginal atrophy associated with menopause. HT is the most effective tx for vasomotor symptoms and genitourinary symptoms of menopause. There is an increased risk of heart disease, stroke, venous thromboembolism, and breast cancer with the use of HT. HT is contraindicated in pts with hormone dependent cancers, such as breast, endometrial, and ovarian cancer, and undiagnosed vaginal bleeding. Patients with liver disease, active thrombosis, or history or stroke should not take estrogen, and progestin should be used with caution. Pregnancy is an ABSOLUTE contraindication to HT. Migraine headache is a relative contraindication to HT. o Estrogen-only therapy (ET) is used in women who do not have a uterus or are treating genitourinary symptoms with low-dose topical preparations. o Estrogen plus progestin therapy (EPT) is used in women who HAVE a uterus to prevent endometrial hyperplasia. Erectile Dysfunction Erectile dysfunction (ED) is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance. ED can also manifest as a lack of sexual desire or an inability to ejaculate. ED can result from many causes, including physiological, psychological, endocrinological, vascular, and neurologic etiologies. It is characterized as the inability to achieve an erection sufficient for intercourse for at least 3 months. In a broader sense, ED encompasses problems with arousal, libido, orgasm, sensation, and relationships Diagnosis: • Initially, lab tests to r/o various causes of ED should be done. These tests include: fasting blood sugar (r/o DM), lipid profile (r/o dyslipidemia), TSH, and testosterone level. If the testosterone level is below 300, serum prolactin level is warranted. • Several specialized tests can be done but usually only if the cause of the ED is not apparent following the standard testing regimen. Most useful: Inocturnal penile tumescence and rigidity (NPTR) test (physical ability to achieve erection) and color doppler sonography (asses vascular causes-integrity of arterial influx in the cavernous artery during erection by measuring the peak systolic blood flow velocity in this artery) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Treatment: - If an organic cause cannot be found, these men will most likely benefit from behavioral based sex therapy - Nonpharmacologic interventions: vacuum constriction devices (takes 2 minutes, use pump, then put ring around base of penis to maintain erection), vasoactive therapy, penile prostheses (surgically implanted into the penis), and penile revascularization (mainly for men <45 yo whose impotence is mainly caused by severe pelvic trauma) 13 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) negligent act performed by a caregiver or another person that may cause harm or risk of harm to an older adult who is vulnerable. Types of abuse: • Physical abuse: causing physical pain or injuring a vulnerable elder • Sexual abuse: sexual contact with a vulnerable elder without his or her consent • Neglect: failing to provide food, shelter, health care, or protection for a vulnerable elder • Exploitation: the taking of funds, property, or any assets of a vulnerable elder without legal consent and not for the benefit of the elder • Emotional abuse: using verbal or nonverbal means to cause mental pain, anguish, or distress in an elder • Abandonment: deserting the vulnerable elder once someone has assumed responsibility for that individual • Self-neglect: the elder fails to perform the needed activities to protect his or her own health and safety (lacks food/utilities, refuses medications, hoards, lives in unsafe conditions, neglects his or her grooming/appearance, is unable to handle finances, is isolated, is disoriented, develops a dependence on drugs and/or alcohol) Risk Factors: - Common features of perpetrators committing elder abuse are partners or spouses living with the victim, history of alcohol or drug abuse, history of mental illness, history of unemployment, and being socially isolated. - The abused elder is more likely an older female who generally has a physical impairment and is in poor health. She may either live alone or with the abuser, or in a household with many members. - The abuser is generally found to be a male who has a history of past or current substance abuse, has mental health issues, is socially isolated, and has a history of past trouble with law enforcement - In 90% of cases (of abuse of adults aged 60 or older) the culprit is a family member. - These cases result in an increased risk of death for the vulnerable elder involved in the abuse Provider responsibilities in suspected abuse- If elder abuse is suspected, it is the health-care professional’s responsibility—and in most cases his or her legal obligation—to report this to either 911 or the state elder abuse hotline. Carefully collect information regarding the patient, using physical findings, patient’s functional abilities, testing results, and verbal information from the patient and his or her caregivers. Use the interdisciplinary team and speak with social workers, nursing staff, and others who may have interacted with the patient and caregiver. Document all findings, because they may be required to be presented in court later. Photograph suspicious injuries and measure or compare size of injury to familiar objects if ruler is not available. Be sure to f/u with case workers to determine outcome. It may take several reports before the true picture of abuse/neglect/etc can be investigated thoroughly and the elder moved to a safe environment. Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Alzheimers *most common form of dementia* Alzheimer’s disease (AD) is a progressive, neurodegenerative condition and the most common form of dementia. Progressive and irreversible cognitive decline; and an array of emotional and behavioral problems that result from cognitive decline. Impaired ability to learn new information or recall 15 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) previously learned information and one or more additional cognitive disturbances in language (aphasia), function (apraxia), perception (agnosia), or executive function. Distinguishing features- • AD is characterized by an insidious onset; slow, progressive cognitive decline, and an array of emotional and behavioral problems that result from cognitive decline. • The cognitive decline in AD manifests as an impaired ability to learn new information or recall previously learned information and one or more additional cognitive disturbances in language (aphasia), function (apraxia), perception (agnosia), or executive function. • Most cases are sporadic but there are rare familial forms of AD. • Pathologic changes in the brains of pts with AD include neuritic plaques and neurofibrillary tangles Subjective • The patient usually presents with an initial complaint of memory problems. Often it is a family member who mentions this because patients with AD do not typically have insight into their memory difficulties. • Recognition of cognitive difficulty on from the family is often due to a change in pattern (getting lost in familiar places, etc.) • Eventually, the person loses the capacity to converse, walk, sit, or hold up the head. • 80% of pts in nursing homes with AD have behavioral problems including: hostility, aggression, suspiciousness and paranoia, delusions, agitation, sundowning, incontinence, and inappropriate or impulsive sexual behavior Objective • Concern about cognitive decline expressed by the pt or family or changes in behavior or cognition should trigger an initial assessment for dementia. Cognitive assessment is central to diagnosis and management of dementias and should be performed on all patients. • Routine social conversation and questions that can be answered automatically will not elicit symptoms of early AD. Instead, the provider should probe the pt’s memory further with questions such as “Do you remember what you did last Sunday? Or “What did you eat for breakfast this morning?” • It is very important to maintain the pts dignity by examining the pt alone before interviewing others and inform the pt if others are being interviewed. And be alert to the possibility that family members are overexaggerating or minimizing symptoms depending on motives • Signs and Symptoms for further assessment: • Learning and memory: the pt becomes repetitive; in daily life the pt has trouble remembering Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Mild-moderate Obvious memory impairment Overt instrumental ADL impairment Basic ADLs failing Prominent behavioral difficulties Shortened attention span Language difficulty Variable social skills Supervision required 2-10yrs severe Memory fragments only No recognition of familiar people Assistance with basic ADLs required Fewer troublesome behaviors 1-2yrs or longer 17 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Reduced mobility Weight loss, infections Seizures, dysphagia Incontinence Groaning, moaning, grunting Treatment: • The principles of management of AD are directed toward slowing progression of the disease pharmacologically, protecting physical health, providing emotional support, and maintaining optimal function through prevention or reduction of excess disability • Maintaining as much normalcy as possible in relationships and everyday activities may be the most effective way to prevent the development of excess disability (defined as the difference between the observed function and the actual underlying impairment). • Both patient and family need assistance in understanding and coping with AD. • Support group attendance can be helpful but should be relevant to the stage of the disease. • Anxiety and depression should be recognized and treated vigorously. • Legal and financial planning and discussion of future care options should take place early in the disease course. • Attention to good nutrition, exercise, and preventive care (imms, dental, vision, hearing care) is important. • A comprehensive, multidimensional treatment plan for dementia includes biological, psychotherapeutic, social, family, and pharmacological interventions • Biological Interventions: Treat underlying medical disorders with medications, medical or surgical procedures, and ongoing evaluation and management as indicated. • Psychotherapeutic Interventions: Include behavioral management, reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration, simulated presence therapy, reality orientation, skills training, recreation and art therapy, exercise, and aromatherapy. • Social Interventions: Include a functional and safety assessment, environmental modifi cations, assessment for abuse and neglect, provision of supervision and home health care, cleaning and meal services, assessment for appropriate level of care, fi nancial and estate planning, and legal provisions for power of attorney. • Family Interventions: Include caregiver education, training and support, respite care, and support groups. • Pharmacological: • Medications may improve cognitive function in mild to mod AD Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) • At the time of dx: treat with cholinesterase inhibitors • Antipsychotics should be used with caution and reserved for pts who exhibit persistent disruptive or dangerous behavior • The failure to institute timely pharmacologic management in pts with AD may result in a more rapid need for institutionalization, an increase in aggression, further difficulty with ALDs, and further cognitive decline • Pharmacotherapy: Cholinesterase inhibitors (ChEIs) are the cornerstone of pharmacological therapy, with the aim to enhance or preserve cognitive and behavioral status. 18 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) conceal deficits. mental status test increase effort to find appropriate replies, frequent near miss answer, word searching - Common: Alzheimer’s disease (AD) is the most common cause of dementia Etiology: - The etiology of dementia includes numerous systemic disorders; however most cases of dementia are irreversible because dementia is a progressive disease - CNS disorders: (AD, mild cognitive impairment, lewy body dementia, parkinsons), cardiovascular disease (vascular insults, cardiac arrhythmias, cerebral hypoxia), Infectious process (AIDS, Creutzfeldt-Jakob syndrome, neurosyphilis), Liver disease (chronic progressive hepatic encephalopathy), Neoplastic conditions (intracranial lesions, primary or metastasis), Pulmonary disease (resp encephalopathy, COPD), Urinary tract disease (UTI, chronic uremic encephalopathy) Most Common Types: - Alzheimers disease - Dementia can be classified as vascular, lewy body/parkinson’s, frontotemporal lob/Pick’s disease, or mixed Most common psychiatric complaint r/t dementia: - It is estimated that 90% of pts with dementia have psychiatric comorbidities. According to the Alzheimer’s association, depression affects up to 40% of persons with dementia, and prevalence is higher in vascular dementia than in AD. - Depressive symptoms may present as initial manifestations of dementia and may fluctuate over time. There are more reports of decreased ability to concentrate and indecisiveness and fewer reports of insomnia or hypersomnia, feelings of worthlessness and guilt, or thoughts of suicide and death. Diagnostic criteria for comorbid depression in dementia include the addition of irritability, social withdrawal, and isolation with frequent, concurrent apathy and anxiety Duration of Preclinical symptoms: stage Associated symptoms duratio n Preclinical Impaired memory, excused or covered Insidious instrumental ADLs losses (money handling, bills) Preserved basic ADLs Poor judgment and decisions Subtle personality changes Decreased spontaneity, sense of initiative Increased anxiety, socially normal 2-4yr or longer Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Staging of Dementia: see staging under Alzheimer’s disease Treatment: - A comprehensive, multidimensional treatment plan for dementia includes: biological, psychotherapeutic, social, family, and pharmacological interventions - Management of Noncognitive Behavioral Symptoms (NCBSs) of Dementia Includes determination and management of other potential or influencing factors, including 20 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) • Environmental: external (noise) or internal (UTI, constipation) • Situational: time of day, unknown trigger • Psychiatric: depression, anxiety, panic, fear • Medical: medication, pain, metabolic, infection, sensory deficits, cardiopulmonary - Nonpharmacological Approaches for NCBSs Include • Ensure safety and provision of adequate supervision • Analyze behavior(s) for clues to potential causes • Use environmental interventions • Provide structure—usual routines and predictability are important to allay anxiety. • Provide pleasurable experiences. • Do not rely on learning or memory. • Educate caregivers and other support systems. • Use of physical or chemical restraint is discouraged and may be used as last resort only, in order to ensure safety to self and others. • Provide caregiver education for managing agitation – ask permission to approach/ provide assistance. Use a calm approach. Slow down (do not rush patient or self). Use visual and verbal cues. Provide time and space. Limit stimuli. Create a calm environment. Follow a routine with set structure and tasks. Use verbal cueing. Redirect attention. Use a clock and calendar. Monitor heat, cold, hunger, sleep, elimination, and comfort. Nonphamcological Approaches • Biological: Treat underlying medical disorders with meds, procedures, and ongoing eval and management • Psychotherapeutic: Include behavioral management, reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration, simulated presence therapy, reality orientation, skills training, recreation and art therapy, exercise, and aromatherapy • Social: functional and safety assessment, environmental modifications, assessment for abuse or neglect, provision of supervision and home health care, cleaning and meal services, assessment for appropriate level of care, financial and estimate planning, and legal provisions for power of attorney • Family: include caregiver education, training and support, respite care, and support groups Pharmacological Approaches • Cholinesterase inhibitors (ChEIs) are cornerstone and aim to enhance or preserve cognitive and behavioral status. Three most common ChEIs: donepezil, rivastigmine, and galantamine. • Memantine (Namenda) is another medication that is a N-methyl-D-aspartate (NMDA) receptor antagonist and assists with high levels of glutamate in the brain Black Box: before initiating pharmacological treatment with antipsychotic medications, the clinician should carefully analyze the risks and benefits of the use of such medications for each patient. Based on studies demonstrating increased risk for stroke and mortality in the elderly, the FDA has issued a black box warning for use of antipsychotic medications in this population. Antipsychotic use is only Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Etiology: Causes of delirium are numerous, and in older adult hospitalized patients there are often multiple etiologies: - Metabolic: renal failure, hepatic failure, anemia, hypoxia, hypoglycemia, thiamine deficiency, electrolyte abnormalities 22 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) - Infection: meningitis, encephalitis, sepsis, urinary tract infection (UTI), respiratory infection - Cardiac: myocardial infarction, congestive heart failure, arrhythmia - Neurological: stroke, intracranial hemorrhage, head trauma, seizures, undiagnosed pain - Pulmonary: respiratory failure, COPD causing hypoxia - Sensory impairment: visual and/or hearing deficits - Medications: benzodiazepines, sedative-hypnotics, opioids, anticholinergics, antihypertensives, corticosteroids, lithium - Toxins: alcohol, amphetamines, cocaine, substance intoxication or withdrawal *Because the cause of delirium is multifactorial, no single neuropathology of delirium has been identified* Prevention strategies: • Preventive measures to lessen the likelihood of delirium include elimination or minimization of risk factors. These measures include judicious use of high-risk medications (Beers list; STOPP/START), timely management and good control of acute and chronic medical disease processes, correction of sensory deficits (eyeglasses, magnifying glasses, adequate lighting, hearing aids, cerumen removal), promotion of normal sleep patterns through good sleep hygiene measures, provision of adequate nutrition and hydration with oral/parenteral supplementation as necessary, prompt attention to elimination needs, participation in activities that maintain and stimulate cognitive and physical functioning, and provision of general supportive measures (environmental modifications, reality orientation, control of external stimuli) • For hospitalized elders and long-term care residents, encourage frequent visits by family members to provide familiarity, reality orientation, reassurance, and comfort. First line treatment for distressing symptoms: • While assessing for probable etiology and definitive treatment, management should focus on ensuring safety from behavioral disturbances by combining environmental, behavioral, and pharmacological therapies • Nonpharmacological tx: therapeutic environment including frequent reassurance and reality orientation, clear communication, caregiver consistency, decreased stimuli (noise reduction, adequate lighting, sufficient time to perform tasks), decreased stress and anxiety through frequent reassurance and provision of a daily routine; comfort maintenance (glasses, hearing aids, personal belongings), maintain a good sleep-wake cycle, ensure adequate fluids, physical activity. And Avoid chemical or physical restraining • Medication should be used as a last resort Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Medications associated with dementia symptoms: • First-generation (ie haloperidol) and second-generation (ie olanzapine, risperidone, ziprasidone, and quetiapine) antipsychotic medications to control behavioral symptoms of delirium and prevent injury to self or others. • AVOID benzodiazepines 23 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) - The POLST document was developed for patients with less than a year life expectancy. This document is not a living will or an advanced directive. This document outlines appropriate care for the patient, it is a set of orders that is to be followed by emergency workers. This document is important because emergency workers are not bound to follow a living well, but they are bound to follow orders outlined a POLST. - Review the POLST laws for your state and your nurse practice act (NPA) to learn if nurse practitioners can develop a POLST. You can find sample documents and instructions through an organization called Respecting Choices. Also, look at The Conversation Project, a free online resource to help you start your conversation with your patients. - The POLST form is a set of medical orders, similar to the do-not resuscitate (allow natural death) order. POLST is not an advance directive. POLST does not substitute for naming a health care agent or durable power of attorney for health care. Palliative Care Definition: - Palliative means relief - Palliative care is an interdisciplinary approach to care aimed at improving the quality of life of patients and their families facing a life-threatening illness. The goal of palliative care is the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual - Palliative care provides a support system to both the patient and the family, integrating psychological and spiritual aspects of care throughout the illness trajectory from diagnosis to death. That may also include end of life and bereavement services. - The basic goal of palliative care is to prevent and relieve suffering and to support the best quality of life possible. Palliative care also focuses on the needs of not only the patient but includes the needs of the family too - Families are included in the care planning. Patients and families benefi t from the availability of palliative care services early in the disease process, particularly when symptoms affect their quality of life. - Criteria: “Would I be surprised if this patient died in the next year?” as well as frequent hospitalizations; admissions prompted by physical or psychological symptoms that are diffi cult to treat; those with complex care requirements; and those with functional decline, feeding intolerance, and/or unintended weight loss are triggers that could indicate need for palliative care Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Eligibility criteria: - Palliative care can be involved at any stage of illness Services offered: - Palliative care services may take place inpatient, outpatient, skilled nursing facility, assisted living, or in the home environment. There are also office space palliative care programs that work to prevent suffering and support quality of life. 25 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) - Most palliative care teams are nurse practitioner or physician led, some may include a RN, a social worker, or a chaplain. - Provides relief from pain and other distressing symptoms, affirms life and regards dying as a normal process, intends to neither hasten nor postpone death, integrates the psychological and spiritual aspects of patient care, offers a support system to help patients live as actively as possible until death, offers a support system to help the family cope during the patient’s illness and in their own bereavement, uses a team approach to address the needs of patients and their families including bereavement counseling if indicated, enhances quality of life and may also positively influence the course of illness, is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications Length of eligibility: - Palliative care can be involved at any stage of the illness Symptom management - A few of the most prevalent symptoms in end-of-life care in the geriatric population are delirium, dyspnea, and pain Hospice: Definition: - A team oriented approach to providing specialized care for people facing a life-limiting illness or injury. - It uses the principles of palliative care, - focusing on quality of life, - to support patients and their families through the dying process, - and includes bereavement services. - Hospice services are covered by Medicare, Medicaid, and most private insurance providers. Eligibility criteria: - Hospice is only included for those with a life expectancy of six months or less Services offered: - It includes expert medical care, pain management, and emotional support for patients and their families. - The hospice agency determines which services, equipment, and medications are covered. Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) - Capsaicin topical: neuropathic and non-neuropathic pain - Lidocaine topical: postherpetic neuralgia - Corticosteroids: pain due to nerve compression, anti-inflammatory - Cannabinoids: state-specific regulations Onset of action for most common medications - Most effective pain medication for terminally ill patients 27 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) - Pain management medication side effects - Monitor for signs of drug accumulation which can include: delirium, sedation, and myoclonus - Common adverse effects: constipation, nausea, sedation, urinary retention, and pruritis - Long-term adverse effects: constipation, mental clouding, fatigue, osteoporosis, osteopenia, reduced libido, risk of myoclonus, mood changes, risk of opioid-induced hyperalgesia, and increased risk of sleep-disordered breathing First line treatment for each level of pain - Mild: NSAIDs and acetaminophen. o Acetaminophen is still considered an effective agent for pain associated with osteoarthritis and low back pain. Liver failure is an absolute contraindication o Recent guidelines advise against routine use of NSAIDS in the elderly due to significant potential for adverse effects (ie. GI toxicity, renal toxicity, and platelet dysfunction, as well as adverse effects of blood pressure control and heart failure management. The risk of MI or stroke is also increased with use of NSAIDs) - Moderate: Acetaminophen PLUS opioids o Continuing use of acetaminophen decreases the amount of total opioid given. (Ie. codeine, hydrocodone with acetaminophen, and oxycodone with acetaminophen) - Severe: Opioid pain meds o Consider long-term opioids in those pts who do not responds to more conservative management and who continue to experience pain-related distress or functional impairment and demonstrate benefit from opioid medication o The only absolute contraindication to the use of opioids is if there is a hx of rash, wheezing, or edema that was experienced in the past. o Common opioids: morphine, oxycodone, and hydromorphone. Tramadol is a weak opioid agonist and a SNRI Evaluation of pain medication necessity and addiction avoidance measures - Clinicians should educate pts and families about potential risks and benefits when initiating treatment, including adopting a universal precautions approach to minimize abuse, addiction, diversion, as well as clarify myths and misconceptions about opioid therapy. - Clinicians should educate pts and families regarding safe storage, use, and disposal of controlled substances as well as caution with using alcohol or sedating OTC medications Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Grief Uncomplicated (symptoms, duration) - Uncomplicated/normal grief includes physical, emotional, cognitive, and behavioral responses. - Common grief reactions include somatic symptoms; sleep and appetite disturbances; memory loss and impaired concentration; social withdrawal and disinterest in prior activities; a sense of the presence of the deceased person, and auditory or visual hallucinations; questioning of 28 Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) atropine, or glycopyrrolate • Assess the dying person frequently for objective signs of distress, such as grimacing and moaning, and treat distressing symptoms as follows: o morphine liquid concentrate for pain and/or shortness of breath/air hunger; o oxygen may be beneficial if the person is hypoxic; o lorazepam liquid concentrate for restlessness and anxiety; o haloperidol liquid concentrate for agitation/delirium or nausea; o atropine ophthalmic drops given orally, scopolamine patch, glycopyrulate, or hyoscyamine for upper airway secretions; o acetaminophen suppository for fever; o and haloperidol liquid concentrate or prochlorperazine suppository for nausea and vomiting. o For seizures, lorazepam can be given subcutaneously or IV, and diazepam or phenobarbital rectally. • In the dying patient, glucocorticoids such as dexamethasone are often effective adjunctive medications for pain, anorexia, nausea, and asthenia Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) Chamberlain College Of Nursing : NR 601 Final Exam Study Guide (Version-2) / NR601 Final Exam Study Guide (NEW, 2021/2022) 30