Comprehensive Exam Study Guide for Nursing, Exams of Nursing

Download Comprehensive Exam Study Guide for Nursing and more Exams Nursing in PDF only on Docsity! NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Genitourinary, gynecologic, renal and acid/base conditions o Carcinoma of the Cervix Increased risk in women who smoke and those with HIV or high-risk HPV types. Considered a sexually transmitted disease as both squamous cell and adenocarcinoma of the cervix are secondary to infection with HPV; squamous cell accounts for 80 percent of cervical cancers, 15 % adenocarcinoma, and 3-5 % neuroendocrine. Prevention through vaccination- recombinant 4 or 9-valent HPV vaccination which target HPV types that pose the greatest risk. Prognosis- overall 5- year relative survival rate is 68 % for white women and 55 % in black women- survival rates are inversely proportionate to the stage of cancer. Signs/Symptoms- Metrorrhagia, postcoital spoting, and cervical ulceration. Gross edema of the legs may be indicative of vacular and lymphatic stasis due to tumor. Pain in the back (lumbosacral plexus region) indicates neurologic involvement. Bladder and rectal dysfunction or fistulas are severe late symptoms. Two to 10 years are required for carcinomas to penetrate the basement layer of the membrane and become invasive- screening has decreased mortality. Diagnostic Tools- Cervical Biopsy- After a positive papnicolaou smear biopsy or endocervical curettage is necessary to determine the extent and depth of the cancer cells. Surgery and radiation should be delayed until biopsy results. Imaging- CT, MRI, lymphangiography, fine-needle aspiration, ultrasound, and laparoscopy are utilized for staging of invasive cancer. Allows for more specific treatment planning. Complications- Metastases to regional lymph nodes occurs with increasing frequency from Stage I to Stage IV. Extension occurs in all directions from the cervix. Hydronephrosis (urine-filled dilation of the renal pelvis due to obstruction) and hydroureters (dilation of the ureter), is a result of the ureters becoming obstructed lateral to the cervix which can lead to impaired kidney function. Treatment/Management- Refer all patients to Gynecologic Oncologist Carcinoma in situ (Stage 0)- women whom child-bearing is not a consideration, total NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 hysterectomy is definitive treatment. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Laparoscopy is often utilized to diagnose PID and imperative if symptoms do not respond to antibiotic therapy within 48 hours of imitating Treatment/Management Antibiotic coverage Mild to moderative infection- treat outpatient 1. Single dose of cefoxitin, 2g IM, with probenecid 1g orally, plus doxycycline 100mg orally twice a day for 14 days OR 2. Ceftriaxone 250mg IM plus doxycycline 100 mg orally twice daily for 14 days. 3. Metronidazole 500 mg orally twice daily for 14 days can be added to either regimen. Severe disease- meet criteria for hospitalization 1. Cefotetan 2g IV every 12 hours OR 2. Cefoxitin 2g IV every 6 hours, plus doxycycline 100mg orally or intravenously every 12 hours. OR alternative regiment is 3. Clindamycin 900 mg intravenously every 8 hours, plus gentamicin loading dose of 2mg/kg intravenously or IM followed by maintenance dose every 8 hours. Either regiment should be continued for at least 24 hours after patient shows symptom improvement and then transitioned to oral regimen for a total of 14 days Surgical Management- Tubo-ovarian abscess is a complication of PID and may require surgical intervention, unless rupture is suspected high dose antibiotics can be initiated. Monitor therapy response with ultrasound. 70 percent of cases respond to ABX, 30 percent require surgical intervention. Admission criteria- Tubo-ovarian abscess, pregnancy, patient is unable to follow outpatient regimen, patient has not clinically improved with 72 hours from outpatient initiation of ABX, serve illness symptoms including nausea/vomiting, or high fever. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 o Uterine bleeding NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Normal menstrual bleeding is 5-7 days as an average blood loss of 40mL per cycle. Menorrhagia is considered blood loss over 80mL Metrorrhagia is bleeding between cycles Polymonorrhea is bleeding that occurs more often than every 21 days Oligomenorrhea bleeding less frequently than 35 days. Abnormal Uterine Bleeding (AUD) is defined by the bleeding pattern, heavy, light, menstrual, intrermenstural and etiology PALM-COEIN P- polp A- Adenomyosis L- leiomyoma M- malignancy C coagulopathy O- ovulatory dysfunction E- endometrial I iatrogenic N- not classified. Adolescents- AUB is often a result of persistent anovulation due to immaturity of the hypothalamic-pituitary-ovarian axis and normal Once menses has been established during adolescence ovulatory dysfunction AUB is most common. Signs/Symptoms 1. History of duration and amount of flow, associated pain, and relationship to the LMP, with presence of blood clots and degree of inconvenience caused by the bleeding 2. History of pertinent illness, such as recent systemic infection, physical or emotional stressors. 3. History of medication such as warfarin or heparin, herbal remedies (ginko, ginsing) that may cause AUB 4. History of coagulation disorders in patient or family members 5. Evaluate for excessive weight and signs of PCOS, thyroid disease, insulin resistance, or NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 3. Ceftriaxone 125mg IM prevent fonorrhea- Metronidazole 2g, and aazithromycin 1g orally OR doxycycline 100mg orall BID for 7 days to treat chlamydial infection- repeat syphilis test 6 weeks after assault. 4. Prevent pregnancy using emergency contraception method 5. Vaccinate against Hep B, conasider HIV prophylaxis 6. Refer for counselling support on psychological support. o Ectopic pregnancy- Ectopic implantation occurs in 2 % of pregnancies with 98 % being tubal- Any condition that prevents or retards migration of the ovum to the uterus can predispose to an ectopic pregnancy, including history of infertility, PID, prior tubal surgeries, and ruptured appendix. Signs/Symptoms Severe lower quadrant pain, sudden onset, stabbing, intermittent and DOES NOT radiate. Back ache may occur- 2/3rd report history of abnormal menstruation. Slight but persistent vaginal spotting, palpable pelvic mass. Abdominal distension (collection of blood in peritoneum) and mild paralytic ileus. Labs/Imaging CBC- anemia and mild leulocytosis HCG- will show levels slightly lower than normal pregnancies of similar length Progesterone level can also be measured for pregnancy viability Normal pregnancy-**Ultrasound will display a gestational sac 5-6 weeks from last menstruation and fetal pole is located in uterus** An empty uterine cavity leads to strong suspicion of an ectopic pregnancy- especially in conjunction with HCG levels. Consider rising HCG levels with an empty uterus- for example a beta-HCG of 6500 milli-unit/mL and an empty uterine cavity. Treatment/Management Differentials including PID, acute appendicitis, ruptured corpus luteum cyst or ovarian follicle Patient with normal liver and renal function- Methotrexate 50 mg/m2 IM- given as single or multiple dose- pregnancy should be less than 3.5 cm and unruptured Unstable- patient is hospitalized, blood type and crossed- goal is to diagnose and operate prior to rupture (prevent intra-abdominal hemorrhage) NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Surgery- Diagnostic Laparoscopy followed by a salpingostomy with removal of the ectopic pregnancy or a partial/complete salpingectomy. Iron therapy for anemia may necessary- Rh immune globulin should be given to Rh- patients Fluid/Electrolyte Imbalance 2/3 body weight intracellular, 1/3 extracellular. Effective circulating volume may be assess by physical examination, blood pressure, pulse, jugular venous distention. Urine- urine concentration of an electrolyte is helpful to determine whether the kidney is appropriately excreting or retaining an electrolyte in response to high or low serum levels. 24 hour urine- most appropriate to assess electrolyte excretion, however, time consuming. Fractional excretion- FE %= (urine X/serum X)/urine CR/Serum CR x 100. Low fraction excretion indicates renal reabsorption (electrolyte retention or high avidity) High fraction- renal wasting (electrolyte excretion or low avidity) Serum Osmolality- solute concentration- normal 285-295 mmol/kg. Differences in osmolyte concentration across cell membranes lead to osmosis and fluid shifts, stimulation of thirst, and secretion of ADH Osmolality = 2 (Na+ meq/L) + glucose/ 18 + BUN/2.8 o Hyponatremia- volume status and serum osmolality are essential to determine etiology- usually reflects excess water retention relative to sodium. HYPOTONIC fluids commonly cause hyponatremia in hospitalized patients. Serum sodium > 135mEg/L Evaluation of the patient should include 1. Urine sodium (normal 10-20 mEg/L) 2. Serum osmolality (usually 2 x NA) 3. Clinical status Measuring urine sodium helps distinguish renal from non-renal causes. Example Urine sodium >20 suggests renal salt wasting (problem with kidneys) Urine sodium <10 suggests renal retention of sodium to compensate for extra-renal fluid loss (problem outside of the kidney) Isotonic Hyponatremia (Pseudohyponatremia) NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Serum Osmolality 284-295 NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 3. Diarrhea NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Laboratory Findings/Diagnosis 1. ECG not particularly sensitive- 50% of patient with K+ >6.5 will not have ECG changes, however, tall pealed T waves are classic finding Management 1. Exchange resins (Kayexalate) 2. If >6.5 or cardiac toxicity or muscle paralysis is present, consider a. Insulin 10 U with one amp D50 (pushes K into cells) Calcium Major cellular ion and important as a mediator of neuromuscular and cardiac function. Normal total calcium of 2.2-2.6 mmol/L (8.5-10.5 mg/dL) and normal ionized calcium of 1.1-1.4mmol/L (4.5-5.5 m/dL). 1. Ionized calcium does not vary with albumin level (useful to measure the ionized calcium level with the serum albumin is not within normal range) 2. Calcium is maintained by Vitamin D, parathyroid hormone, and calcitonin. 3. Acidemia increase ionized calcium and alkalemia decrease 4. The total amount of total calcium varies with the level of serum albumin (since 50 % of calcium is bound to albumin, a normal calcium level in the presence of low albumin level suggests that the patient in hypercalcemic. 5. Corrected calcium (mg/dl) = measured total Ca (mg/dl) +0.8 or [4.0- serum albumin (gldl)], where 4.0 represents the average albumin level o Hypocalcemia Causes include hypoparathyroidism, hypomagnesemia, pancreatitis, renal failure, severe trauma, and multiple blood transfusions. Signs/Symptoms 1. Increase deep tendon reflexes, muscle/abdominal cramps 2. Carpopedal spams (Trousseaus sign) or Chvostek’s sign (sustained cheek) 3. Convulsions, prolonged OT interval Management 1. Check blood pH- look for alkalosis 2. If acute, IV calcium gluconate 3. If chronic, oral supplements, vitamin D, albumin hydroxide o Hypercalcemia NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 causes include hyperparathyroidism, hyperparathyroidism, vitamin D intoxication, prolonged immobilization- rarely thiazide diuretics will promote hypercalcemia. Signs/Symptoms 1. Fatiguability, muscle weakness, anorexia, depression 2. Nausea/vomiting/diarrhea/constipation 3. Severe hypercalcemia can cause coma and dealth Management 1. May need calcitonin if impaired cardiovascular or renal function 2. May need NS with loop diuretics – dialysis in severe cases. o Hypophosphatemia Causes include malabsorption, vitamin D deficiency, starvation, parental alimentation with inadequate phosphate content, electrolyte abnormalities (hypercalcemia, hypomagnesemia) metabolic alkalosis, recovery from starvation, inadequate DM control, hyperparathyroidism, hyperthyroidism. Alcohol, acute alcohol withdrawal (promotes intracellular shift of phosphate) Serum phosphate levels decrease after food intake, fasting samples are recommended for accuracy Moderate hypophosphatemia- 1.02.4 mg/dL Severe hypophosphatemia- less than 1 mg/dL . Impairs tissue oxygenation and cell metabolism – resulting in muscle weakness or even rhabdomyolysis. Specific Patient Populations Alcohol withdrawal- increased plasma insulin and epinephrine along with respiratory alkalosis promotes intracellular shift of phosphate Chronic alcohol use decreases renal threshold of phosphate excretion- renal dysfunction reverses after a month of abstinence. COPD- attributed to xanthine derivatives causing shifts oh phosphate intracellularly and the phosphaturic effects of beta-adrenergic agonists, loop diuretics, corticosteroids. Refeeding or glucose administration to phosphate-depleted patient may causes fatal hypophosphatemia. Signs/Symptoms 1. Severe can lead to rhabdomyolysis paresthesia, and encephalopathy (confusion, irritability, dysarthria, seizures) NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Magnesium Normal plasma magnesium level is 1.83.0 mg/dL, with about 1/3 bound to protein and 2/3 existing as free cation. Excreted via the kidney, physiologic effects on the nervous system resembles those of calcium. Altered magnesium concentration usually provokes an associated alteration of Ca. Both hypo/hyper can decrease PTH secretion or action o Hypomagnesemia Causes include malabsorption, laxative abuse, PPT, prolonged gastrointestinal suction, malnutrition, alcoholism, increased renal loss Signs/Symptoms - Weakness and muscle cramps, CNS hyperirritability may produce tremors, athetiod movements, jerking, nystagmus, Babinski response, confusion, disorientation. - EKG may show prolonged QT interval, due to lengthening of the ST segment. - PTH secretion is suppressed Management/Treatment - 250-500mg orally once or twice a day for chronic hypomagnesemia - IV 1-2 g over 5-60 minutes for symptomatic hypomagnesemia - Cautious replacement in patients with CKD to avoid hypermagnesemia- reduced doses o Hypermagnesemia Almost always the result of advanced CKD and impaired magnesium excretion. Antacids and laxatives. Pregnant patients may have severe hyper-magnesemia from IV magnesium for preeclampsia and eclampsia. Signs/Symptoms - Muscle weakness, decreased deep tendon reflexes, mental obtundation, confusion. Weakness, flaccid paralysis, ileus, urinary retention, and hypotension. - EKG may show broadened QRS complex and peaked T-waves (related to hyperkalemia) Treatment -Sources of magnesium should be discontinued - Calcium antagonizes Mg+ and can be given intravenously as calcium chloride - Hemodialysis or peritoneal dialysis may be required for CKD patients \ Acid-Base Disorders NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Metabolic (decreased or increased HCO3-) NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Respiratory (decreased or increased PCO2) If pH is <7.4 the primary process is acidosis, either respiratory (pCO2 >40 ) or metabolic (HCO <24) If the pH is >7.4 the primary process is alkalosis, either respiratory (pCO2 <40) or metabolic (HCO > 24) Once the primary acid base disturbance has been determined, assess whether the compensatory response is appropriate. An inadequate or exaggerated response indicates the presence of another primary acid-base disturbance. Anion gap should always be calculated0 >20 mEgq/L suggests a primary metabolic acid-base disturbance regardless of the pH or serum bicarb because an anion gap is never a compensatory response to a respiratory disorder. Anion gap- Na – (HCO3 +Cl) o Metabolic acidosis Hallmark is low serum HCO3 and low pH. Measurement of anion gap helps to evaluate cause and treatment options. Normal anion gap is 7-17 NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Licorice * assocated with hight urine Cl levels Endo: Cushings/Bartters NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Vomiting, NG suction Excess Alkali Refeeding Syndrome Post- Hypercapnia Diuresis Treatment for Saline Responsive Metabolic Alkalosis - Correction of the extracellular volume deficit with isotonic saline. Diueretics should be discontinued. H2 blockers or PPIs may be helpful in patients with M.A. from NG suctioning. Pulmonary or cardiovascular status limits resuscitation; acetazolamide will increase renal bicarb excretion. Treatment for Saline Unresponsive Metabolic Alkalosis - Surgical removal of the mineralcorticoid-producing tumor and blockage of aldosterone effect with an ACE inhibitor or spironolactone. Caused by primary aldosteronism, can be treated by potassium repletion o Respiratory acidosis (Hypercapnia) Results from hypoventilation and subsequent hypercapnia. Arterial pH is low and PCO2 NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 increased. Serum HCO3 is elevated but does not full correct the pH. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Symptoms include headache, amenorrhea, galactorrhea and visual field defects • Causes: neoplastic, vascular, inflammatory/infiltrative disorders, infections, congenital, postradiation, postsurgical, traumatic brain injury, empty sella syndrome, hypothalamic diseases, medications (opiods, megestrol) ▪ DDx • Addison’s disease, primary hypothyroidism, cardiogenic shock, septic shock ▪ Diagnostic studies • Serum electrolytes, serum and urine osmolarity, 8am cortisol and adrenocorticotropic hormone, thyroid function tests, (8am testosterone, follicle-stimulating hormone, luteinizing hormone in men), (estradiol, follicle-stimulating hormone, and luteinizing hormone in women), prolactin, insulin-like growth factor-1, cosyntropin/tetracosactide stimulation test ▪ Treatment Options • Underlying cause must be addressed, where causes are not correctable, treatment focuses on replacing target hormones o ACTH deficiency o Thyroid deficiency o Gonadotropin deficiency o Prolactin deficiency o Growth hormone deficiency o ADH deficiency o Hypophysitis associated with anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4) therapy o Diabetes Insipidus ▪ Evaluation • Characterized by polydipsia, polyuria, increased thirst, and formation of hypotonic urine, volume depletion • Central Diabetes Insipidus – due to defective synthesis or release of arginine vasopressin (AVP) from the hypothalamo-pituitary axis o Pituitary surgery o Craniopharyngioma o Posttraumatic head injury o Pituitary stalk lesions – Langerhans cell histiocytosis o Congenital malformations o Genetic mutations – Wolfram syndrome, AVP-neurophysin gene mutations o Autoimmune disorders – Hashimoto thyroiditis, DM1 o CNS infections – late complication of meningitis or encephalitis o Cerebrovascular accident – subarachnoid hemorrhage o Medications - phenytoin NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 o Recognized causes- temozolomide, IgG4 • Nephrogenic Diabetes Insipidus – due to renal insensitivity or resistance to AVP, with a resultant lack of permeability of the collecting duct to water. o Risk factors include lithium therapy, chronic renal disease, and chronic hypercalcemia or hypokalemia ▪ DDx • Psychogenic polydipsia, DM, hyperosmolar hyperglycemic state, hyperaldosteronism, diuretic use, hypercalcemia ▪ Diagnostic studies • Urine osmolality, serum osmolality, serum sodium, serum calcium serum potassium, urine dipstick, 24-hour urine collection for volume, serum BUN, serum glucose ▪ Treatment options • Treatment goals are correction of any pre-existing water deficits and reduction in ongoing excessive urinary water losses. • Central DI, desmopressin is the treatment of choice. • Nephrogenic DI is treated with adequate fluid intake; salt restriction and diuretics may help reduce polyuria • o Acromegaly ▪ Evaluation • Rare, chronic disease caused by excessive secretion of growth hormone (GH), usually die to a pituitary somatotroph adenoma. • Must be screened for in the presences of pituitary adenoma, profuse sweating, acral growth, coarsening of facial features, and when suspected in conjunction with commonly associated conditions such as carpal tunnel syndrome, arthralgia,, glucose intolerance or diabetes, amenorrhea, hypertension, and sleep apnea. ▪ DDx • Acromegaloidism • Pseudoacromegaly ▪ Diagnostic studies • Serum insulin-like growth factor (IGF-1), oral glucose tolerance test, random serum growth hormone (GH) • Consider MRI or CT of pituitary ▪ Treatment options • Goals of treatment are to: o Restore life expectancy to normal o Relieve symptoms of the condition o Completely remove the causative tumor, if possible; if not possible, control its growth and related mass effects o Preserve normal pituitary functioning o Hyperprolactinemia NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 ▪ Evaluation NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 ▪ Treatment options • Radioactive iodine – causes gland to shrink • Anti-thyroid medications – tapazole and propylithiouracil • Beta blockers – ease the symptoms of hyperthyroidism • Thyroidectomy o Thyroid nodules ▪ Evaluation • Most do not cause symptoms and are typically discovered during routine physical exam or on imaging tests like CT or US. • Thyroid tests are typically normal, even when cancer is present in a nodule • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879398/ ▪ DDx • Thyroid cancer ▪ Diagnostic studies • Thyroid US, fine needle biopsy, nuclear thyroid scan ▪ Treatment options • Surgical removal if cancerous • Monitor if small and benign o Thyroid cancer ▪ Evaluation • Most commonly presents as an asymptomatic thyroid nodule ▪ DDx – benign thyroid nodule ▪ Diagnostic studies • Fine needle aspiration NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 ▪ Treatment options NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Surgical removal of thyroid, followed by radioactive iodine ablation and TSH suppression • Thyroid hormone replacement • TSH checked 4-6 weeks after hormone treatment starts o Iodine deficiency disorder ▪ Evaluation • Associated with diffuse and nodular goiter • Iodine is an essential component of thyroxine (T4) and triiodothyronine (T3) and must be provided in the diet. ▪ DDx • Goiter, hypothyroidism, thyroiditis, infertility, pericardial effusion, thyroid nodule, thyroid cancer ▪ Diagnostic studies • Test for iodine by urine ▪ Treatment options • Iodized salt intake increased • Iodine tablets • Iodized water o Hypoparathyroidism ▪ Evaluation • Presentation varies: asymptomatic with low serum calcium to acutely symptomatic with neuromuscular irritability, tetany, painful muscle cramps, stridor, and even seizures with low serum calcium • Majority are post-surgery for benign and malignant thyroid disorders, hyperparathyroidism, and laryngeal or other head and neck cancers. ▪ DDx • Hypovitaminosis D, Hypomangnesemia, hypoalbuminemia, pseudohypoparathyroidism, renal failure, chronic kidney disease ▪ Diagnostic studies • Serium calcium, serum albumin, EKG, plasma intact PTH, serum magnesium, serum phosphorus, serum 25-hydroxyvitamin D, serum creatinin ▪ Treatment options • Calcium gluconate 90mg IV over 10 min (can be repeated), followed by 0.5-1.5mg/kg/hr infusion • Magnesium sulfate 1g IV q6hrs until normal range o Hyperparathyroidism ▪ Evaluation • Diagnosis confirmed with serum calcium and inappropriate evaluation of PTH • Depression, cognitive changes, change in sleep pattern, and myalgias are common complaints NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 ▪ Diagnostic studies • Adrenocorticotropic hormone stimulation test is performed to confirm or exclude the diagnosis of Addison’s disease. ▪ Treatment options • Hydrocortisone sodium succinate 50-100mg IV q6-8hrs for 1-3 days • NS to correct hypotension and dehydration • Glucose when necessary to correct hypoglycemia • Treatment of underlying cause o Cushing syndrome ▪ Evaluation • Clinical manifestation of pathologic hypercortisolism from any cause • Caused by adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma (most common cause) • Features more specific to Cushing syndrome include proximal muscle weakness, supraclavicular fat pads, facial plethora, violaceous striae, easy bruising, and premature osteoporosis ▪ DDx • Metabolic syndrome ▪ Diagnostic studies • Urine pregnancy, serum glucose, late-night salivary cortisol, 1mg overnight dexamethasone suppression test, 24-hour urinary free cortisol, 48-hour 2mg dexamethasone suppression test ▪ Treatment options • First line therapy is transsphenoidal resection of the causative pituitary adenoma • Medical therapy before surgery: mifepristone 300mg daily initially, increase in 300mg/day increments every 2-4 weeks according to the response, max 1200mg/day • Post-surgical tx: hydrocortisone 10-25mg per meter sqare body surface area/daily in 2-3 divided doses • Levothyroxine 1.8mcg/kg/day and/or testosterone transdermal 2.5- 7.5mg daily, titrate according to response o Primary aldosteronism ▪ Evaluation • Most common treatable and curable form of HTN • Aldosterone production exceeds the body’s requirements • ▪ DDx • Essential HTN, thiazide-induced hypokalemia in patient with essential HTN, secondary HTN, syndrome of apparent mineralocorticoid excess, hypertensive forms of congenital adrenal NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 hyperplasia, primary glucocorticoid resistance, Ectopic ACTH syndrome ▪ Diagnostic studies • Optimal detection involves screening all hypertensive patients using the plasma aldosterone/renin ratio • Plasma potassium, aldosterone/renin ratio ▪ Treatment options • Unilateral PA o Unilateral adrenalectomy ▪ Immediately before sx, potassium supplementation should be withdrawn, aldosterone antagonists discontinued and other antihypertensive therapy reduced, if appropriate. Post-operative IV fluids should be given, generous sodium diet recommended ▪ Spironolactone 12.5-50mg PO daily ▪ Amiloride 2.5-10mg daily o Non-surgical candidates ▪ Amiloride 2.5-10mg daily • Bilateral PA o No adrenal lesion> or equal to 2.5cm ▪ Amiloride 2.5-10mg daily ▪ Unilateral adrenalectomy if bilateral cannot be removed with post and preop meds as above o Adrenal lesion > or equal to 2.5cm ▪ Unilateral adrenalectomy ▪ Post and preop meds as above o Pheochromocytoma ▪ Evaluation • Presents with palpations, diaphoresis, pallor, and paroxysmal hypertension • Risk factors include multiple endocrine neoplasia type 2, Von Hipple-Lindau syndrome, and neurofibromatosis type 1 • Complications include hypertensive crisis, myocardial infarction, and hypotension ▪ DDx • Anxiety and panic attacks, essential or intractably hypertension, hyperthyroidism, consumption of illicit substances, carcinoid syndrome, cardiac arrhythmias, menopause, preeclampsia ▪ Diagnostic studies • Diagnosed by increased levels of urine and serum catecholamines, metanephrines and normetanephrines • Serum free metanephrines and normetanephrines, plasma catecholamines, genetic testing ▪ Treatment options NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Hypertensive crisis NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Initially try lifestyle changes, glycemic management, blood pressure management, lipid management and antiplatelet therapy • HbA1c above goal at diagnosis o Metformin 500mg daily, increase by 500mg.day increments every week, max 1000mg BID • HbA1c above goal on metformin o Add glipizide 2.5-5mg PO daily, increase by 2.5 to 5mg/day increments every 1-2 weeks, max 10mg BID o Can add insulin glargine at HS • HbA1c above goal on metformin and insulin o Add insulin lispro premeal o Diabetic Ketoacidosis ▪ Evaluation • Biochemical triad of hyperglycemia, ketonemia, and acidemia with rapid symptom onset • Common symptoms and signs include polyuria, polydipsia, polyphagia, weakness, weight loss, tadycardia, dry mucous membranes, poor skin turgor, hypotension, and in severe cases, shock. • ▪ DDx • Hyperosmolar hyperglycemic state (HHS), lactic acidosis, starvation ketosis, alcoholic ketoacidosis, salicylate poisoning, ethylene glycol/methanol intoxication, uremic acidosis ▪ Diagnostic studies • Serum glucose level, serum electrolyte levels, bicarbonate level, amylase and lipase, urine dipstick, ketone levels, serum beta- hydroxy, ABG, CBC, BUN, Cr, urine culture, blood culture if infection suspected, EKG,CXR ▪ Treatment options • Successful treatment includes correction of volume depletion, hyperglycemia, electrolyte imbalances, and comorbid precipitating events with frequent monitoring. • Complications of treatment include hypoglycemia, hypokalemia, hypoxemia, and rarely pulmonary edema. • Fluid resuscitation – isotonic saline infused at 1-1.5L (or 15- 20ml/kg) for first hour. When plasma glucose reaches 200mg/dL, fluid therapy should be changed to 5% Dextrose with 0.45% NS at 150-250ml/hr. Potassium chloride 20-30meq/L/hr added. • Reversal of acidosis or ketosis • Reduction of plasma glucose • Replenishment of electrolyte and volume losses • Identify underlying cause • Insulin therapy should not be started until serum K+ reaches 3.3 NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Dopamine 5-10 mcg/kg/min IV, adjust according to BP and other hemodynamic parameters • Sodium bicarbonate for serum pH 6.9-7.0: 50mmol IV over 1 hr at a rate of 200ml/hr for 2hrs or until pH>7.0 o Hyperglycemia hyperosmolar state ▪ Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose, hyperosmolarity, and little or no ketosis ▪ Physical findings of hyperosmolar hyperglycemic state include those associated with profound dehydration and various neurologic symptoms such as coma. The first step of treatment involves careful monitoring of the patient and laboratory values ▪ Precipitating factors may be divided into six categories: infections, medications, non-compliance, undiagnosed diabetes, substance abuse, and coexisting diseases. Myocardial infarction, cerebrovascular accident, pulmonary embolus, and mesenteric thrombosis have been identified as causes of hyperosmolar hyperglycemic state. ▪ DDx • DKA, lactic acidosis, alcohol ketoacidosis, ingestion of toxic substances, acetaminophen overdose, salicylate overdose, seizures, stroke ▪ Diagnostic studies • Plasma glucose level, serum or urinary ketone level, serum BUN, serum Cr, serum Na, K, Cl, Mg, Ca, Phos, serum osmolality anion gap, serum lactate, blood gas, UA, LFT, CBC, EKG, CXR, cardiac panel ▪ Treatment options NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 o Lactic acidosis ▪ Evaluation • Severe lactic acidosis is often associated with poor prognosis. Recognition and correction of the underlying process is the major step in the treatment of this serious condition. Intravenous administration of sodium bicarbonate has been the mainstay in the treatment of lactic acidosis. • S/s – fruity-smelling breath, jaundice, confusion, difficulty breathing, exhaustion, muscle cramps, body weakness, abdominal pain, diarrhea, decrease in appetite, headache, rapid heart rate • Causes: heart disease, sepsis, HIV, cancer, short bowel syndrome, NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 o Fever of unknown origin ▪ https://emedicine.medscape.com/article/217675-treatment ▪ https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical- resources/clinical-tools/infectious-diseases/fever-of-unknown-origin o Infections in immunocompromised patient ▪ https://emedicine.medscape.com/article/973120-overview ▪ http://www.pidsphil.org/home/wp-content/uploads/2017/02/08Lec- PREVENTION-OF-INFECTIONS-IN-THE- IMMUNOCOMPROMISED.pdf o Infections in the CNS NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 o Animal and human bites Skin and Musculoskeletal System • Evaluation, differential diagnosis, diagnostic studies, and treatment options o Cellulitis: Evaluation: Usually caused by gram-positive cocci/A beta-hemolytic streptococci and S aureus, diffuse infection usually in lower legs, infection of the dermis and subcutaneous tissues. Pain, chills and fever present and possible septicemia can develop. Swelling erythema and pain, lymphangitis and lymphadenopathy can be present. Differentials: DVT and necrotizing fasciitis, sclerosing panniculitis and acute severe contact dermatitis. Diagnostic studies: leukocytosis or neutrophilia left shift, positive blood cultures, aspiration of the advancing edge (not common) and full thickness skin biopsy. Treatment: IV antibiotics (the first 2-5 days) to cover strep/staph, MSSA can be treated with nafcillin, cefazolin, clindamycin, dicloxacillin, cephalexin, doxycycline, or TMP-SMZ. MRSA: vancomycin, linezolid, clindamycin, daptomycin, doxycycline, or TMP-SMZ. Mild cases or following IV treatment, dicloxacillin or cephalexin, 250-500 mg four times a day for 5-10 days. Recurrent cellulitis: PO PCN 250 BID daily or erythromycin can delay reoccurrence. o Necrotizing fasciitis: Evaluation: infection of the deep soft tissues that results in progressive destruction of the muscle fascia NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 atopic dermatitis includes: pruritus, typical morphology and NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 distribution, onset in childhood and chronicity, personal or family HX of atopy, xerosisichthyosis, facial pallor with infraorbital darkening, elevated serum IgE, and repeated skin infections. Pruritic, xerotic, exudative or lichenified eruption on face/neck/upper trunk/wrists and hands/antecubital and popliteal folds. Differentials: seborrheic dermatitis, psoriasis, secondary staphylococcal or herpetic infections-infra-auricular fissure. Dermatologist consult for atypical dermatitis after the age of 30. Diagnostics: itching, and clinicals findings, discrete plaques with weeping, Eosinophilia and increased serum IgE levels may be present. TREATMENT: determined by the pattern and stage of the dermatitis-acute/weepy, subacute/scaly, or chronic/lichenified. Mainly emollient and corticosteroids/topical. Acute weeping lesions: r/o infection, water/aluminum subacetate solution or colloidal oatmeal for soaks, wet dressing for 10-30 minutes 2-4 times daily, high-potency corticosteroids after soaking, Tacrolimus ointment, or systemic corticosteroids-only indicated for severe acute exacerbation, PO prednisone over 2-4 weeks taper off. Systemic corticosteroids are not indicated for maintenance therapy. Subacute or scaly lesions: Mid-to-High potency corticosteroids in ointment form, 2-4-week taper from twice a day to daily dosing with topical corticosteroids to reliance on emollients, then switch to low-potency. Chronic dry/lichenified lesions: high-potency to ultra-high potency corticosteroid ointments, nightly occlusion for 2-6 weeks may enhance the initial response, add tar preparation such as liquor carbonis detergents 10% in Aquaphor or 2% crude coal tar. Maintenance: effective moisturizers to prevent flairs, use of topical anti-inflammatories only on weekend or three times a week. VITAL to taper off corticosteroids and substitute emollients to avoid steroid side effects. Also/other types of dermatitis: Seborrheic dermatitis (dry scales with underlying erythema/body folds), Exfoliative dermatitis (scaling/erythema over most of the body, itching fever/chills, and contact dermatitis (erythema and edema, often followed by vesicle’s, bullae, weeping or crusting in area of contact with suspected agent). o Malignant melanoma: Evaluation: leading cause of death due to skin disease. ABCDE rule: asymmetry, border irregularity, color variegation, diameter greater than 6 mm and evolution-change in mole is the single most important historical reason for close evaluation and possible referral. Different types of melanomas: lentigo maligna melanoma, superficial spreading malignant NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 melanoma, nodular malignant melanoma, acral-lentiginous NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 0.5-0.75 mg/kg/day, check liver enzymes and serum lipids, teratogen agent. Cyclosporine for severe cases; tumor necrosis factor inhibitors etanercept (Enbrel), infliximab (remicaid), and adalimmab (Humira) are effective in pustular and chronic plaque psoriasis and for associated arthritis. Oral phosphodiesterase 4 inhibitors apremilast approved option for plaque-type psoriasis with minimal immunosuppressive effects. o Rosea: Pityriasis Rosea: Evaluation: common mild acute inflammatory disease that is 50% more common in females. Itching, oval fawn-colored, scaly eruption following cleavage lines of trunk, herald patch precedes eruption by 1-2 weeks. Eruption lasts 6-8 weeks. Diagnostic: finding one or more classic lesions: oval, fawn-colored plaques up to 2 cm in diameter, centers have a crinkled or cigarette paper appearance and collarette scale, lesions follow cleavage lines on the trunk/Christmas tree pattern, and proximal portions of the extremities are often involved. Inverse pityriasis rosea affects the flexures, papular variant can occur especially in black patients. Herald patch-often larger lesion, initial lesion that precedes eruption by 1-2 weeks. **check for serologic testing for syphilis. Differentials: Tinea corporis, seborrheic dermatitis, tinea verisicolor, certain medications (ACEi and metronidazole) and immunizations can mimic this disease. TREATMENT: often requires no treatment unless symptomatic. UVB treatments, short course of prednisone, topical corticosteroids of medium strength, triamcinolone 0.1%, and oral antihistamines. Macrolide antibiotic are controversial. o Tinea Corporis or Tinea Circinata (ringworm): Evaluation: Trichophyton rubrum is most common pathogen, ring-shaped lesions with scaly boarder, central clearing or scaly patches with a distinct boarder. Exposure to pets/microsporum infections, face arms, trunk. Diagnostics: diagnosis confirmation by KOH preparation or culture. Positive fungal studies distinguish tinea corporis from other skin lesions. Differentials: annular lesions of psoriasis, lupus erythematosus, syphilis, granuloma annulare, and pityriasis rosea. TREATMENT: topical antifungals like econazole, miconazole, clotrimazole, butenafine, and terbinafine. Treatment for 1-2 weeks after clinical clearing. Betamethasone diporpionate with clotrimazole (Lotrisone) is not recommended. Systemic measures: Itraconazole 200 mg daily for one week or Terbinafine 250 mg daily for one month. Also/Other Tinea: Tinea cruris (jock itch), tinea manuum and NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 tinea pedis (interdigital tinea pedis is the most common NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 predisposing cause of lower extremity cellulitis in health individuals), and tinea versicolor (malassezia infection of the skin-usually upper trunk). o Impetigo: Evaluation: contagious and autoinoculable infection of the skin/epidermis caused by staphylococci or streptococci. Superficial blisters filled with purulent material that rupture easily, crusted superficial erosions, and positive gram stain and bacterial culture. Often in face, ecthyma is a deeper form of impetigo with ulceration and scarring that happens on extremities. Diagnostics: gram stain and cultures confirm diagnosis. Differentials: acute allergic contact dermatitis and herpes simplex. TREATMENT: first line treatment: topical agents like bacitracin, mupirocin, and retapamulin for small areas. Systemic antibiotics for wide-spread cases. Cephalexin 250 mg four times a day or Doxycycline 100 mg BID. CA-MRSA coverage with doxycycline or TMP-SMZ, 50% of CA-MRSA are quinolone resistant. Recurrent impetigo/S Aureus treated with rifampin 600 mg daily for 5 days intranasal mupirocin ointment twice daily for 5 days clears the nasal carriage of MRSA strains. Bleach baths 3-4 times weekly ¼ to ½ cup per 20 liters of bathwater for 15 minutes. Household bleach to clean surfaces and reduce spread. o Acne Vulgaris: Evaluation: most common skin condition, polymorphic, open/closed comedones, papules, pustules, and cysts, more common in younger adults and males. Comedones are the hallmark of acne, affects face and upper trunk, and can cause scarring. Hyperandrogenism may be a cause of acne in women. Differential diagnosis: Rosacea, gram-negative folliculitis, tinea infections, staphylococcal folliculitis, miliaria/heat rash, or malassezia folliculitis or eosinophilic folliculitis. TREATMENT: education on use of medications and cosmetics, Diet-low glycemic diet/hyperinsulinemia has been associated. Comedonal acne: Proper hygiene, topical retinoids 0.25% cream use first twice weekly at night and then to nightly. Benzoyl peroxide/different concentrations, water-based gels, other topical agents like adapalene and topical antibiotics (erythromycin, clindamycin phosphate). Papular or cystic inflammatory acne: (3 weeks to 3 months) with topical or oral antibiotics, clindamycin phosphate and erythromycin in combination with benzoyl peroxide. Common oral antibiotics are doxycycline 100 mg BID, minocycline 50-100 mg once or BID daily, Bactrim (one double strength tab BID, or cephalosporin/cefadroxil or cephalexin 500 NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 erodes cartilage bone ligaments and tendons, effusion are common NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 signs of inflammation. Symptoms include dryness of mouth, eyes, and other mucous membranes, and scleritis. Other symptoms include interstitial lung disease, pericarditis, pleural disease, palmar erythema, vessel vasculitis, narcotizing arteritis, and Felty syndrome. Diagnostics: Anti-CCP antibodies and rheumatoid factor are present in 70-80 percent of cases, ESR/C-reactive protein are typically elevated and antinuclear antibodies are found in about 20% of RA patients. Arthrocentesis is needed to diagnose superimposed septic arthritis-common complication. Imaging: radiographic changes are the most specific to RA. Differentials: osteoarthritis, CPPD disease, gouty tophi, spondyloarthropathies, Chronic Lyme arthritis, acute viral infections like chikungunya virus and parvovirus B19, chronic infection with hepatitis C, SLE, polymyalgia rheumatica, granulomatosis with polyangiitis, rheumatic fever, carditis and erythema marginatum, variety of cancers, hypertrophic pulmonary osteoarthropathy. TREATMENT: (corticosteroids, synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and DMARD combinations) Low-dose corticosteroids like oral prednisone 5-10 mg daily, intra-articular corticosteroids may be helpful, triamcinolone 10-40 mg intra-articular. Methotrexate/synthetic DMARDs, 7.5 mg initially orally once weekly, increase by 15 mg once per week if initial does is not therapeutic, max dos is 20-25 mg/wk. Sulfasalazine, second line agent 0.5 BID, increase by 0.5 up to 3 g. Leflunomide/pyrimidine synthesis inhibitor, FDA approved for RA treatment, daily dose of 20 mg. Antimalarials, hydroxychloroquine sulfate 200-400 mg/day orally and tofacitinib/inhibitor of janus kinase 3 for refractory RA to methotrexate and dose includes tofacitinib 5-10mg twice daily. Biologic DMARDs: Tumor necrosis factor inhibitors, abatacept, rituximab, tocilizumab. DMARD combinations: methotrexate and TNF, methotrexate, sulfasalazine, and hydroxychloroquine, methotrexate plus etanercept. o Osteoarthritis (OA): Evaluation: Degenerative disorder with minimal articular inflammation, no systemic symptoms, pain relieved by rest, most common form of joint disease, disease of aging. Age, obesity, and sex (more females than males) are risk factors, degeneration of cartilage and by hypertrophy of bone at the articular margins. Hereditary and mechanical factors for pathogenesis. Causes Heberden nodes and Bouchard nodes. Primary (most commonly affects DIP and proximal interphalangeal joints in fingers, hip, knee MTP joint and cervical/lumbar spine) vs NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 secondary (occurs in any joints). Onset insidious. Diagnostics: NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 are most common features. Precipitated by antecedent gastrointestinal and genitourinary infection (1-4 weeks) and manifests as an asymmetric sterile oligarthritis typically lower extremities. Diagnostics: HLA-B27-positive in 50-80% of patients, radiographic sings of permanent or progressive joint disease seen in sacroiliac as well as peripheral joints. Differentials: Gonococcal arthritis, RA, ankylosing spondylitis, and psoriatic arthritis, Behcet disease and HIV common with reactive arthritis. Treatment: NSAIDs or individuals who do not response to NSAIDs can use sulfasalazine 1000 mg PO BID or methotrexate 7.5-20 mg PO per week, or if that is ineffective than anti-TNF agents. o Poisonings – symptoms / antidotes: Symptoms: Coma/airway protection, Hypothermia, hypotension, hypertension, arrhythmias, seizures, hyperthermia. Antidotes: Naloxone-opioid antagonists, and Flumazenil-for benzodiazepine overdose. TABLE 38-3 page 1594; Chapter 38; page 1591-1619 o Acetaminophen overdose: Specific antidote: N-Acetylcysteine (based on serum level). Overdose-greater than 150-200 mg/kg, or 8-10 g in an average adult. Causes hepatotoxicity, recommended maximum dose of 4g/day for several days. Causes nausea or vomiting, signs of toxicity may not show until 24-48 hours after ingestion. Fulminant hepatic necrosis can occur, jaundice, hepatic encephalopathy, AKI and death. Could cause acute comma, seizures, hypotension and metabolic acidosis. Diagnosis: Based on measurement of the serum acetaminophen level. TREATMENT: activated charcoal if it can be given 1-2 hours of ingestion; if serum or plasma acetaminophen level falls above the line on monogram/Figure 38-1 page 1599, treatment with N- acetylcysteine is indicated. PO or IV, PO 140 mg/kg followed by 70 mg/kg Q4H, 72-hour treatment. IV 150 mg/kg over 60 minutes, then 4-hour infusion 50 mg/kg and then 16-hour IV infusion of 100 mg/kg. Call poison control center. o Amphetamine/Cocaine overdose: euphorigenic and stimulant properties, causes anxiety, tremulousness, tachycardia, HTN, NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 diaphoresis, dilated pupils, agitation, muscular hyperactivity and psychosis. TREATMENT: maintain patent airway, assist if NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 necessary, treat for seizures, lower body temperature, give IVF to prevent myoglobinuric kidney injury in patient with rhabdomyolysis. Treat symptoms with benzodiazepines such as diazepam 5-10 mg or lorazepam 2-3 mg IV. Phenobarbital 15 mg/kg IV for persistent seizures. Phentolamine 1-5 mg IV for HTN or nitroprusside, treat arrhythmias with short-acting BB such as esmolol. o Shoulder impingement syndrome: EVAULATION: subacromial impingement syndrome-shoulder pain with overhead motion, night pain while sleeping on shoulder; a collection of diagnosis that cause mechanical inflammation in the subacromial space, can be caused due to muscle strength imbalances, poor scapula control, rotator cuff tears, and subacromial bursitis/bone spurs. Clinically presents with one or more of the following: pain with overhead activities, nocturnal pain with sleeping on the shoulder or pain on internal rotation (putting on a jacket or bra). Atrophy in the supraspinatus or infraspinatus fossa, dyskinesis, rolled-forward shoulder posture of head forward posture, tenderness over anterolateral shoulder, lack full active range of motion but should have preserved passive ROM, + NEER and +HAWKINS impingement signs. Diagnostics: AP scapula, AP acromioclavicular joint, lateral scapula, and axillary lateral radiographs. MRI/US show tears or tendinosis, US can also show thickening of rotator cuff tendons and tendinosis. TREATMENT: conservative: first-line treatment: Education and PT, activity modification. No evidence for ICE/NSAIDS, some relief with corticosteroid injections. o Rotator cuff tear: Evaluation: common cause of shoulder impingement syndrome after age 40 (partial tears), difficulty lifting the arm with limited active ROM, weakness with resisted strength testing, caused by trauma or can be degenerative. Common with falls, outstretched arm or pulling on the shoulder, overhead movement or lifting. Full thickness rotator cuff tears may require surgical treatment. Tears at supraspinatus. Weakness or pain with overhead movement and night pain. Clinical findings include impingement syndrome except that full-thickness rotator cuff tears there may be more obvious weakness noted with light resistance testing of specific rotator cuff muscles. Supraspinatus tendon strength +OPEN CAN test. Will also have +NEER/HAWKINS NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 o Hip fractures: Evaluation: increased mortality in elders, osteoporosis, female sex, height greater than 5’8” and over 50 y/o are risk factors. Secondary to fall, internal rotation of hip, require surgical repair, patient may not be able to bear weight, Pain with internal rotation of the hip is the most sensitive test to identify intra-articular hip pathology. + Trendelenburg test can examine weakness or instability of the hip abductors. Diagnostics: AP views of the pelvis and bilateral hips, and frog-leg-lateral views of the painful hip. MRI/CT for hip fracture pattern. TREAMENT: most hip FX need surgery, surgery is recommended with the first 24 hours. Stress FX-protected weight bearing immobilizer and gradual return to activities. Femoral neck FX, hemiarthroplasty or total hip replacement. Peritrochanteric hip FX treatment with ORIF, plate and screw construct or intramedullary devices o Knee injuries: ACL injury (+Lackman test, anterior drawer test, and Pivot tests), MCL injuries (+valgus stress test, and varus stress test), and PCL injuries (+safe sign and posterior drawer test). Meniscus injuries (+McMurray test, Modified McMurray test, and Thessaly test). Patellofemoral pain, AKA runner’s knee (+apprehension sign and patellar grind test). TREATMENT: ACL Most people with need surgery, MCL injuries can be treated with protected weight bearing and PT, Isolated PCL injuries can be treated nonoperatively, immobilization with knee brace and knee extension, crutches, PT, however, PCL associated with other injuries that require operative reconstruction. Conservative treatment with Meniscus injuries, analgesics and PT. Conservative treatment ice/anti-inflammatory medication for runner’s knee and surgical treatment is last resort. o Ankle injuries: Both Inversion (localized pain/swelling, majority of ankle injuries/lateral ligaments) and Eversion-high ankle sprains (severe and prolonged pain, limited ROM, mild swelling, difficulty with weight bearing). Inversion +anterior drawer test, subtaler tilt test. Imaging: Ottawa ankle rules. Eversion +external rotation stress test, affects anterior tibiofibular ligament, more painful than typical ankle sprain. TREATMENT: Inversion-MICE: modified activities, ice, compression, and NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 elevation. PT and early motion. Eversion: Conservative with a NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 cast or walking boot for 4-6 weeks, then weight bearing with crutches and PT. o Bone density: Bone density screening: Identify patients at risk for osteopenia or osteoporosis. Calcium and vitamin D intake, bone health-bone densitometry serum calcium and 25-OH vitamin D levels. • Procedures (review the indications, procedure steps, and education) o Nerve block: digital nerve block for nail removal or ingrown toenails procedures, paronychia sutures dislocation or removal of foreign body. 1% lidocaine, 2-3 mL, and 3 mL syringe, 27-30 gauge, ½-1 inch. Procedure: Position patient, cleanse with antiseptic skin cleanser, and put on gloves. Fingers: insert needle at 45-degree angle, along palmar crease on either side of digit, on anterior surface of the digit close to the bone. Toes: insert needle toward the plantar surface of both sides of the toe, aspirate the syringe before injecting lidocaine, if no blood returns, lidocaine can be injected safely, then redirect the needle across the extensor surface and insert needle further, inject 0.5 mL of lidocaine while withdrawing needle, repeat and wait 5-10 minutes. o Fish hook: three methods: pull-through, barb sheath, or angler’s string-yank. For pull-through method: 1-position client, 2-put on gloves and cleanse skin with antiseptic, 3-inject 1% lidocaine using the 27-30-gauge needle at the point of the hook, 4-using pliers or hemostat, force the fishhook tip through the skin. 5-cut off the eye of the fishhook close to the skin with wire cutters. 6-attach pliers or hemostats to the sharp end of the hook and pull the hook out. Tetanus prophylaxis if more than 5 years ago, observe for s/s of infection, 5 days of antibiotics including cephalexin 500 mg TID, pain medications, soak in warm salt water for 2 days, return follow up in 28 hours. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 syndrome of wrist and thumb. Ankle splinting (Posterior splint and air cast technique), knee immobilization: use with grade II and NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 II knee strains, wrist splinting (premade wrist splint or volar splinting), and thumb splinting-use for adductor pollicis tendinitis (premade wrist splint with thumb support, aluminum thumb splint and thumb spica). o Trigger finger: (stenosing flexor tenosynovitis) if persistent symptoms not relieved by splinting or use of NSAIDs, glucocorticoid injections with methylprednisolone or triamcinoloine with lidocaine can be used. Injection can be repeated in six weeks if symptoms have not improved. If this does not work, then ultra-sound guided percutaneous and open surgical release of the first annular (A1) pulley ligament are both effective. Trigger point injections page 202 NEURO After heart disease and cancer, stroke has been ranked as the third leading cause of death in the United States. Stroke, defined as a sudden onset of focal neurologic deficiency, is due to interruption of blood flow to the brain. Blood flow may be impaired due to structural abnormalities in blood vessels or blockage of vessels due to thrombi. The two major categories of stroke include hemorrhagic (intracerebral, subarachnoid) and ischemic. During the stroke patient’s stay in the hospital, the major concern is to limit the neurologic deficit due to the acute stroke by placing patients on the proper treatments to prevent the reoccurrence of strokes. In addition, prevention of complications from the acute stroke is also a major concern. Complications may include hemorrhagic transformation, ischemic cerebral edema, infections, venous thrombosis, or pulmonary embolisms. Impact of Stroke • 3rd leading cause of death in the U.S. • Leading cause of adult disability • Over 700,000 new stroke cases per year in U.S. with 150,000 stroke deaths per year • 85% are ischemic • Less than 25% of eligible thrombolytic candidates receiving therapy The most common cause of non-traumatic intracerebral hematoma is hypertensive hemorrhage. Other causes include amyloid angiopathy, a ruptured vascular malformation, coagulopathy, hemorrhage into a tumor, venous infarction, and drug abuse. Stroke Assessment Scales Overview A P P R OX I M AT E T IM E T O NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 T Y P E N A M E A N D S O U R C E A D M I N I S T E R S T R E N GT H S W E A K N E SS E S Level-of- Glasgow Coma Scale 2 minutes Simple, valid, None observed. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 for assessing sensorimotor function and balance. Reliability Good, brief assessed only assessment of in stable movement patients. Motor Assessment and physical Sensitivity not Scale [k] 15 minutes mobility. tested. Brief assessment of motor function of arm, leg, and Sensitivity not Motricity Index [l] 5 minutes trunk. tested. Simple, well established with stroke patients, Balance Berg Balance sensitive to assessment Assessment [m] 10 minutes change. None observed. Valid, brief, Mobility Rivermead Mobility reliable test of Sensitivity not assessment Index [n] 5 minutes physical mobility. tested. Widely used, comprehensive, good Time to standardization administer Boston Diagnostic data, sound long; half of Aphasia Examination theoretical patients cannot [o] 1-4 hours rationale. be classified. Time to administer long. Special training required to administer. Inadequate Widely used, sampling comprehensive, of language Porch Index of careful test other than one Communicative development and word and single Ability (PICA) [p] 1/2-2 hours standardization. sentences. Time to administer long. “Aphasia Assessment of quotients” and speech and “taxonomy” language Western aphasia Widely used, of aphasia not NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 functions Battery [q] 1-4 hours comprehensive. well validated. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 Less useful in elderly and in patients with Widely used, aphasia or easily neglect.High administered. rate of false Norms available. positives. Beck Depression Good Somatic items Inventory (BDI) (BDI) with somatic may not be due [r] 10 minutes symptoms. to depression. Brief, easily administered, Center for useful Epidemiologic in elderly, Studies effective for Not appropriate Depression (CES-D) < 15 screening in for aphasic [s] minutes stroke population. patients. Brief, easy to use with elderly, cognitively impaired, and those with visual High false Geriatric Depression or physical negative rates Scale (GDS) problems in minor [t] 10 minutes or low motivation. depression. Multiple differing versions Observer rated; compromise Depression Hamilton Depression < 30 frequently used interobserver scales Scale [u] minutes in stroke patients. reliability. Good internal consistency, correlates significantly with clinician ratings of Quick Inventory of depression Depressive severity, and is Symptomatology 5-10 sensitive to (QIDS) minutes change Measures of Measures broad instrumental base of ADL PGC Instrumental information Activities of Daily necessary Has not been Living 5-10 for independent tested in stroke [v] minutes living. patients. Frenchay Activities 10-15 Developed Sensitivity and Index [w] minutes specifically interobserver NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 left cerebral hemisphere produces sensory and motor deficits on the The cerebellum, the second largest area, is responsible for maintaining balance and further control of movement and coordination. The brain stem is the final pathway between cerebral structures and the spinal cord. It is responsible for a variety of automatic functions, such as control of respiration, heart rate, and blood pressure, wakefullness, arousal and attention. The cerebrum is divided into a right and a left hemisphere and is composed of pairs of frontal, parietal, temporal, and occipital lobes. The left hemisphere controls the majority of functions on the right side of the body, while the right hemisphere controls most of functions on the left side of the body The crossing of nerve fibers takes place in the brain stem. Thus, injury to the right side, and vice versa. One hemisphere has a slightly more developed, or dominant, area in which written and spoken language is organized. Over 95% of right-handed people and even the majority of left handed people have dominance for speech and language in the left hemisphere. Thus, a left hemisphere stroke will be more likely to produce aphasia and other language deficits. Layers of the Cerebrum – Gray and White Matter The entire cerebrum is composed of two layers. The 20-millimeter thick outermost layer, called the cerebral cortex (or gray matter), contains the centers of cognition and personality and the coordination of complicated movements. As shall be seen, the gray matter is also organized for different functions. The white matter is a network of fibers that enables regions of the brain to communicate with each other. Cerebellum and Brainstem A stroke involving the cerebellum may result in a lack of coordination, clumsiness, shaking, or other muscular difficulties. These are important to diagnose early, since swelling may cause brainstem compression or hydrocephalus. Strokes in the brainstem are usually due to basilar occlusion, although in many cases the clinical syndrome may fit the criteria for a lacunar stroke [Mohr JP and Sacco RL, 1992]. Brainstem strokes can be serious or even fatal. People who survive may be left with severe impairments or remain in a vegetative state. Blood Vessels of the Brain The common carotid arteries have two divisions. The external carotid arteries supply the face and scalp with blood. The internal carotid arteries supply blood to most of the anterior portion of the cerebrum. The vertebrobasilar arteries supply the posterior two-fifths of the cerebrum, part of the cerebellum, and the brain stem. Any decrease in the flow of blood through one of the internal carotid arteries brings about some impairment in the function of the frontal lobes. This impairment may result in numbness, weakness, or paralysis on the side of the body opposite to the obstruction of the artery. Occlusion of one of the vertebral arteries can cause many serious consequences, ranging from blindness to paralysis. At the base of the brain, the carotid and vertebrobasilar arteries form a circle of communicating arteries known as the Circle of Willis. From this circle, other arteries—the anterior cerebral artery (ACA), the NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 middle cerebral artery (MCA), the posterior cerebral artery (PCA)—arise and travel to all parts of the brain. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 lenticulostriate arteries Because the carotid and vertebrobasilar arteries form a circle, if one of the main arteries is occluded, the distal smaller arteries that it supplies can receive blood from the other arteries (collateral circulation). The anterior cerebral artery extends upward and forward from the internal carotid artery. It supplies the frontal lobes, the parts of the brain that control logical thought, personality, and voluntary movement, especially of the legs. Stroke in the anterior cerebral artery results in opposite leg weakness. If both anterior cerebral territories are affected, profound mental symptoms may result (akinetic mutism). The middle cerebral artery is the largest branch of the internal carotid. The artery supplies a portion of the frontal lobe and the lateral surface of the temporal and parietal lobes, including the primary motor and sensory areas of the face, throat, hand and arm, and in the dominant hemisphere, the areas for speech. ***The middle cerebral artery is the artery most often occluded in stroke. The posterior arteries supply the temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere. When infarction occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from lower segments of the vertebral basilar system or heart. Clinical symptoms associated with occlusion of the posterior cerebral artery depend on the location of the occlusion and may include thalamic syndrome, thalamic perforate syndrome, Weber’s syndrome, contralateral hemplegia, hemianopsia and a variety of other symptoms, including including color blindness, failure to see to-and-fro movements, verbal dyslexia, and hallucinations. The most common finding is occipital lobe infarction leading to an opposite visual field defect. Small, deep penetrating arteries known as the branch from the middle cerebral artery Occlusions of these vessels or penetrating branches of the Circle of Willis or vertebral or basilar arteries are referred to as lacunar strokes. About 20% of all stokes are lacunar and have a high incidence Left (Dominant) Hemisphere Stroke: Common Pattern • Aphasia • Right hemiparesis • Right-sided sensory loss • Right visual #eld defect • Poor right conjugate gaze • Dysarthria • Difficulty reading, writing, or calculating Right (Non-dominant) Hemisphere Stroke: Common Pattern • Neglect of left visual field • Extinction of left-sided stimuli • Left hemiparesis • Left-sided sensory loss • Left visual #eld defect • Poor left conjugate gaze • Dysarthria • Spatial disorientation Brain Stem / Cerebellum / Posterior Hemisphere Stroke: Common Patterns • Motor or sensory loss in all four limbs • Crossed signs • Limb or gait ataxia • Dysarthria • Dysconjugate gaze • Nystagmus • Amnesia in patients with chronic hypertension. NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Check glucose NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Two large IV lines • Oxygen as needed • Cardiac monitor • Continuous pulse-ox • Stat non-contrast CT scan • ECG • CXR • Get rt-PA > Prepare to mix > Have pharmacy alerted • Discuss options with patient and family • Contact primary care provider American Heart Association Recommendations Oxygen - Use to correct hypoxia; Suggestion that supernormal levels may hurt > one- year survival 69% 3L NC vs 73% control Glucose - Maintain euglycemia; Treat glucose > 300 mg/dl with insulin MODIFIABLE R/F: High blood pressure • Cigarette smoking • Transient ischemic attacks • Heart disease • Diabetes mellitus • Hypercoagulopathy • Carotid stenosis • Other NON-MODIFIABLE R/F: Age • Gender • Race • Prior stroke • Heredity Early CT Changes in Ischemic Stroke • Loss of insular ribbon • Loss of gray-white interface • Loss of sulci • Acute hypo density • Mass effect • Dense MCA sign Differential Diagnosis: Intracerebral hemorrhage • Hypoglycemia / Hyperglycemia • Seizure • Migraine headache • Hypertensive crisis • Epidural / Subdural • Meningitis / Encephalitis / Brain abscess • Tumor Exclusions to Thrombolytics • Stroke or head trauma in 3 mos • Major surgery within 14 days • Any history of intracranial hemorrhage • SBP > 185 mm Hg • DBP > 110 mm Hg • Rapidly improving or minor symptoms • Symptoms suggestive of subarachnoid hemorrhage • Glucose < 50 or > 400 mg/dl • GI hemorrhage within 21 days • Urinary tract hemorrhage within 21 days • Arterial puncture at non-compressible site past 7 days NURS 6550N Final Exam Study Guide Comprehensive Exam Study Guide Latest Updated Version 2024/2025 • Seizures at the onset of stroke • Patients taking oral anticoagulants