Comprehensive Guide to Lupus, Rheumatoid Arthritis, Gout, and Stroke Management, Exams of Nursing

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NURS 640 Test

lupus complications - correct answer - Renal failure

• Premature heart disease
• Lung disease
• Hypercoagulation
• Stroke
• Avascular necrosis of joints
• Increased risk of infection lupus monitoring tests (5) - correct answer CBC Urinalysis Complement levels ESR or CRP LFT lupus risk factors - correct answer - women > men
• age 15- 44
• African american, Asian, Native American ethnicity
• possible associated with Epstein-Barr
• Family Hx (mother to daughter) RA labs - correct answer Anti CCP abs

High IgM rheumatoid factor

• 20% can be antinuclear negative RA monitoring - correct answer - non-specific inflammatory markers
• renal disease
• CBC (anemia)
• increased platelets common RA Subjective HPI - correct answer - bilateral joint abnormalities *pain, swelling and stiffness
• functional status decline
• constitutional complaints (fatigue) RA complications - correct answer - infections
• pulm
• CV
• neuropathy
• renal RA risk factors - correct answer - women > men
• risk increase with age *uncommon men < 45 *prevalence women plateau age 60

*peak onset: women (40-50)/ men (60 to 80)

• family history Gout Differential Diagnosis - correct answer - Cellulitis
• Septic arthritis
• RA
• Psoriatic arthritis
• Pseudo-gout Gout Complications - correct answer - renal insufficiency
• pain and disability
• heart disease Gout presentation - correct answer - rapid onset
• precipitants factors: fasting, ETOH, and med change
• great toe common place
• hips/shoulders are uncommon Gout labs - correct answer - WBC
• Uric acid level
• ESR/CRP (rarely change management)
• Synovial fluid analysis (arthrocentesis)
• Baseline renal, liver, and chem panel

Gout (Imaging Appearance) - correct answer - Early: normal

• Chronic gout shows punched out lesions, joint destruction, and tophi; Martel's sign is punched-out lytic lesions with overhanging bony edges Osteoarthritis Hallmark Signs - correct answer - pain
• insidious onset
• limited to joints
• "aching" pain
• stiffness with inactivity (morning) Osteoarthritis HPI - correct answer - pain assessment
• injury history Contraindications to Thrombolysis - correct answer - Onset: 4.5 hours or greater of last known normal
• severe HTN
• severe hypoglycemia
• bleeding
• abnormal platelets, INR, and aPTT
• effective anticoagulation/antiplatelet
• hemorrhage on CT
• large infarction

Acute management of stroke - correct answer - Avoid hypotonic fluids (cerebral edema)

• fluid replacement with NS
• correct hypoglycemia/hyperglycemia
• NPO until swallowing assessment
• elevate HOB d/t risk of increased ICP, aspiration
• treat fever Stroke BP management - correct answer - BP not treated unless >200/ in ischemic stroke for non-TPA candidates
• If giving TPA, must treat >185/
• With hemorrhage, treat >180 or MAP >
• restart home medications after 24 hours Imaging for stroke - correct answer Non-contrast CT *Before thrombolysis/anti-platelet therapy *evaluate hemorrhagic vs ischemic stroke MRI for stroke - correct answer - better for ischemic stroke assessment
• contraindication: *implanted device *metals *medical instability

angiography - correct answer - usually used to evaluate etiology of stroke or during intervention

• a radiographic study of the blood vessels after the injection of a contrast medium intracerebral hemorrhage causes - correct answer - HTN
• trauma
• bleeding
• amyloid
• angiopathy
• illicit drug use
• vascular malformations subarachnoid hemorrhage - correct answer - worst headache of my life
• "thunderclap" headache +/- photophobia +/- vomiting +/- AMS +/- CN3 palsy Lacunar infarcts - correct answer - Small vessel infarcts
• Small vessel lesions Lacunar infarct risk factors - correct answer - poorly controlled HTN

• poorly controlled DM Lacunar infarcts may present with - correct answer - unilateral pure motor or sensory deficit
• dysarthria with hand clumsiness
• may have PROGRESSIVE neuro deficit over 24-36 hours Stroke mimics - correct answer - seizure
• somatoform/conversion disorder
• migraine
• hypoglycemia
• systemic infection
• toxic metabolic dx
• syncope
• tumor
• acute confusion state
• vertigo
• dementia
• encephalitis neuro exam on unconscious patient - correct answer - temp and BP
• GCS and/or RASS
• neck stiffness
• pupils, fundi, eye positions, corneal reflex, doll's eye

• gag and cough
• respiration (rate and pattern)
• muscle tone, posturing and reflexes
• scars
• tubes/drains
• track marks NIHSS - correct answer Stroke scale *useful with ischemic strokes
• components *LOC *LOC questions *LOC commands *best gaze *visual *facial *arm motor *limb ataxia *sensory *best language *dysarthria *extinction *inattention

IC mass presentation - correct answer - headache

• seizures
• focal neuro deficits
• systems worsen with change of position
• compression of adjacent structure IC mass risk factors - correct answer None IC mass symptoms - correct answer - headache
• seizures
• focal deficits
• cognitive dysfunction
• increased ICP *triad: HA/nausea/papilledema *might also see: nausea/positional symptoms/syncope IC mass evaluation - correct answer - detail neuro exam
• MRI preferred vs CT IC mass management - correct answer - Meds *high dose glucocorticoids *Dexamethasone 10mg loading than 4mg every 4-8 hours

• surgery *tissue sampling *chemo for tumors when to do neuro exam "screening"/limited exam - correct answer - asymptomatic patient
• non-neurologic presentation
• primary care well visit when to do a neuro detailed/full exam - correct answer - when evaluating a possible stroke
• prior to interventions that have high risk of strokes *cardiac thrombolytics Osteomyelitis Diagnosis/Chronic Test - correct answer - accurate diagnosis essential
• increased WBC and inflammatory markers
• positive radiologic findings
• clinical history of infection
• positive cultures
• bone biopsy *Chronic
• no bedside wound cultures
• bone probing higher diagnostic value

Osteomyelitis testing - correct answer - X-ray *rule out fracture *evaluate bone destruction in chronic *limited diagnostic role

• Advance imaging *MRI preferred *CT or nuclear imaging scans *US to assess fluid accumulation Osteomyelitis causes - correct answer - seeding from other infections (distant)
• spreads from other infections (skin/joints)
• penetrating organisms (trauma) Osteomyelitis Etiology - correct answer - Staphylococcus aureus
• coagulase-negative staph
• aerobic gram negative
• multi-microbial *found in contiguous NOT hematogenous Life/Limb threatening conditions & adverse outcome - correct answer 1) open fracture- osteomyelitis

2. fracture/dislocation with major vascular disruption- amputation

3. major pelvic fracture- major blood loss
4. hip dislocation- avascular necrosis Hip fracture clinical findings - correct answer - injury history

• pain in groin that radiates to lateral hip/buttock
• pain with deep palpation
• internal rotation
• pain with weight bearing or inability to walk Hip Fracture Risk Factors - correct answer - higher rate in older adults (ALSO HAVE HIGHER MORBIDITY/MORTALITY)
• osteoporosis
• age > 50
• female
• height > 5'8" Hip fracture classifications - correct answer - by anatomic location
• by fracture type
• three types

1. femoral neck
2. intertrochanteric
3. trochanteric Triage orthopedic referral - correct answer - obvious tissue disruption

• significant loss of function > 2 weeks
• greater than 6 weeks of pain/functional deficits
• recurrent dislocation/instability Orthopedic rule of thumb - correct answer Injury < 2 weeks needs a "wait and see" approach is no evidence of trauma Testing after a fall - correct answer 1) injury
• x-ray
• head/spine assessment

2. cardiac

• EKG
• cardiac monitor
• echo

3. neurologic

• head CT
• spine assessment (stenosis)

4. blood testing

• anemia, infection, and metabolic disease
• chemistry and coagulation panels Physical evaluation after fall - correct answer 1) ABCs

2. injury assessment

• head/spine

• 6 P's

3. cardiac

• VS (BP, and heart sounds) 4)neuro
• neuro deficits (injury vs stroke)
• general neuro exam: focal neuro exam

5. musculoskeletal

• area of injury: inspect, palpate and assess ROM

6. infection What are the 6 P's? - correct answer Pain Pallor Pulselessness Paresthesia Paralysis Poikilothermia Assessment after fall (injury/risk factor) HPI - correct answer 1) injury assessment

• head/neck assessment
• area of injury: fracture vs soft tissue vs hematoma

2. risk factor assessment

• precipitating events
• recent changes (medications or environment)

• changes from normal baseline
• past falls
• foot wear What is the first line medication for diabetes - correct answer metformin 500mg everyday with meals What is the second line medication for diabetes - correct answer glipizide Type 1 inpatient management - correct answer 1) Insulin must ALWAYS be administered regardless of PO
• give basal insulin
• sliding scale alone is inappropriate

2. avoid hypoglycemia
3. ideally maintain home regimen/insulin pump Inpatient insulin dosing - correct answer Total daily dose (TDD) = weight (kg) X 0.

• 50% basal
• 50% prandial (divided into 3 meals) Ex: 100 kg patient 100 X 0.5 = 50 TDD
• 25 units basal

• 8 units (8 X 3 = 24) round up to 25 because you rather give less insulin Hyperglycemic Hyperosmolar State (HHS) symptoms - correct answer - glucose higher than DKA (>600)
• absent of ketone production
• hyperosmolar
• onset may be insidious
• most patients middle-older age HHS causes - correct answer - conditions resulting in dehydration (restricted fluid or decreased intake)
• Infection
• new DM onset,
• MI
• CVA
• Pancreatitis
• some meds (like steroids, thiazides, and atypical antipsychotic drugs) DKA management - correct answer - provide insulin SQ or gtt
• aggressive rehydration (NS)
• monitor for hypokalemia after insulin given
• monitor glucose every hour
• monitor BUN, electrolytes, creatinine, and venous pH every 2 hours

Hypoglycemia define as (number) - correct answer - BG < 70

• BG < 60 (pregnant) Hypoglycemia treatment - correct answer - immediate ingestion of 15-20g quick acting carbohydrates
• wait 15 minutes
• repeat if needed
• provide a snack/meal with complex carbs Do you continue insulin infusion with type 1 diabetics if hypoglycemic? - correct answer Yes Severe hypoglycemia treatment (IV vs no IV) - correct answer - IV access: *25 g of 50% glucose (Dextrose)
• No IV access: *0.5-1.0 mg glucagon IM/SQ injection Definition of severe hypoglycemia - correct answer neurologic decline regardless of BG value OR BG < 40 Oral medication cautions with DM patients (what is the medications side effect) - correct answer 1) sulfonlyureas: hypoglycemia

2. meglitinides: hypoglycemia
3. thiazolidinediones: CHF & edema

4. biguanides: "Metformin" renal and reaction with contrast
5. alpha-glucosidase inhibitors: hypoglycemia & caution with N/V/D
6. incretin mimetics: delayed GI emptying
7. amylin agonist: must be eating No NPO patients What is the beers criteria used for? - correct answer - medication to avoid/reduce in older adults due to an increase falls risk

• limit medications with history of falls
• avoid prescribing these medication with overlapping drug-drug interaction that increase falls
• evaluate if other interventions can be used to reduce fall risk What are the BEER's criteria medication classes? (10) - correct answer 1) anticonvulsants

2. antipsychotics
3. benzodiazepines
4. non-bzras (non-benzo)
5. TCAs
6. SSRIs
7. Opioids
8. Digoxin
9. 1st generation antihistamines
10. long-acting sulfas