Diagnostic and Management Strategies for Common Medical Conditions, Exams of Nursing

Download Diagnostic and Management Strategies for Common Medical Conditions and more Exams Nursing in PDF only on Docsity! AGACNP Exam Review (DIC) Disseminated Intravascular coagulation - Acquired coagulation disorder which results from the intraascular activation of both the coagulation and fibrinolytic system (thrombin and plasmin) causing simultaneous thrombosis and hemorrhage Mortality is 50-85% (HIT) heparin induced thrombocytopenia - STOP heparin Argatoban Lepirudin #1 consideration with transplant patients - Immunosuppressed 101.5 degrees F - 38.6 degrees C 1st priority is the - most salvagable pts. Most critically injured cared for last. 25 yo. M s/p MVC and cannot feed himself. Who do you consult? - Occupational Therapy 35 yo. M is admitted to the hospital with viral PNA. During his hospitalization, a HIV test is drawn and it is positive. Pt is married with two small children and states that he will not tell his wife or you have to do it. What is the most appopriate next step in the management of his care? - Explain to him the importance of informing his wife and offering support. Telling the wife would be a breach of confidentiality. 4 distinct roles for NPs: - clinician, consultant/collaborator, educator, researcher A healthcare plan in which nurse practitioners and MDs are employed directly by the health plan is: - a staff-model health maintenance organization (HMO) ABCDE to Melanoma - Asymmetry Border irregularity Color variation Diameter > 6mm Elevation Enlargement 2+ = malignant melanoma ABCDEE of melanoma - A: asymmetry B: border irregularity C: Color variation D: diameter >6mm E: elevation E: enlargement 2 or more of ABCDEE = 90% sensitivity Absence (petite mal) - Sudden arrest of motor activity with blank stare Common discovered in children/adolescents; begin and end suddenly Acute Pain - Duration is usually less than 6 months, Caused by tissue damage Acute Pain - Pain caused by tissue damage, usually < 6 months Acute Pancreatitis - inflammation of the pancreas due to escape of pancreatic enzymes into surrounding tissue, result in in auto digestive state of the pancreas. Acute Renal failure - Sudden impairment in renal function Acute Renal Insufficiency - Sudden impairment BUN is increased out of proportion to serum creatinine Due to obstruction, acute tubular necrosis, or contrast media Reversible with proper therapy Acute weeping dermatitis with Chron ven. Insuff. Treatment - Wet compress 0.5% hydrocortisone cream after compress systematic antibiotics only indicated if active bacterial infection Addison's Disease - Deficient cortisol, androgens and aldosterone. Autoimmune destruction of the adrenal gland, CA, Bilateral adrenal hemorrhage, pituitary failure resulting in decreased ACTH Admitting privileges to hospitals (non physican) were granted - 1983 by JC Adrenergic inhibitors - Common preparations as first line choices Ex: clonidine, methylodopa, guanethidine, guanadrel, prazosine, doxazosin, labetalol, carvedilol no standard of care for these Advance Directive - Written statement of patient's intent regarding medical treatment Alkalemia_____ionized calcium - decreases Alpha-glucosidase inhibitors how do they work? - less glucose is absorbed by the gut Acarbose and miglitol Alzeihmer's Disease must include what s/s to dx? - memory impairment and one of the following: Aphasia: difficulty with speech Apraxia: inability to perform previously learned task Agnosia: inability to recognize an object Inability to plan, organize, sequence, and make abstract differences American Burn Association Criteria for Burn Center Referral - 1. Partial thickness > 10% 2. Burns involving: face, hands, feet, genitalia, perineum, major joints 3. Third degree in any age group 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation Injury 7. Pre-existing medical disorders 8. Burn + trauma 9. Burned children 10. Special requirements with social or emotional rehabilitation amount of strokes that are embolic - 80% An ACNP notices an MCV and stops at the scene to offer assistance. Which of the following statutes protects the CNP from malpractice in this situation? - Good Samaritan statute ANCC is creating questions for boards and is trying to make sure that these questions they are asking are correctly for ACNP's. Is this reliability or validity? - Validity. The degree to which a variable measures what it is intended to measure Anemia of Chronic Disease - Chronic normocytic normochromic anemia associated with chronic inflammation, infection, renal failure and malignancy Angina definition - Decreased blood flow through the vessel=>tissue ischemia Anion Gap Calculation - Na - (Cl + HCO3) Normal: 10-14 anion gap can still be normal in these conditions - diarrhea, ileostomy, renal tubular acidosis, recovery from DKA Anion Gap normal values. What does an increase indicate? - Normal: 7 to 17 12 - or +5 either way If gap is increased the clinical situation is generally more acute autonomy - Respect an individuals thoughts and actions Bacterial vaginosis - "Fishy" smelling discharge that is watery and gray Basal Cell Carcinoma - 1. most common skin cancer 2. slow growing lesion (1-2cm after years) 3. waxy, 'pearly' appearance (may be shiny red) 4. central depression or rolled edge 5. may have telangiectatic vessels Basal Cell Carcinoma define? Treatment? - Most Common Slow Growing Waxy, pearly appearance (may be shiny red) Central depression or rolled edge May have telangiectatic vessels Treatment: Shave/punch biopsy & surgical excision Basal Cell Carcinoma Treatment - shave/punch biopsy and surgical excision Battery - Violent contact Beneficence - duty to prevent harm and promote good Beneficence - Prevent harm and promote good Benzo Antidote - Flumazenil Benzodiazepine OD drugs - Diazepam, clonazepam, lorazepam Benzodiazepine Overdose | Management - 1. Respiratory and BP support 2. Flumazenil (Romazicon) IV 3. GI lavage/Activated charcoal Benzodiazepine Overdose | Signs and Symptoms -Diazepam -Lorazepam -Clonazepam - 1. Drowsiness 2. Confusion 3. Respiratory Depression 4. Hyporeflexia Beta Blockers what are they used for - Effective in pts with migraines and angina; monitor for potential wheezing Ex: metoprolol, propranolol, atenolol, nadolol, acebutolol Decrease workload of heart Biguanides what are they? Side effects? - Good adjunct to sulfonylureas by can be used alone, especially for obese patients Metformin: Standard of care upon the diagnosis of DM type 2 Lactic acidosis is a potential side effect Bites (Dog, Cat, Human) - - cat bites = infection - copious pressure irrigation of bite with LR - rabies status - X-rays if face bitten - primary closure still controversial - wounds on hands/legs should be left open - consult plastics - prophylactic antibiotics : AUGMENTIN Bowel Obstruction - Blockage of the lumen of the intestine that impedes passage of gas and contents through the bowel BPH - Affects 50% if males by the age of 50 BPH lab/diagnostic - PSA >4 abnormal age specific ranges Trend PSA BPH s/s - Starting and stopping urinary flow** Brain Death considerations - 1. criteria 2. family education and support brain death=death (functionally and legally) Brain Death Criteria - Burn Classifications - First Degree: dry, red, no blisters, involves epidermis only Second Degree/ Partial thickness: moist, blisters, extends beyond epidermis. Third Degree/Full thickness: Dry, leathery, black, dead nerves, extends from dermis to underlying tissues, fat muscle and/or bone Burn Management Pearls - 1. submerge injured area in clean water ASAP 2. no ice, lotions, toothpaste, lard, butter or anything else 3. wrap in clean wet towel 4. sterile normal saline initially only Cause of anemia of chronic disease Most common in who and in what place? - Most common in elderly and hospital etiology unclear, involves decreased erythrocyte life span Cause of Folic acid deficiency - inadequate intake/malabsorption of folic acid (needed for RBC production) Ask them if they are alcoholics? Cause of Iron deficiency anemia; symptoms rarely seen before what hct? S/S - Most common cause of anemia Iron loss exceeds intake -> decrease in iron available for RBC formation Caused by: blood loss, inadequate iron intake, impaired absorption of iron Symptoms rarely seen before hct <30- pica, pallor, fatigue, weakness, h/a, tachycardia Causes of appendicitis - Fecalith Inflammation Foreign body Neoplasms Causes of bowel obstruction - Adhesions, hernia, volvulus, tumors, fecal impaction, ileus (functional obstruction) Causes of Chronic venous insufficiency - More common in women genetic Hx of leg trauma; may be associated with varicose veins Causes of CVA - Atherosclerotic changes Aneurysm AV malformation Tumor Trama Chronic HTN Causes of Endocarditis - Usually caused by a bacteria Recent dental/ oropharyngeal surgery prolonged use of IV catheters or TPN Burns Hemodylasis Causes of Fever - -Bacterial, viral, rickettsial, fungal or parasitic infection -Autoimmune disease (SLE, arteritis) -CNS disease (cerebral hemorrhage, brain tumor, MS) interference with thermoregulatory process rather than fever - Malignant neoplastic disease (primary liver metastasis of cancer) -Hematologic disease (lymphoma/leukemia) - CV disease (MI, phlebitis, PE) - GI disease (IBD, alcoholic hepatitis) - Endocrine disease (hyperthyroidism, pheochromocytoma) -Misc causes (Familial Mediterranean fever, hematoma) - Neuroleptic malignant syndrome-->caused by antipsychotics causing a serotonin like response Causes of fever - Autoimmune, CNS, Malignant neoplastic disease, hematologic disease, CV disease, GI disease, Endocrine disease, Neuroleptic malignant syndrome (anti-psychotics) Causes of increased ICP - Hypotension Hypoxemia Hypercapnea Causes of infections post-op fever - Surgical incisions, IV sites, UTI, Lungs, abcess **sinusitis: NG tubes associated with increased incidence Causes of metabolic alkalosis - post-hypercapnia alkalosis NG suctioning Vomiting Diuretics Saline responsive (volume contraction)-most common Causes of non-infectious post-op fever - #1: Post-op atelectasis, increased metabolic rate, dehydration, and drug reactions Causes of Obstruction - Adhesions Cancer Impaction Causes of Pericarditis - Viruses: Most common Post MI Renal failure Endocarditis Causes of PUD - H. pylori, medications, more common in men, duodenal ulcers between 30-55, Gastric ulcers between 55-65 Alcohol and dietary factors do not seem to play a role in ulcer disease Certification is granted by nongovernmental agencies such as - ANCC, AANP Chancroid - Superficial painful ulcer, surrounded by erythematous halo ulcers maybe necrotic or severely erosive Chlamydia - Most Common STD Cholecystitis - Inflammation of gallbladder, associated with gallstones in >90% of cases Chronic Lymphocytic Leukemia (CLL) - Most common leukemia in adults Lymphocytosis (hallmark of disease) 42,000 WBC Median survival is 10 years Chronic Myelogenous Leukemia (CML) - Occurs in older than 40 Survival is 3-4 yrs Philadelphia chromosome seen in leukemic cells (hallmark of disease) Chronic Pain - Continual or episodic pain of longer duration (> 6 months); combination therapy usually needed Chronic Pain - Continual or episodic pain of longer than 6 months Chronic Renal insufficiency - Progressive impairment Steady increase in BUN and Creat (10:1) ratio Intrinsic kidney damage which is irreversible but progression can be slowed chronic venous insufficiency - impaired venous return due to either destruction of valves, changes due to deep thrombophlebitis, leg trauma,or sustained elevation of venous pressure Classifications of HTN - JNC 8 patients under 60- 140/90, 60 and over 150/90, ckd, dm- 140/90 Cluster Headache - Very painful syndromes, mostly affecting middle aged men Cluster Headache | Causes/Incidence - 1. No family history 2. Precipitated by ETOH 3. Severe, unilateral, periorbital pain occurring daily for several weeks 4. Occur at night, awakening from sleep 5. < 2 hours; pain free for months/weeks between episodes 6. Ipsilateral nasal congestion, rhinorrhea and eye redness may occur Cluster Headache | Management - 1. Treatment of individual attacks with oral drugs usually not helpful 2. Inhalation of 100% O2 may help 3. Sumatriptan 6mg SQ may be effective 4. Ergotamine tartrate aerosol inhalation may be effective Cluster Headache | Physical Exam - May see eye redness and rhinorrhea Cluster Headache who gets them the most? - Very painful, mostly affecting middle-aged men CN 5 is associated with - Migraines CN 7 is associated with - Bells palsy CNS symptoms present in hyponatremia - 3% NS with loop diuretic (Loop diuretics inhibit sodium chloride (NaCl) reabsorption in the thick ascending limb of the loop of Henle.) Coagulation tests (normal values) - INR( used to follow coumadin).8-1.2 Activated Coag time (ACT) 70-120sec Activated part. Thromboplastin time 28-38 PT 11-16sec PTT 60-90 PTT and APTT follows heparin Coagulation tests (therapeutic values) - INR for MI 2.5-3.5 COUMADIN 2-3 ACT 150-190 OR >300 POST STENT APTT 1.5-2.5X NORMAL PTT AND PT 1.5-2.5 normal COBRA - protects health insurance coverage for workers and their families in the event worker loses or changes jobs Concepts of TIA - Approximately 1/3 of pts with a TIA with experience a cerebral infarction in 5 years Confusion/Delirium vs. Dementia - Delirium-sudden transient onset; dementia-gradual memory loss consent is assumed if... - pt's condition is life threatening Contraction Alkalosis | Management - 1. Correct volume deficit with NaCl and KCl 2. Discontinue Diuretics 3. H2 blockers in patients with GI losses 4. Acetazolamide 250-500 IV q 4-6 hours if volume replacement is contraindicated Contraction Alkalosis | Signs/Symptoms & Labs - -none characteristic -weakness and hyporeflexia may be present if K low Arterial pH > 7.45 Arterial HCO3 > 26 Arterial PCO2 > 45 and <55 Serum K+ and Cl- decreased May see increased anion gap Coumadin Antidote - Vitamin K Cranial Nerves (OOOTTAFAGVSH) - CN I-Olfactory CNII-Optic CN III- Oculomotor CN IV- Trochlear CN V -Trigeminal CN VI- Abducens CN VII- Facial CN VIII- Acoustic CN IX- Glossopharyngeal CN X-Vagus CN XI- Spinal Accessory CNXII-Hypoglossal On old Olympus towering tops a Finn and German view some Hops. Creatinine clearance (cockcroft-gault equation) - 140 minus age in yrs X body weight in kg divided by 72 x serum creatinine in mg/dl In females multiply value by 85% Credentialing and Privileging - Process by which a nurse practitioner is granted permission to practice in an inpatient setting Credentialing and privileging - process which an NP is granted permission to practice in an inpt setting Credentialing is necessary to: - ensure that safe healthcare is provided by qualified individuals; comply with federal and state laws r/t APN Credentialing with hospital privileges is granted by a - Hospital Credentialing Committee Credentials - Encompass required education, licensure and certification to practice as an NP Establish MINIMAL levels of acceptable performance Credentials also... - acknowledges the scope of practice of NP, mandates accountability, enforces professional standards for practice Credentials encompass... - required education, licensure and certification to practice as an NP Credentials establish... - minimal levels of acceptable performance Crisis Intervention - Boundaries Security if necessary, NOT police Establish trust/rapport Crisis/Acute Grief Communication - Acknowledge feelings Offer self Criteria For Dialysis - A= Acidosis E= Electrolyte imbalance I= Intoxication O=Oliguria (output <400 in 24 hr) anuria <100 in 24 hr U=Uremia Cross sectional research - Population with a very similar attribute but differ in one specific variable Diabetes Insipidus - Central: Related to pituitary or hypothalamus damage resulting in ADH deficiency Nephrogenic: due to defect in the renal tubules resulting in renal insensitivity to ADH. Acquired due to phelonephritis, K+ depletion, sickle cell anemia, chronic hypercalcemia, medications Diabetes Mellitus (type 2) define? - Most common type; >90% diabetes in the US Circulating insulin exists enough to prevent ketoacidosis Caused by either tissue insensitivity to insulin or an insulin secretory defect resulting in resistance and/or impaired insulin production Diagnostics of GERD - consider referral for EGD: rule out CA, Barrett's esophagus Diastole definition - Period between S2 & S1 Diastolic heart failure - heart is relaxing and has no ability to relax stiffening beta blockers give heart time to fills. CA+ channel blockers like verapmil can decrease rate and stiffness ACE inhibitors are used under control to prevent cardiac remodeling but cautiously to avoid hypotension Differential Value Indicative of Allergic Reaction - Increased eosinophil count Diminished Renal reserve - 50% nephron loss, creatinine doubles Dismissing/discharging a pt or closing practice - NP cannot withdraw from caring for a pt without notification Diuretics who do we use them with - effective in pts with isolated systolic hypertension or pts with CHF Diverticulitis - Inflammation or localized perforation of one or more diverticula with abscess formation DKA define: - Intracellular dehydration as a result of elevated blood glucose levels often an acute complication of type 1 DM DKA how to correct the acidosis - Correct severe acidosis (<7.1) with bicarb gtt (44-48mEq in 900ml 1/2 NS until pH reaches >7.1) DO NOT treat hyperkalemia DKA insulin management cont. - 0.1u/kg regular insulin IV bolus followed by 0.1u/kg/hr. if glucose does not fall by at least 10% after the first hour, repeat bolus. Does direct supervision require MD to be physically in the room with NP to be eligible for incident-to-billing - no same office suite and easily accesible does incident-to-billing apply to the inpatient hospital setting - No. NP must bill under their NPI in the hospital setting Drawback of qualitative research - researcher bias Drug of choice for organophosphate poisoning? - Atropine Drugs in Parkinson's mechanism of action, name some - Increases available dopamine (Carbidopa-levodopa) Sinemet; Mirapex, Requip, Tasmar Anticholinergics alleviate tremor and rigidity Cogentin, Artane) Drugs that can cause fever - Amphotericin B, trimethoprim sulfamethaxazole, beta-lactam antibiotics, procainamide, isoniazid, alpha-methyldopa, quinidine Durable Power of Attourney - Individual designated in the living will that is authorized to make medical decisions in the event patient is incapacitated Duration of time to keep medical records after closing a practice - Minimum five years Duty to Warn - Patient's condition may endanger others overrides confidentiality Earlier complaint from family in Alzheimer's Disease - short term memory loss Elevated Euphoria - dilated pupils; mydriasis cocaine Emergent Hyperkalemia Treatment! - 10 U regular insulin and 1 amp D50 First NP program was peds, begun in... - 1964 by Dr. Loretta Ford and Dr. Henry Silver at CU Health Sciences mainly focusing on ambulatory and outpt care Fluid resuscitation for burns parkland formula - 4ml/kg X TBSA in the first 24 hours 1/2 of all fluid should be given in the first 8 hours the remaining fluid given over the next 16 hours. ALL NS or LR **Fluid resuscitation begins at time of burn injury Folic Acid Deficiency - Macrocytic, normochromic anemia due to folic acid defeiciency Following do not constitute pt abandonment - NP refuses to accept responsibility for pt assignment when NP has given reasonable notice to proper authority that NP lacks competence to carry out assignment; NP refuses assignment of a double shift or addtl hrs beyond posted work schedule when proper notification has been given..latter phrase can be controversial Four Roles of NPs - Clinician Consultant/collaborator Educator Researcher General concepts of sickle cell anemia - RBCs become sickle shaped causing vessel obstruction cellular hypoxia results in acidosis and tissue ischemia factors that precipitate; hypoxia, infections, high altitudes, dehydration, physical or emotional stress, sugary, blood loss, acidosis GERD - A disorder characterized by back flow of acidic gastric intents into the espohagus Gerontology considerations for Cardiovascular changes - Physiologic: Arterial walls become thicker and stiffen results in decreased compliance Heart becomes slightly stiffer , may increase in size related to left ventricular and atrial hypertrophy Maximum heart rate decreases (resting HR and cardiac output unaffected) baroreceptors less sensitive loss of pacemaker cells AV conduction less sensitive Gerontology considerations for gastrointestinal - Physiologic: decreases in strength of jaw muscles for chewing, thirst, taste, gastric motility and delayed emptying, liver size, and decreased liver blood flow Increases in intestinal transit time. impaired defecation signal gerontology considerations for renal physiologic changes - diminished renal blood flow, decreased kidney size GFR diminishes,decreased hormonal respose to vasopressin impaired ability to conserve sodium (increased risk of dehydration) bladder tone reduced increased urine residual, enlarged prostate Gerontology findings for renal in older adults - adverse drug reaction, nephrotoxcitiy, fluid over load,dehydration,hypernatremia hyper kalemia esp. with potassium sparing diuretics incontenence (never a normal finding) UTIs polyuria GI contamination - - History most important piece of information - serum, gastric and urine tox screens to aid in assessment of ingested substance GI contamination | Activated charcoal - -1g/kg to max 50g when mixed with water -give q 4 hours -combine first dose with sorbitol (so patient poops after charcoal binds) GI contamination | GI lavage - - "lavage until clear" - 28-38 F or nasogastric tube - limited use for ingestion > 30 minutes - pill fragments may not be able to be removed with small sized tubes GI contamination | Ipecac - - at home ingestions of solid matter (pills, capsules) - not used in emergency settings GI contamination | Severe Ingestion Remedies - forced diuresis, dialysis, hemoperfusion, plasmapheresis Heart failure definition - cardiac output cannot meet the needs of the body Heart Murmurs what is heard with each grade? - I/VI barely audible II/VI audible but faint III/VI moderately loud easily heard IV/VI loud and associated with a thrill V/VI very loud heard with one corner of stethoscope off VI loudest Hemodynamics of Cardiogenic Shock - Low CO/CI, High CVP, High PCWP, High SVR, Low SVO2 Hemodynamics of Obstructive Shock - Low CO/CI, High CVP, Low PCWP, High SVR, High SVO2 Hemorrhagic CVA - Changes in lOC, Motor weakness or paralysis, visual alterations, changes in vital signs Hep A - an enteral virus, transmitted via the oral fecal-route and rarely, parenterally Contaminated water and food; oral sex! blood and stool are infectious during 2-6 week incubation period Hep B - Blood borne DNA virus present in serum, saliva, semen, and vaginal secretions. Transmitted via blood and blood products, sexual activity and mother fetus Hep C - Blood bore RNA virus in which the source of infection is often uncertain Traditionally associated with blood transfusions 50% cases are related to IV drug use Leading cause of liver transplant Heparin antidote - Protamine sulfate Hepatitis - Inflammation of the liver, with resultant liver dysfunction types: A, B, C, E, G Herpes - Most common STD in US Herpes signs and symptoms - intial fever and malaise, dysuria,painful puretic ulcers for usually 12 days and less painful ulcers for 5 days Herpes simplex I - associated with infections of lips, face, and mucosa Herpes simplex II - associated with genitalia Herpes test - Papanicaloau or Tzanck stain most definative is viral culture Herpes Zoster (Shingles) define - Vesicular eruption due to infection with varicella-zoster wires; maybe life-threatening in immunocompromised adults Hgb - Main component of RBCs and the essential protein that combines with and transports O2 to the body 14-18males 12-16 females Hgb:Hct Ratio - 1:3 Hgb/Hct Ratio - 1:3 HHNK define it. Who does it occur with? - Hyperosmolar Hyperglycemic Nonketoacidosis. State of intracellular dehydration as a result of greatly elevated BG. Usually occurs as a complication of type 2 DM. Pts cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion HHNK Labs - Elevated serum glucose (>600; commonly >1000) Hyperosmolality (>310) elevated BUN and Cr, elevated Hgb A1C, normal pH, normal anion gap. MOST DEHYDRATED 6-10L down HHNK management - NS IV for massive fluid replacement (overall fluid deficit may be 6-10L). Once pt is hemodynamically stable or serum Na reaches 145 change to 1/2 NS (expect 4-6L in first 8-10hrs of therapy) HHNK management parameters for plasma glucose - When plasma glucose reaches 250 add D5 to IV solution 15U regular insulin IV followed by 10-15U SQ (immediately) Hyperkalemia & Causes - > 5.0 Excess intake Renal failure Drugs (NSAIDS) Hypoaldosteronism Cell death Shifts of K into the extracellular space occur with acidosis Hyperkalemia causes and what happens cellularly - Causes: Excessive intake, renal failure, drugs, hypoaldosteronism, cell death.Shifts of intracellular K+ to the extracellular space occurs with acidosis. K+ increase 0.7 with each 0.1 drop in pH Hyperkalemia Labs/Diagnostics - - EKG not always sensitive - Tall peaked T's = classic finding Hyperkalemia Management - - Exchange resins - kayexelate - > 6.5 or cardiac toxicity or muscle paralysis is present, consider: 10 U regular insulin and 1 amp D50 Hyperkalemia S/S - weakness, flaccid paralysis Abdominal distention diarrhea Tall peaked waves on ECG Hyperkalemia S&S - - weakness - flaccid paralysis - abdominal distension - diarrhea Hypernatremia - Usually do to excess water loss, always indicates hyperosmolality/hypertonic Hypernatremia what causes it what are the indications - Due to excess water loss. Always indicates hyperosmolality (deficit of water) excessive sodium intake is rare Hypernatremia with euvolemia Treatment - Treat with free water Hypernatremia with euvolemia treatment: - D5W Hypernatremia with hypervolemia should be treated with: - Free water and loop diuretics - may need dialysis In hypervolemic and hypernatremic patients in the ICU who have an impaired renal excretion of sodium and potassium (eg, after renal failure) an addition of a loop diuretic to free water boluses increases renal sodium excretion Hypernatremia with hypervolemia treatment - Treat with free water (D5NS) and loop diuretics....may need dialysis Hypernatremia with hypovolemia treatment - Give NS followed by 1/2 NS Hypertension definition - Sustained elevation of systolic BP >140 or diastolic BP >90 at least three times on two different occasions Hyperthyroidism who gets it? What are their age groups? - More common in women (1:8) Onset 20-40 y/o, Graves disease most common presentation Hypertonic - > 290 mosm/kg Hypertonic Hyponatremia Causes - Serum Os > 290 1. Hyperglycemia (HHNK) 2. Osmolality is high and sodium is low Hypertonic Hyponatremia lab value? What causes it? - (Serum osmo >290) Hyperglycemia: Usually HHNK Osmo is high and Na is low Hypervolemic Hypotonic Hyponatremia Causes - 1. Edematous states 2. CHF 3. Liver disease 4. Advanced renal failure Hypervolemic, hypotonic hyponatremia treatment? What causes it? - (restrict water) Edematous states, CHF, Liver disease, advanced renal failure Hypocalcemia Causes - - hypoparathyroidism - hypomagnesemia - pancreatitis - renal failure - severe trauma - multiple blood transfusions Hypovolemic Hypotonic Hyponatremia with Urine Na > 20 (what is happening here and what is the cause) - Renal Salt wasting 1. Diuretics 2. ACE inhibitors 3. Mineralocorticoid deficiency (Excessive release of ADH) renal disorders, endocrine deficiencies, reset osmostat syndrome, SIADH, and medications. Hypovolemic w/urine Na+ <10 causes? - Dehydration, diarrhea, vomiting Hypovolemic w/urine Na+ >20 is caused by? - Low volume and kidneys cannot conserve Na Diuretics, ACE inhibitors, and mineralocorticoid deficiency I cal does albumin effect it? - Does not vary with the albumin level ICU patient is improving but fails the swallow evaluation. What is your next action? - Patient does not need ICU. Transfer to sub-actue not med-surg Idopathic Thrombocytopenia Purpura (ITP) - Thrombocytopenia resulting from autoimmune destruction of platelets If C/O worst H/A of life - SAH If patient will be receiving nutritional support > 6 weeks: - Enterostomal tube Important things to remember about feeding duodenal and gastric ulcers? - feeding makes gastric ulcers better and duodenal ulcers worse In evaluation of hyponatremia, a urine sodium <10 meq/L suggests: - Renal retention of sodium to compensate for extra renal fluid losses A problem outside the kidney In evaluation of hyponatremia, a urine sodium > 20 meq/L suggests: - Problem with the kidneys, renal salt wasting In what level of paraplegia is ambulation possible? - T11-L1 In what level of paraplegia would you have bowel and bladder reflex, and be able to move trunk and upper thigh - T9-T10 In what level of Vertebral Damage in Quadriplegia may you be capable of feeding and dressing yourself with elbow extension - C6-C7 Incident-to-Billing - Services billed under MD provider number to get the full physician fee Under MD direct supervision Increase in esosiophils are a sign of: - Allergic reaction Increased anion gap causes - DKA, Alcoholic Keto Acidosis, Lactic Acidosis, Drug or chemical anion Increased gap treatment - underlying disorder, fluid resuscitation HCO3 not indicated if acidosis is due to hypoxia or DKA HCO3 is indicated if significant hyperkalemia is present Indication for prophylactic intubation post burn - burns to the face singed nares or eyebrows dark soot/mucous from nares and/or mouth Indications for pharmacologic revascularization - Unrelieved chest apin (>30 min and < 6 hours) WITH: ST segment elevation >0.1 mV in 2 or more contiguous leads INFECTIOUS causes of post-operative fever - 1. Usually w/ subjective complaints, WBC elevation and left shift (bandemia) 2. WBC > 30,000 not usually from infection 3. Surgical incisions 4. IV sites 5. Point of entry for any catheter: culture? 6. UTI 7. Lungs 8. Sinusitis 9. Abscess (ie: intra-abdominal) Infectious indicators of post-op fever? What are the WBC indicators? - Usually accompanied by subjective complaints and a WBC elevation with left shift. Increased 5-10000 is normal for ITP concepts- what sex does it occur in more often, how often does it require hospitilization; s/s of dx - Only occasionally do pts with ITP develop bleeding that requires hospitalization Women outnumber men 3:1 s/s bleeding gums and hematuria; more severe would require hospitilization ITP Precautions - Avoid constipation No flossing No shaving Justice - duty to be fair Justice - To be fair Key elements of the NP role include - integration of care across the acute illness continuum with collaboration and coordination of care; research based clinical practices, clinical leadership, family assessment, and discharge planning Key ethical principles are: - nonmaleficence, utilitarianism, beneficence, justice, fidelity, veracity, autonomy L sided CVA Causes - aphasia Lab/ Diagnostics of Mesenteric Infarct - Elevated amylase, Leukocytosis, Abdominal films, CT Lab/ Diagnostics of Resp Alkalosis - Increased pH >7.45 Low PCO2 < 35 Serum HCO3 low if chronic Lab/Diagnosis of DI - Hypernatremia, elevated BUN/Creat, serium osmo >290urine, urine osmo >100, urine specific gravity <1.005 If Central DI is suspected DDAVP challenge test 0.05-0.1ml nasally or 1 SQor IV. If no apparent cause MRI should be ordered to look for mass or lesion Lab/Diagnosis of SIADH - Hyponatremia: yet euvolemic Decreased serum osmolality (<280) Increased urine osmolality (>100) Urine Sodium >20 Renal, cardiac, thyroid function normal Lab/diagnositics of DIC - Thrombocytopenia (platelets <150,000) Hypofibrinogenmia (Fibrinogen <170) Decreased RBCs Increased fibrin degradation products (FDPs) >45 or present at >1:100 dilution Prolonged PT (>19sec) Prolonged PTT (>42 sec) D-Dimer( + at 1:8 dilution) Reflects simultaneous activation of thrombin and plasmin with increased FDPs; dives a predictive accuracy of 96% for diagnosing DIC Lab/Diagnostic findings with angina - ECG may be normal with down sloping of ST segment or T wave peak or inversion during attactk Exercise ECG Infarction=ST elevation/or prinzmental angina angina=ST depression Lab/Diagnostic for type 2 diabetes - Same for type I except no ketones in blood or urine Lab/Diagnostic of Addison's - Hypoglycemia, Hyponatremia, hyperkalemia (Addison's disease), Elevated ESR, lymphocytosis, plasma cortisol <5mg Lab/diagnostic of Chronic venous insufficiency - Nonspecific R/O edema d/t HF Lab/Diagnostic of Cushing's - Hyperglycemia) Hypernatremia) ~~~~Cushings Trio hypokalemia) Elevated plasma cortisol in the am, Serum ACTH, dexamethasone suppression test to differentiate cause Lab/Diagnostic of Diverticulitis - Mild to mod leukocytosis, elevated ESR, Stool heme + in 25 % of cases, plain and films are obtained on all patients to look for evidence of free air Surgical consult Lab/Diagnostic of DKA - Glucose >250, Ketonemia and/or ketonuria, glycosuria, acidosis (metabolic) <7.30, low HCO3, Low PCO2, elevated Hct, BUN/Crt, Hyperkalemia, Leukocytosis, hyperosmolality Lab/Diagnostic of HTN - CX ray,ECG, renovascular disease studies, plasma aldosterone, AM/PM cortisol levels to rule out Cerebral angiography Lumbar puncture may be performed if the pt has a grade I or II aneurysm to detect blood in CSF. CT should be obtained first. Lab/diagnostics of endocarditis - WBC elevated or normal, always a left shift with bands Echocardiogram for valvular damage Blood cultures ESR always elevated Lab/diagnostics of folic acid deficiency - Hct/RBC decreased MCV elevated (macrocytic) MCHC normal (normochromic) Serum folate decreased <5 RBC folate <100 Lab/Diagnostics of heart failure - hypoxemia, hypocapnia on ABG, echo will show contractile/relaxation, valve function, ejection fraction PFTs for wheezing during exercise, BMP usually normal unless chronic failure is present, urinalysis ,Chest X-Ray: pulmonary edema, Kerley's B lines, effusions Lab/diagnostics of Hepatitis - WBC: low to normal UA: proteinuria, bilirubinuria Elevated AST and ALT (500-2000) norma 35-40 LDH, bilirubin, alkaline phosphatase, and PT normal or slightly elevated Lab/Diagnostics of hypokalemia - Decreased amplitude of ECG, broad T waves, prominent U waves, PVCs, Vtach or Vfib Lab/diagnostics of Iron Deficiency Anemia - Low serum ferritin (stores) <25 High TIBC (Room to store) Low Hgb/Hct/RBC Low MCV (microcytic) Low MCHC (hypo chromic) High RDW (red cell distribution width) Lab/diagnostics of ITP - Low platelet count hx of easy bruising or bleeding. Lab/Diagnostics of leukemia - Peripheral blood smear to differentiate acute from chronic. Bone marrow aspiration is required to confirm the diagnosis Lab/Diagnostics of metabolic alkalosis - Arterial pH 7.45 Arterial HCO3 >26 Arterial pCO2 >45 and < 55 Serum K and Cl --decreased May see increased anion gap Lab/Diagnostics of MI - ECG changes ~ 30% of pts have not initial ECG changes Peaked T waves, ST elevations, Q wave development Cardiac enzyme elevations are above normal within 4-6 hours (Trop I- 100% cardio selective) Leukocytosis 10-20,000 on 2nd day Lab/Diagnostics of Pericarditis - ST segment elevation in all leads Depression of PR segment**highly indicative of pericarditis ESR elevation Echo cardiogram to confirm presence of fluid Baseline of BMP Lab/diagnostics of pernicious anemia What tests affirm deficiency? What test may help to determine a cause? - Hgb/Hct/RBCs decreased MCV increased (macrocytic) Serum b12 decreased < 0.1mcg/ml Anti-IF and anti parietal cell antibody test affirms deficiency; schilling may help det cause. Lab/Diagnostics of Pheochromocytoma - TSH is normal, Plasma free metanephrines; plasma concentration of normetanephrine >2.5 or metanephrine levels .1.4 CT of adrenals to confirm and localize tumor Lab/Diagnostics of PUD - Normal; anemia on CBC Consider endoscopy after 2-8 weeks of treatment Consider H pylori testing Lab/diagnostics of PVD - Dopplar U/S to evaluate flow ABI X-Rays sow calcification Arteriography: Most definitive test Lab/Diagnostics of Resp Acidosis - Low arterial pH PCO2> 45 Serum HCO >26 Low serum chloride (<93) in chronic patients Licensure vs. Certification - Government state board of nursing vs. nongovernmental agencies ancc Living Will - Compilation of statements that specify which life- prolonging measures one does and does not want if they become incapacitated Longitudinal study - Multiple measures of a group over an extended period of time Lymphomas defintion, diagnostics, and tx; confirmation how? - Lymphocytic maligmancy Diagnosed by enlarged lymph nodes Lbs: CT, Xrays, US, MRI used to locate and stage Biopsy and histopathologic examination confirms diagnosis Malignant Melanoma - 1. highest mortality of all skin cancers 2. median age at diagnosis=40 3. may metastasize to any organ Malignant Melanoma? Define? Treatment? - Mortality rate highest of all skin cancers Median age at diagnosis = 40 May metastasize to any organ Treatment: Biopsy and surgical excision Malpractice - Failure to render services with the degree of care, diligence and precaution that another member of the same profession under same circumstances would do to prevent injury to patient Malpractice involves - professional misconduct unreasonable lack of skill illegal/immoral conduct Management for intrarenal - Maintain renal perfusion, stop nephrotoxic drugs Management for post renal - Remove source of obstruction Management for prerenal - Expand intravascular volume Management of acetaminophen - Emesis for recent ingestions; gastric lavage/activated charcoal N-Acetylcysteine (mucomyst) with loading dose p.o should be ordered as needed Management of Acute Pulmonary Edema - O21-2L/min, Morphine 2-4mg IVP repeat 20-30 min PRN, Furosemide 40mg IVP repeat in 10min if no response, if severe, after load and preload reduction with nitroprusside, hydralazine . If Cardiac index remains low, dobutamine 2.5-20mcg/kg/min; if SBP <100 dopamine 5-20mcg/kg/min is preferred. Management of acute renal insufficiency - determine cause and intervene to prevent permanent kidney damage Management of Angina - Dietary changes, start ASA therapy, lowering of LDL cholesterol (dose until you get to goal) Management of antidepressant toxicity - Admit to ICU if CNS or cardiac toxicity Gastric lavage/activated charcoal Benzodiazepine IV to control seizures Sodium bicarb IV to counter dysrhythmias and maintain pH Management of Appendicitis - Surgical treatment IV broad spectrum abx IV fluids Pain management Management of Benzodiazepine OD - Respiratory and blood pressure support, romazicon IV, gastric lavage/activated charcoal Management of bowel Obstruction - Fluid resuscitation, NGT suction, broad spectrum antibiotics, surgical intervention in all cases of complete obstruction, partial obstruction may treat medically Management of BPH - Alpha-Blockers: Terazocin, Minipress, Flomax to relax muscles of prostate 5-alpha reductase inhibitors: Proscar and avodart to shrink prostate Saw Palmetto: decrease PSA; improves symptoms in some Avoid: benadryl, sudafed, afrin, SSRIs Management of Cholecystitis - Pain management NGT for decompression Maintain NPO Crystalloid solutions antacids PRN H2 blockers (-tidines) PPI (-zoles) GI/Surgical consult PRN Management of Hepatitis - Increase fluids to 3,000 to 4,000/day no/low protein diet: cause ammonia Serax if sedation is necessary Vit K for prolonged PT (>15 sec) Lactulose 30ml orally or rectally for elevated ammonia levels: hepatic encephalophathy Management of Herpes - acyclovir for topical, oral and IV use Valacyclovir: useful for asymptomatic vial shedding Management of Herpes Zoster - Treatment: Acyclovir, famciclovir, valaciclovir If suspected ocular involvement, immediate referral to ophthalmologist Post herpetic neuralgia: Gabapentin and pregabalin Zostavax @ 50 Management of HTN emergencies - Require IV agents, critical care bed, and invasive arterial pressure monitoring Nipride is a potent vasodilator, the drug of choice, given by continuous IV infusion at .25 to 10mcg/kg/min Pressure should be lowered acutely to the SBP 160-180 range then lowered gradually over a period of days with oral therapy. **Avoid Rapid severe drops in BP as cerebral infarction can occur** Management of HTN urgencies - Oral therapy: clonidine, captopril, nifedipine, loop diuretics Parenteral therapy rarely required (Don't drop too low) Management of Hypercalcemia - Calcitonin if impaired cardiovascular or renal fx, dialysis, if >12 begin NS and loop diuretics. Management of Hyperkalemia - Kayexalate if >6.5 or cardiac toxicity or muscle paralysis is present, consider: Insulin 10U with one amp D50 (pushes K into cell) Management of Hyperthyroidism - Propanolol (inderal) for symptomatic relief: begin dosing with 10mg p.o. may go to 80mg four times daily. Thiourea drugs: Methimazole (tapazole) 30-60mg/day divided into 3 doses, Propylthiouracil 300-600mg daily divided into 4 doses. Management of hypocalcemia - Check pH for alkalosis, if acute give IV calcium gluconate, if chronic give oral supplements, vitamin d, and aluminum hydroxide Management of hypokalemia - Oral replacement if >2.5 and no ECG abnormalities IV replacement at 10mEq per hour if can't take PO If <2.5 or s/s are present. Can give 40mEq/L/Hr IV, check every 3 hours and do continuous ECG monitoring Mg++ deficiency frequently impairs K correction Management of Hyponatremia - 1. Treat based on cause 2. Treat underlying condition 3. If hypovolemic- give NS IV 4. If urine sodium > 20 - treat the underlying cause 5. If hypervolemic, implement water restriction 6. If patient symptomatic, give NS IV with a loop diuretic 7. If CNS symptoms are present give 3% NS with loop diuretic (Loop diuretics inhibit sodium chloride (NaCl) reabsorption in the thick ascending limb of the loop of Henle.) Management of hyponatremia - Treat cause if hypovolemic: give NS if urine sodium > 20 treat cause if hypervolemic: restrict water If symptomatic : give NS with IV loop diuretic If CNS symptoms: give 3% with loop diuretic Management of inpatient diverticulitis - NPO dependent upon condition IV fluids IV abx: Flagyl, Cipro, Fortaz, Clindamycin, Ampicillin Management of insecticide poisoning - Wash skin activated charcoal atropine-drug of choice for insecticide poisoning Management of Iron deficiency anemia - Oral Ferrous Sulfate 300-325mg 1-2 hours after meals Iron not to be take with antacids Taking iron with Vitamin C increases absorption Foods high in iron: Rasins, green leafy veggie, red meats, citrus products, and iron fortified bread and cereals Exercise to develop collateral circulation trental (pentoxifylline Pletal (Cilostazol) weight reduction bypass surgery angioplasty Management of Resp Acidosis - Narcan 0.4-2mg Improve ventilation, intubate if necessary increase vent rate Management of Resp Alkalosis management if acute and chronic - Manage underlying cause If acute hyperventilation, have pt breath into paper bag decrease rate of vent sedation may be necessary rapid correction of chronic alkalosis may result in metabolic acidosis Management of salicylate intoxication - emesis for recent ingestions; gastric lavage/activated charcoal sodium bicarbonate IV to correct sever acidosis <7.1 Management of Saline Responsive Alkalosis - Correct volume deficit with NaCl and KCL D/C diuretics H2 blockers in pts with GI loss Acetazolamide 250-500mg IV q4-6hr if volume replacement is contraindicated Management of seizures - Benzo (Valium) 5-10mg IV or Ativan 2-4 mg IV Q 1-2min for status Dilantin: loading dose 20mg/kg @ 50mg/min continuous infusion Cerebyx: prodrug of dilantin Doses should be titrated, never abruptly withdrawn Management of serotonin syndrome - Treated with dantroline (Dantrium); clonazepam used to treat rigor; cooling blankets to control temperature Management of SIADH - If serum Na+ >120 restrict total fluids to 1000ml/24hr and monitor. If serum Na+ 110-120 without neuro symptoms, restrict fluids to 500 ml/24hr If serum Na+ <110 or neuro symptoms present, replace with isotonic or hypertonic saline and lasix. Management of sickle cell anemia - fluids for dehydration, analgesics for pain, and oxygen for hypoxemia. Management of Tension H/A - Over the counter analgesics and relaxation Management of TIA - ASA Plavix Ticlopidine (requires more monitoring) Assess for HTN Carotid endartectomy decreases the risk of stroke and death in patients with recent TIAs Management of type 2 DM - Oral Antidiabetics (5 classes) Management of Type I DM - If Ketones present: Insulin therapy is warranted. General rule: begin with 0.5 u/kg/day giving 2/3 of the dose in the AM and 1/3 of the does in the evening Management of Ulcerative Colitis - Mesalamine suppositories or enemas for 3-12 weeks Hydrocortisone suppositories and enemas Management of Upper UTIs - 14 day course vs. 6 week course Patients with pyelonephritis who have nausea and vomiting and those with more severe illness should be hospitalizied MCHC (Mean corpuscular hemoglobin concentration =chromic - Normal 32-36% Expression of the avg hgb concentration or proportion of each RNP occupied by HGB as a percentage MCV (mean corpuscular volume) =cytic - Average volume and size of individual erythrocytes (RBCs) Normal 80-100 Measuring Extent of Burn Injury (methods) - 1. Adult rule of 9's 2. palm = 1% 3. Lund and Browder chart: most common in tertiary burn centers-takes into consideration TBSA with age and specific calculations Medicaid - Third party payers O — oxoproline, a metabolite of paracetamol L — L-lactate, the chemical responsible for lactic acidosis D — D-lactate M — methanol A — aspirin R — renal failure K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis M — Methanol U — Uremia (chronic kidney failure) D — Diabetic ketoacidosis P — Propylene glycol ("P" used to stand for Paraldehyde but this substance is not commonly used today) I — Infection, Iron, Isoniazid, Inborn errors of metabolism L — Lactic acidosis E — Ethylene glycol (Note: Ethanol is sometimes included in this mnemonic as well, although the acidosis caused by ethanol is actually primarily due to the increased production of lactic acid found in such intoxication.) S — Salicylates Metabolic Acidosis | Normal Anion Gap Causes - Diarrhea Ileostomy Renal Tubular Acidosis (Infrarenal Failure) Recovery from DKA Metabolic Acidosis with normal gap causes "Hard ASS" - Hyperalementation, Addisons,Renal tubular necrosis, Diarrhea, Acetazolamine, Spironolactone Metabolic Acidosis with wide gap causes MUD PILES" - Methanol, Uremia (kidney failure) DKA, Popylene gylcol, IRON/INH, Lactic Acidosis/lack of O2, Ethylene glycol (oxalic acid) Salicylates (late response) Metabolic Alkalosis - high plasma HCO3 and compensatory pCO2 rarely exceeds 55 - If pCO2 is > 55 superimposed respiratory acidosis is likely Metabolic Alkalosis | Saline Responsive (Volume Contraction) AKA Contraction Alkalosis causes: - 1. Post-Hypercapnia alkalosis 2. NG suction 3. Vomiting 4. Diarrhea 5. Diuretics Metabolic Alkalosis how is HC03 affected? pCO2? - High plasma HCO3 and compensatory pCO2 rarely exceeds 55mmHg. If PCO2 is >55, superimposed resp. acidosis is likely Metabolic Syndrome - Waste Circumference: >40 inches in men and >35 inches in women BP: >130/85--only need one number Triglycerides >150 FBG >100 HDL: < 40 in men and <50 in women abnormal lipids ANY 3=Metabolic syndrome microcytic - <80 Microvascular Angina another definition - Metabolic syndrome Middle cerebral CVA can cause - hemiplegia Migraine H/A signs and symptoms and different types - Classic- Migraine with aura Common-Migraine w/o aura Related to dilation and excessive pulsation of branches of the external carotid artery. Lasts 2-72 hours following the trigeminal nerve pathway. Migraine Headaches - Dilation and excessive pulsation of the branches of the external carotid artery, usually lasting 2-72 hours along the Trigeminal nerve pathway Migraine Headaches | Causes/Incidence - 1. Onset is usually in adolescence or early adult years 2. Often + family history 3. Females > Males 4. A variety of triggers 5. Nitrate containing foods 6. Changes in the weather Migraine Headaches | Classifications - 1. Migraine with aura "classic" 2. Migraine without aura "common" Migraine Headaches | Laboratory & Diagnostics - 1. Baseline studies important to rule out other organic causes 2. Blood chemistries, BMP monitor for hypokalemia following fluid resuscitation/diuresis around 3 days post burn. Monroe0 Kellie Doctrine - When one of the contents of the skull increase, another must decrease to compensate and maintain normal ICP Most common causes of cellulitis Inpatient and Outpatient - Outpatients: Strep pyogenes (Gp A Strep) --Usual cause S aureus--less common Inpatients: Gram negative organisms (E Coli, Klebisiella, Pseudomonas, Enterobacter), S. Aureus (MRSA, CA-MRSA), Strep Most common method of documentation for risk mgmt - incident reports Most common method of documentation in Risk Management - Incident Reports Most common type of headache - Tension Headache most powerful data collected from patient - subjective or data you observed as the np Movement of NPs expanded to the... - inpt setting as a result of managed care, hospital restructuring, and decreases in medical residency programs Mucosal protecting Agents PUD - "coats"ulcer sucralfate, Bismuth, Misoprostol (may stimulate uterine contraction-abortion) Antacids: Milanta and Maalox, do not decrease gastric acidity Mucosal Protective agents - give 2 hours apart form other medications sucralfate 1gm/qid: Requires acidic environment (avoid antacids and H2 blockers) Associated with decreases in nosocomial pneumonia Pepto-Bismal Cytotec Antacids Multiple Sclerosis diagnosis - never made on lab findings definatively Csf elevated protein elevated IgG MRI of the brain some mild lymphocytosis Multiple sclerosis incidence - young adult bw 20-50 Western european in temperate weather multiple Sclerosis s/s - weakness numbness, spastic parapareparesis diplopia, Disequalibrium,Urinary urgency, Optic atrophy, Nystagmus Multiple Sclerosis treatement - neurology referral. no treatment ot prevent progression antispasmotics, plasmpheresis, interferon , immonosuppression Mutiple Sclerosis Cause - autoimmune marke with numbness adn weakness loss of muscle coordination. Body's immune system attacks the myelin sheaths (nerve insulators/helps transmit nerve signals) like MG variable clinical course with exacerbations mydraisis - dilated pupils Myocardial infarction - Contributing to leading cause of death in adults in the US; 1.5 million annually result in myocardial necrosis; "clot on plaque" myosis - constricted pupils / notice o in both! Mysthenia Gravis - Cause: autoimmune reduction in acetylcholine receptors sites at NMJ. Weakness worse after excersise. Clinical course varies with exacerbations, More common in women peaks 20-40 years of age Name High MCV Anemias - Pernicious or folate deficiency Name Low MCV Anemia - iron deficiency anemia and thalassemia Name medications used in Alzheimer's and their mechanism of action - Increase the availability of acetylcholine Donepezil (Aricept) Galantamine (Razadyne) Rivastigmine (Exelon) Narcotic Overdose Management - 1. Emetics contraindicated 2. GI lavage/ activated charcoal 3. Naloxone 4. Stadol Normal Albumin level - 3.5-5 Normal body temperature in C - 37 Normal BUN and Creat - BUN 10-20 Creat .5-1.5 Ratio 10:1 Normal creatinine clearance - Males <40 107 to 130ml/min or 1.8-2.3 ml/sec Females <40 87 to 107ml/min or 1/5 to 1.8ml/sec Normal gap treatment for chronic conditions - Common with chronic conditions like renal failure Bicitra 10-30 cc with meals and h.s. Normal Labs BUN Creatine and Bun/creatine ratio and Specific Gravity - BUN: 10-20 Creat: .5-1.5 Bun/Creat Ratio: 10:1 Specific gravity: 1.010- 1.030 Normal LFT - 35-40 Normal MAP - 70-105 maintain brain, heart, lungs, kidneys Normal Serum Osmolality - 275-285 mosm/kg Safe average of 280 2x the sodium Normal Urine Sodium - 10-20 meq/L normochromic - 32-36% Normocytic - 80-100 Normocytic causes - Anemia of chronic disease; sickle cell, renal failure, blood loss, hemolysis NP fails to do an EKG on a patient presenting with chest pain. This is an example of - negligence NP must notify department of health with what dx - Gonorrhea Chlamydia Syphillis HIV TB NPs must report to state - Criminal acts and injury from dangerous weapon (GSW) Gonorrhea Chlamydia Syphillis HIV TB Animal bites Suspected/actual child abuse Domestic violence Nutritional Considerations | Clinical Observations indicative of proper nutrition - - Hair not easily plucked - Pink mucous membranes - Clear nail beds free of ridges - Musculature Nutritional Considerations | Hgb levels indicative of malnutrition - - < 12 women - < 13.5 men Nutritional Considerations |Albumin Levels Indicative of Malnutrition and Protein Malnutrition - - < 3.5 = malnutrition - < 2.5 = edema NYHA Class 2 - Slight limitation of physical activity NYHA Class 3 - Marked limitations of physical activity NYHA Class 4 - Severe; inability to carry out any physical activity without discomfort. Symptomatic all the time. NYHA Class I - No s/s Obligations in closing practice d/t relocation, retirement - give pt adequate time to find another provider, keep all files for min 5 years, provide timely notification and names of other providers and resources for future care obstructive disease - Reduces airflow rates; asthma, COPD Occupational Therapy - ADLs Patient reluctant to undergo procedure. you should? - Fully educate patient and tell them why Patient Safety and Quality Improvement Act (PSQIA) - Voluntary reporting system improve patient safety outcomes through anonymous reporting by providers of patient safety outcomes and events Patient Safety Rule - Protects patient information to analyze patient safety events and improve Pericarditits (Outside) what/where is it? - Inflammation of the pericardium. Pernicious Anemia definition and what is it d/t - Macrocytic, normochromic anemia due to deficiency of intrinsic factor, which results in malabsorption of B12 + neuro with pernicious Pharm management for hypercholesterolemia - reduce risk factors manage diet (low sat fats) statins, lower LDH, Low dose ASA(check LFTs Q3mo), Niacin, Fibrates myocytitis-pain from statin therapy, move to niacin Pharm management HF - ACE inhibitors (#1) Diuretic: Thiazides, loop, etc Anticoagulation therapy for atrial fibrillation Pharm management of angina - nitrates, beta blockers, calcium channel blockers Pharm Management of HTN - Stage I HTN: Thiazide diuretics for most Stage II HTN: Two drug combo; usually a thiazide and ACEI, or ARB, or BB, or CCB Pheochromocytoma S/S - Hypertension (labile), tremor, tachycardia, weight loss, diaphoresis, hyperglycemia, palpitations; profuse sweating Pheochromocytoma what is it? What does it do? - Resulting from excessive catecholamine release (epi & norepi) characterized by paroxysmal or sustained hypertension; almost always due to a tumor of the adrenal medulla (tumor in adrenal) Physical exam findings of MI - Dysrhythmia common, S4 common, wheezing, plum crackles, low grade fever, tachycardia Physical findings of Appendicitis - RLQ guarding with rebound tenderness Psoas sign (Iliopsoas Test): Pain with right thigh extension Obturator Sign: Pain with internal rotation of flexed right thigh Postitive Rovsing's Sign: RLQ pain with pressure is applied to LLQ Physical Findings of bowel obstruction - High pitched, tinkling bowl sounds, minimal abd distention, pronounced and distention, mild tenderness but no peritoneal findings, unable to pass still or gas *Longer it takes to vomit the lower the obstruction *Bigger the belly the lower the obstruction Physical findings of Cholecystitis - Murphy's sign: Deep pain on inspiration while fingers are place under the right rib cage RUQ tenderness to palpation Muscle guarding and rebound pain Fever Physical findings of diverticulitis - Low grade fever LLQ tenderness ot palpation Physical findings of endocarditis - Murmur often present but may be absent in up to 30% of patients, especially those with right sided endocarditis Osler's nodes: Painful, red nodules in the distal phalanges Petechie, purpura, pallor Splinter Hemorrhages: linear, subungal splinter appearing Janeway lesions: RARE small and non painful macules on the palms and soles Roth Spots: small retinal infarcts, white in color, encircled by areas of hemorrhage Physical findings of pancreatitis - Upper abdomen tender to palpation usually without guarding, rigidity, or rebound Distended abdomen Absent bowl sounds Fever Tachycardia,pallor, cool skin Mild jaundice common If hemorrhagic: Grey Turner's sign:Flank discoloration Cullen Sign: Umbilical discoloration