NR 601 Comprehensive Final Exam Study Guide Practice Questions

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NR 601 Comprehensive Final Exam Study Guide & Practice Questions

How to conduct Mini-Cog- • The Mini-Cog has been demonstrated to have comparable psychometric properties to the MMSE • The primary advantage of the Mini-Cog is that it is shorter than the MMSE and measures executive function.• It is composed of a three-item recall and the Clock Drawing Test (CDT) and takes about 3 minutes to administer • The Mini-Cog is a short dementia assessment that combines three-word recall with clock-drawing capability.• Patients are given a total score reflecting accuracy in clock drawing and recollection of the given three words.• A score of 0 to 2 is a positive screen for dementia Causes of delirium in elderly- • Causes of delirium are numerous and in elderly hospitalized patients there are often multiple etiologies, including metabolic, infection, cardiac, neurological, pulmonary, sensory impairments, medications, and toxins.• Regardless of cause, a consistent finding is significant reduction in regional cerebral perfusion during periods of delirium in comparison with blood flow patterns after recovery.• A possible neurological common pathway may involve acetylcholine and dopamine, and the disruption in the sleep-wake cycle in delirium indicates melatonin as a possible factor. (Kennedy-Malone 59) Agnosia • Loss of ability to identify objects ADA criteria for diagnosing DM- • FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.* • 2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.* • A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).• Urinary incontinence- • Involuntary loss of urine from the bladder ▪ So common in women many consider it normal ▪ Common in older men w/ enlarged prostate

• Can affect quality of life
• Significance-One of the most common complains w/ older adults, Distress & embarrassment, Cost burden to pt &

society as a whole, Not life-threatening, may effect QOL, PCP essential to educating individuals

• Epidemiology- Increased prevalence w/ age in men & women, Nursing home population – 40-70%, Often a factor in

placement ▪ URGENCY UI is greater in men ▪ STRESS UI is greater in women

• Terminology

▪ UI- Unintentional voiding, loss or leakage of urine ▪ Continuous incontinence-Continuous loss or leak of urine ▪ Increased daytime frequency-More frequent during day than considered normal ▪ Nocturia-Interruption of sleep one or more times due to the need to urinate – increases in frequency after age 50 ▪ Urgency-Sudden, compelling desire to pass urine that’s difficult to prevent ▪ Overactive bladder syndrome- Urgency, frequency, nocturia w/ or w/o incontinence

• Risk Factors-Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diuretics
• Risk Factors by gender-Women:Aging, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen

deficiency, hx of pelvic surgery, diuretics

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Men:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diuretics

• Physical changes w/ aging that contribute to UI

▪ Lower urinary tract-Detrusor muscle over activity,Decrease in detrusor contractility, Increase in post void residual,Decrease in urethral blood flow ▪ Women – decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral mucosal epithelium & increase in urethral sensation ▪ Men can experience constriction of urethra due to BPH which may result in bladder outlet obstructing symptoms

• Initial clinical workup for UI in Men

o PMH, PE, UA, DRE: Eval of prostate,PSA w/ new onset in men

• UI workup in women:Exclude underlying causes,PMH, PE, UA, Pelvic exam, vaginal exam, perineal, Identify estrogen

status of pt, Pelvic prolapse, fistula, -Cough test, Integrity of pelvic musculature, leaking of urine ▪ Full bladder ▪ Standing position ▪ Asked to cough ▪ If urine leak is observed, stress incontinence is confirmed

• Red flags in males
• Higher level of suspicion for serious diseases, Refer to urology if Previous pelvic surgery, Pelvic radiation, Pelvic pain,

Severe incontinence, Severe UTI symptoms, Recurrent urologic infection,Abnl Prostate exam,Elevated PSA

• Be alert to these with NEW ONSET UI- Hematuria,Pelvic pain,Abdominal mass, Dysuria, Proteinuria, Glucosuria, CVA

tenderness,Nodular prostate,Any new neuro symptoms

• Goals of treatment: Reduce symptoms, Improve QOL, Increase social activity, Reduce leakage volumes, increase

dryness, use less protection; Increase independence in incontinence management; Decrease caregiver burden

• 1st line management guidelines
• AHRQ guidelines for management of UI in women

▪ Behavioral therapy ▪ Lifestyle modification ▪ Try for 3 months before pharm management

• Weight loss, Smoking cessation(Tobacco is a bladder irritant),Less coughing
• Dietary changes-Alcohol, soda, coffee with or without caffeine, acidic foods and spicy foods
• Maintain adequate fluid balance to reduce constipation, provide adequate flow to kidneys
• Behavioral strategies:Bladder training, Bladder control strategies,Timed voiding,Kegels, Pelvic floor training
• 2nd line management - Medication

o Antimuscarinic medication: 1st line for women

▪ Block the parasympathetic muscarinic receptors ▪ Inhibit involuntary detrusor contractions ▪ Side effects due to the effects on other muscarinic receptors

• Outcomes unpredictable and side effects common
• Common s/e: Dry mouth**, Blurred vision, Constipation,Nausea,Dizziness, Headache
• AntimuscarinicsMechanism of action

● Blocks acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detrusor contractions (anticholinergic) ● CYP3A4 substrates

▪ Indications: UI and OAB

▪ Contraindications: Untreated/uncontrolled narrow angle glaucoma,Gastric retention, Urinary retention

▪ Precautions:CNS depression,Caution in elderly

● Renal dosing

• CrCl <30
• Beta 3 Adrenergic Agonist – Mirabegron (Myrbetriq)

▪ Also approved for UI and OAB ▪ Clinical trials – significant reduction in incontinence and micturations ● No anticholinergic s/e ▪ Mech of action ● Selectively stimulates beta-3 adrenergic receptors

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● Relaxes smooth muscle – bladder

▪ Contraindications/caution: HTN- Do not use if SBP >180, DBP >100

▪ Avoid severe renal/liver disease ▪ Dose – 25-50mg PO QD ▪ CrCl <30 – max 25mg

• 2nd line of UI in Males – Alpha 1 blockers
• Men, not women!
• Alpha 1 blockers antagonize peripheral alpha 1 adrenergic receptors
• Used in men d/t high incidence of BPH in aging men
• Alpha antagonists

▪ Alpha 1A – prostatic smooth muscle relaxation ▪ 1B – vascular smooth muscle contraction ▪ 1D – bladder muscle contraction and sacral spinal cord innervation

• Meds

▪ Doxazosin SE: Dizziness, dyspnea, edema, fatigue, somnolence

▪ Terazosin SE: Asthenia, dizziness, postural hypotension

▪ Tamsulosin SE:Abnormal ejaculation, asthenia, back pain, dizziness, increased cough

▪ Alfuzosin- CrCl <30 use with caution, SE: Dizziness, URI

▪ Silodosin SE- Retrograde ejaculation Differentials as cause for erectile dysfunction-

• Differential diagnosis:

• Vascular, Endocrine, Neurological, Neurovascular, Substance abuse, End-organ disease, Psychogenic,

Social causes (Kennedy-Malone 376) Elder abuse • Types-

• Physical, Emotional, Sexual, Neglect, Exploitation, Abandonment, Self-Neglect

• Risk Factors-

• Age, Gender, Cognitive Impairment, Living Arrangement, Social Isolation

• Signs of abuse-

• bruises, slap marks, unexplained burns, increased accidents, lack of hygiene, failure to meet medical

needs, weight loss, decubiti, changes in personality, decreased interaction, unexplained STD • Provider responsibility in reporting abuse

• If you suspect elder abuse perform a physical exam and order any necessary tests.
• Include a cognitive screen.
• Document your findings. This includes what the patient says and your objective findings.
• You may need to interview your patient and the caregiver separately to see if the stories are the same.
• Be aware of your state laws regarding mandatory reporting of suspected abuse.

Differentials as cause for hematuria- Differentials per class notes • Dietary substances

• Caffeine, spices, Tomatoes, chocolate, alcohol, Citrus, soy sauce, & some herbal meds

• Medication

• Beta-lactam antibiotics, sulfonamide, NSAIDs, Cipro, allopurinol, Tagamet, & dilantin

• Anticoagulation and papillary necrosis

• Coumadin, Heparin, aspirin, & NSAIDs

• Glomerular nephritis • Hydrocarbons (glue, paint) NSAIDs • Urolithiasis • menses Terazosin use(s)- • Alpha blocker for BPH. 1-10 mg P.O. nightly.• Caution in those with cataracts and in elderly.• Side effects

• hypotension, priapism, dizziness, dyspnea, tachycardia.

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• 2nd Line Management of UI in males ***Alpha 1 Blockers • Pharmacologic agents for men with urinary incontinence differ from women; • Alpha 1 blocker antagonize peripheral alpha-1 adrenergic receptors and commonly referred to as alpha 1 blockers *Lifestyle changes and Behavioral Management are first-line but when not effective alpha 1 blocker is initiated; *This difference in choice of medication for men is due to the high incidence of BPH associated with aging men • Alpha 1 Adrenergic Receptor antagonists • Alpha 1A- Prosthetic smooth muscle relaxation • Alpha 1B- Vascular smooth muscle contraction • Alpha 1D -Bladder muscle contraction and sacral spinal cord innervation UTIs in men and women UTI treatment guidelines BPH- • Progressive, benign hyperplasia of prostate gland tissue • Etiology/incidence-

• Cause is uncertain, About 50% of men have it by 60, By age 85, 90% have it
• Most common cause of bladder outlet obstruction in men over 50

• Symptoms are attributed to mechanical obstruction of the urethra by the enlarged prostate gland • Signs/Symptoms-

• Gradual worsening of the following, Frequency, urgency, urge incontinence, Nocturia, dysuria, Weak

urinary stream, dribbling, hesitancy, Sensation of full bladder even after voiding, Retention • Diff Dx-

• Urethral stricture, Prostate or bladder cancer, Neurogenic bladder, Bladder calculus, Acute or chronic

prostatitis, Bladder neck contractor, Medications that affect micturition • Physical findings-

• Abdomen,May have distended bladder secondary to retention; Prostate,Nontender w/ asymmetric or

symmetrical enlargement, gross enlargement atypical, Consistency is smooth, rubbery (eraser), Nodules may be present • Differentiation from BPH and CA needs biopsy • Tests/Findings

• UA-No hematuria or UTI, Urinary flow rate, Voided volume and peak urinary flow rate (uroflowmetry)

may detect obstruction flow, Abdominal US – rules out upper tract patho, PSA, Consider PVR urine volume, Cr to assess renal function, elevated levels suggest urinary retention or underlying renal disease – refer this patient • Treatment/Management-

• Refer men who have the following,

 Refractory urinary retention who have failed one attempt at cath removal,  Recurrent infection, recurrent retention, refractory hematuria, bladder stone, large bladder, diverticula, or renal insufficiency related to BPH,  Consider referral if complications exist or if patients have severe symptoms • Management-

• Men who have no indications for surgery,

 Discuss risks/benefits of all options, Watchful waiting (observation), Behavioral techniques to reduce symptoms, Limit fluid after dinner,  Avoid medications such as Antidepressants, Antiparkinson drugs, Antipsychotics, Antispasmodics, Cold meds, Diuretics • Medication Treatments

• Alpha adrenergic blocker – for smaller prostates
• 5-alpha adrenergic blocker – larger prostates
• Combo therapy is an alpha-adrenergic blocker and finasteride is used now for men w/ large prostates

• Surgery has the best chance for relief of symptoms, but greater risks

• Follow up:

• Teach signs/symptoms of retention and obstruction,