Exam 2 Flashcards Preview

255 > Exam 2 > Flashcards

Flashcards in Exam 2 Deck (263):
1

pain management at end of life

  • assessment
  • type of pain
  • standard pharm and non pharm tx
  • morphine most common

2

nursing considerations unique to hemorrhagic stroke

  • risk for imbalanced body temp r/t damage to hypothalamus
  • hemodynamic instability 

3

intracranial venous vasculature

  • veins are called sinuses when in head
  • super sagittal sinus
  • inferior sagittal sinus
  • cavernous sinus (drains into jugular and sigmoid veins)
    • can get thromboses in these, causing venous stasis that backs up into arterial system and cause congestive failure

4

clinical manifestations of rheumatoid arthritis

  • joints
    • pain, stiffness
    • inflammation
    • deformity, disability
  • extraarticular
    • Rheumatoid nodules
    • Sjogren's syndrome
    • Felty syndrome

5

radioprotectors

  • protect benign cells and limit protective effects to hypoxic tumor cells
  • absorb free radicals that would otherwise injure healthy cells

6

indications for thrombolytic therapy

  • known onset time or observed onset of Sx
    • fibrolytics w/in 3 hours (some push to 4-5 hrs, but risks increase)
    • longer time --> more vasculature system dies
      • break clot and reperfuse (increase pressure) weak vessels may break
  • focal neuro findings w/o other known causes
  • outside of absolute contraindications, little evidence to NOT administer

7

top five cancer deaths among males

  • lung and bronchus
  • prostate
  • colon and rectum
  • pancreas
  • liver and intrahepatic bile duct

8

cardiotoxicity r/t chemotherapy

  • risk factors
    • cumulative dosing; concurrent radiation; female; pre-existing cardiac condition
  • etiology
    • agents may cause mass free radical release resulting in loss of cardiac contractility = cardiomyopathy
  • prevention
    • monitoring; cardioprotective agents?
  • treatment
    • refer to cardiology; treat as HF

9

complications of chemotherapy

  • anemia
  • thrombocytopenia
  • neutropenia
    • neutrophila fight bacteria and fungus

10

trajectory of frailty

  • often with dementia
  • progressive, slow delcine - death often takes family by surprise
    • were "dying" for a while
  • death usually from sepsis or renal failure

11

fecal incontinence overview

  • involuntary loss of rectal contents via anal canal
  • contributes to morbidity
    • UTI, pressure ulcers
  • affects QoL
    • shame, depression, engaging in social events
  • up to 46% in long-term care
  • disproportionately affects those with severe physical/mental disbilities
    • poor functional status; impaired cognition; institutionalization

12

diagnosing ischemic stroke

  • physical exam: sudden onset; focal deficits; speech disruptions
  • CT w/o contrast
  • NIH stroke scale score
  • Cincinnati Stroke Scale
    • facial droop
    • arm drift
    • speech
    • 1/3 = 72% indicative of ischemic event
    • 3/3 = 85% indicative

13

significance of obvious changes in wart or mole as warning sign of cancer

melanoma & skin cancer

  • A - asymmetrical borders
  • B - blurry or jagged edges
  • C - color variation
  • D - diameter > 6mm
  • E - elevated/uneven surface

14

indications/advantages to auto BMT

  • hematologic disease
    • MM; NHL; HD; AML (rare)
  • solid tumors
    • testicular; sarcomas
  • no risk for GVHD
    • no need for immune suppression ppx
  • viable option for geriatric pt that cannot withstand toxicity 

15

transient ischemic attack (overview)

  • transient episodes of neuro dysfxn that mimic stroke sx
    • treat like ischemic stroke until proven otherwise
  • usually self-resolve in <24 hr w/ minimal residual damage
  • often occur in presence of existing vascular dx
  • risk for stroke highest w/in 48 hrs
    • 42% of post-TIA strokes within 48 hrs
  • consider preventive anticoag or antiplt therapy
  • long-term management = risk reduction
    • statins, weight, BP and glucose control

16

trajectory of terminal illness

  • long, fairly stable portion of disease
  • trajectory suddenly declines over weeks to day
  • 5% of people die this way
    • seen in some cancer patients

17

etiology of rheumatoid arthritis

  • unknown - autoimmune, genetics, environment
  1. precipitating event - trauma, infection
  2. body believes synovial fluid is foregin and attacks
  3. formation of abnormal immunoglobulins (IgG)
    1. body makes autoantibodies (rheumatoid factor) to fight IgG
    2. rheumatoid factor + IgG = immune complexes that deposit around synovial membrane to cause inflammation
  4. blood is high in IgG and rheumatoid factor

18

anorexia at end of life

  • distressing to caregivers
    • cultural & religious considerations
  • feed for comfort not nutrition
  • high risk for aspiration
  • if treated:
    • megestrol acetate (synthetic progesterin): high DVT risk
    • corticosteroids 

19

common areas of osteoporosis r/t fractures

 

  • vertebrae
  • hip
  • wrist

20

osteoarthritis overview

  • wear and tear arthritis
  • hypertrophy and spurring of bone and erosion of cartilage
  • Sx show up at 50-60 yo
    • hands, neck, low back, knees, hips
  • over 55, women > men (menopause)

21

types of fractures

  • open - broken skin
  • closed - intact skin
  • complete - two+ pieces
  • incomplete - bone still somewhat connected

22

collaborative care of osteoporosis

  • education
  • weight-bearing exercise
  • 1500 mg calcium/day
  • smoking/alcohol can worsen
  • 6 small meals/day
  • fall prevention

23

clinical manifestations of osteoarthritis

  • unilateral
  • joints 
    • pain, stiffness
      • early OA - pain relieved by rest
      • late - some relief but after rest 30 min stiffness before feeling mobile again)
    • crepitus, effusion
  • deformity
    • Heberden's nodes
    • Bouchard's nodes
    • bowlegged

24

TNM classification evaluted for stage

  • Stage I - T1, N0, M0
  • Stage II - T2, N0, M0
  • Stage III - T3, N0, M0 or T1, T2, or T3 N1 M0
  • Stage IV -
    • IVa - T4a N0 or N1 M0, or T1, T2, T3, or T3a N2 M0
    • IVb - Any T N3 M0 or T4b any N M0
    • IVc - Any M1 lesion

25

trajectory of sudden death

  • trauma, MVA, stroke, MI
  • usually in younger people

26

financial or material exploitation of elders

illegal or improper use of older adult's fund, property or assets

27

falls risk factors

  • age, gender (over 75)
  • hx
  • polypharm
  • impaired mobility/gait
  • medical conditions
  • sedentary
  • psychological status - altered social life
  • nutrition
  • cognitive impairment - dementia 2x likely
  • visual impairment
  • assistive device - lack of education
  • environmental hazards

28

general signs of elder abuse and neglect

  • incongruity between accounts given by patient and caregiver
  • vague or improbable explanations for injuries
  • presentation of mentally impaired patient without a care provider
  • laboratory or radiology findings inconsistent with history

29

goals of end of life care

  • pain and symptom management
    • bothers patients and families the most
  • clear decision-making
  • preparation for death
  • completion
  • contribution to others
  • affirmation of the whole person

30

4 stages of rheumatoid arthritis

  • Mild - thickening of synovial membrane but no loss of function
    • little pain, some stiffness
  • moderate - loss of cartilage; pannous formations (abnromal grannulation tissue growth)
    • membrane thickens - some immobility
  • severe - cartilage/bone breaks down b/c of inflammation of membrane
    • joint deformities
  • terminal - fibrous connective tissue forms in spaces; bone collapses on itself
    • complete joint immobility

31

diagnostic tests for osteoporosis

  • osteoporosis cannot be seen on normal x-ray
    • need bone mineral density scan
  • dual energy x-ray - spine, hip, forearm
  • quantitative ultrasound - knees, hips, shins

32

development of tumor lysis syndrome

  • most frequent oncology emergency and indication for nephrology consult in inpatient
  1. rapid cellular lysis of malignant cells
  2. intracellular contents and nucleic acids released into circulation and accumulate
  3. hyperkalemia; hyperphosphatema; hyperuricemia; hypocalcemia
  4. acute renal failure

33

primary graft failure as complication of allo BMT

  • no sign of engraftment for 3-4 weeks
  • pts require 2nd BMT
    • mortality increases 70%

34

epidural hematoma

  • above skull, usually arterial
  • characterized by head injury leading to loss of consciousness
    • followed by lucid period
    • subsequent, often fatal decline in fxn
  • very dangerous

35

acute treatment of ischemic stroke

  • emergent revascularization therapy
  • angioplasty
  • thrombolytics
    • tissue plasminogen activators (t-PA) and streptokinase, urokinase, anistrepteplase
    • physically dissolve clots by breaking down bonds formed in coag cycle (destroy fibrin bonds)

36

tumor grading

  • GX - cannot be assessed
  • G1 - well-differentiated
  • G2 - moderately well-differentiated
  • G3 - poorly differentiated
  • G4 - undifferentiated

to determine tx and predict prognosis in brain/spinal cord tumors and soft tissue sarcomas

37

diagnostic tests for urinary incontinence

  • urinalysis - hematuria, URI
  • PVR > 100 cc post void
  • labs
    • electrolytes
    • BUN, creat
    • thyroid fxn
    • glucose

38

ischemic stroke overview

  • obstruction in arteries leading to hypoxia/anoxia
    • cerebral thrombi if formed in brain; cerebral emboli if traveled to brain
  • brain has ~ 3 min oxygen reserve with increasing damage leading to cellular death by 10 min mark
    • restoration of cerebral blood flow = top priority
  • Time is Brain
    • 1 min untreated = 1.9 million lost neurons
  • factors affecting damage:
    • pt condition before
    • temp of ambient environment 

39

bisphosphonates for osteoporosis

  • inhibits osteoclastic bone resorption
    • increase total bone mass
  • side effects:
    • anorexa, weight loss, gastritis, jaw osteonecrosis
  • teaching:
    • 30 min prior to meals, stay upright 30 min
    • reflux can cause esophageal irritation 

40

radiation precautions of brachytherapy

  • lead shields
  • minimize time in room - maximize distance
  • cluster nursing care
  • stat call to rad onc to remove seeds if patient deteriorates
  • lead tongs to put seeds that fall out into lead box
    • stat call to rad onc

41

chronic complications of allo BMT

  • chronic GVHD - flares
  • eyes - cataract development
  • infectious complications
  • secondary malignancies

42

4 Rs of radiation

  • repair
    • normal cells repair w/in 4-24 hrs but malignant cells have reduced repair ability over time
  • redistribution
    • disruption in cell cycle allows for more time in mitotic phase = more cell kill
  • repopulation
    • tumor cells likely die after; normal cells recover and repopulate
  • reoxygenation
    • XRT can break down tumor, exposing core to oxygen and making it more sensitive 

43

diagnostic studies of rheumatoid arthritis

  • positive rheumatoid factor (RF) (80%)
  • positive ANA titer (20%)
    • autoimmune in general
  • ESR and C-reactive protein = active inflammation
  • bone scan
    • x-ray inconclusive 

44

tumor necrosis factor inhibitors in rheumatoid arthritis

  • Enbrel, Humira - can be in combo with DMARD
  • TNF is agent in blood that is released when autoimmune system is activated
    • meds release TNF to diminish inflammatory reponse 

45

death

  • patient unarousable to any stimuli
  • no heart sounds or respirations for 60 sec
  • no carotid pulse
  • no pupillary light reflex
  • local laws govern who can pronounce death

46

comparison of rheumatoid arthritis and osteoarthritis

47

post-mortem care of expected death

  • ID body
  • remove all lines and tubes
  • wash body
  • toe tag
  • bag tag

48

urination is dependent on...

  • sympathetic, parasympathetic, somatic nervous systems
  • brain and spinal cord mechanisms
  • neurotransmitters

49

collaborative care of osteoarthritis

  • rest and joint protection
  • heat and cold
  • nutritional therapy & exercise
    • increase calcium; six meals/day; weight-bearing exercise
  • alternative therapy
    • yoga; acupuncture; massage; guided imagery; approved supplements
  • drug therapy
  • surgery - total or partial joint replacement
    • knee arthroscopy to grind down bone spur

50

hyperfractionation principle of radiation oncology

  • smaller doses per treatment
  • delivered BID
  • minimum 6 hr gap

51

types of hip replacements

  • partial
    • replace femur and neck
  • total
    • replace femur, neck, head, acetabula

52

methods of end of life care delivery

  • palliatve
    • supportive
    • symptom management
  • hospice
  • acute care

53

allogeneic BMT overview

  • for patients with liquid tumor that have
    • poor cytogenetic indicating high risk of relapse
    • good PS and limited comorbidities
    • relapsed disease in past and are in remission
    • intent is curative
  • healthy donor donates marrow or stem cells to pt with cancer
    • ALL; AML; CLL; CML; Hodgkins; MDS; NHL

54

relative contraindications to thrombolytic therapy during ischemic stroke

  • hyperglycemia (can be corrected)
  • seizure (active)
    • stop seizure before to determine stroke Sx
  • coexisting terminal dx

55

signs of elder neglect

  • lack of medical aids
  • lack of adequate food, basic hygiene, heat, water, clothing
  • untreated medical issues
  • confinement to bed without assistance for long periods of time

56

elder abandonment

desertion of an older person by an individual who has assumed responsibility for providing care for older adult or by person with physical custody

57

preparation for death

  • spiritual or existential issues more important
  • life review, conflict resolution, quality time with friends/family
  • time to say goodybw
  • leaving a legacy

58

Parkinson's nursing diagnoses

  • impaired physical mobility r/t stiffness, muscle weakness
  • self-care deficits r/t neurmuscular weakness, decreased strength, loss of muscle control/coordination
  • impaired bowel elimination - constipation
  • imbalanced nutrition r/t tremor, slowed eating process, difficulty chewing and swallowing, diminished appetite
  • impaired verbal communication r/t decrease in speech volume, delayed speech, inability to move facial muscles, psych conditions
  • ineffective individual coping r/t depression and dysfxn d/t disease progression 

59

collaborative care of rheumatoid arthritis

  • education
  • PT/OT for ADLs or getassistive devices
  • drug therapy
  • nutritional therapy
    • many have anorexia
    • home health screen to ensure they can cook
  • surgery
    • synovinectomy - remove synovial membrane
    • total/partial joint replacements

60

Parkinson's exam findings

  • motor
    • tremors, bradykinesia, rigidity, postural 
    • unilaterally and spread over years
  • non-motor
    • depressio, anxiety, apathy
    • cognitive problems, dementia
    • psychosis, hallucinations, paranoid overtones
    • judgement alterations, emotional instability
    • sleep alterations
    • loss of smell
    • topical pain (tingling, pins and needles)

61

chemotherapy during pregnancy

  • some can be administered safetly after third trimester as organs are formed
  • higher risk of miscarriage in liquid tumor pts d/t low platelets and need for extremely aggressive chemotherapy

62

pulmonary complications of allo BMT

  • 40% of all deaths following BMT
  • diffuse alveolar hemorrhage
    • within 2 weeks
    • hypoxia, dyspnea, fever, cough, hemoptysis
    • tx with steroids
    • r/t damage from preparative chemo regimen

63

post-mortem care for unexpected./traumatic death

  • coroner's case
  • do not remove lines
  • do not wash
  • ID body
  • toe tag
  • body tag

64

etiology of dyspnea at end of life

65

risk factors of hemorrhagic stroke

  • Asian > Blacks/Mexican > Whites
  • risk doubles every decade after 35
  • gender does not play a role
    • but age; HTN; alcohol; ethnicity; low triglyc and total cholesterol do
  • concurrent risk with anticoags/antiplt increase risk

66

skin toxicity r/t external beam radiation

  • within 2-3 wks at 20-25 Gy
  • at site of xrt only
  • rashes may occur if using biologic agent
  • risk for more acute skin rxns:
    • concurrent chemo
    • areas with folds that expose more surface area
      • breasts; perianal or perineal skin; head and neck

67

types of cancer

  • carcinoma - solid
  • leukemia, lymphoma - liquid
  • sarcoma - cancer from fatty tissue, bone, muscle 

68

skin care guidelines r/t radiation therapy

  • avoid sun
  • loose clothing
  • no harsh soaps, deodorants
  • wash with dove and pat dry
  • avoid shaving, but use electric if necessary
  • avoid cream application up to 4 hours before
    • may allow for bolus of xrt
  • pain control
    • aquaphor

69

drug therapy of rheumotid arthritis

  • disease-modifying antirheumatic drugs (DMARDs) - gold standard
  • tumor necrosis factor inhibitors
  • NSAIDs
  • salicylates

70

neutropenic precautions

  • first temp spike 100.4 = medical emergency
  • pan culture
    • blood, urine
    • CXR, other works ups
    • rectal abscess, look in mouth
  • broad spectrum antibiotics until count recovery
  • antifungals if febrile for 4 days with negative cultures
    • maybe ppx if afebrile and neutropenic
  • no fresh flowers; meticulous hand washing
  • avoid invasive procedures

71

healthcare provider barriers to pain management

  • inadequate pain assessment and reassessment
  • reluctance to prescribe opioids 
  • fear of causing death
  • stereotypes about
    • minorities
    • women
    • elderly
    • non-cancer

72

diagnostic studies of osteoarthritis

  • bone scan
  • CT
  • MRI
  • x-ray (advanced OA)
  • synovail fluid
    • remains clear in OA
    • differentially diagnose from other causes i.e. cellulitis or cancer which would change fluid

73

hierarchy of medical decision-making

  • spouse
  • adult child
  • parent
  • adult sibling
  • adult grandchild
  • close friend
  • healthcare facility director

74

significance of indigestion or difficulty swallowing as warning sign of cancer

  • esophageal, stomach, pharynx
    • indigestion, GERD
    • spasm
    • early satiety, dysphagia

75

autologous BMT

  1. bone marrow removed/blood drawn
  2. stem cells collected
  3. stem cells stored or frozen
  4. chemotherapy destroys bone marrow
  5. stem cells returned to bloodstream

pts must achieve molecular remission before harvesting their own stems

76

Parkinson's pathophysiology

  • cognitive fxns intact and functional
    • as are muscles/receiving cells
    • control apthways are impaired

77

Levadopa

  • synethic dopamine precursor
  • metabolized extremly quickly
  • given with carbidopa
    • inhibits conversion of Levadopa
    • active metabolites work on carbidopa first
    • carbidopa does not cross BBB
  • helps motor and non-motor Sx

78

significance of thickening or lump in the breast or elsewhere as warning sign of cancer

  • breast, testes, soft tissue
    • painless, lump or mass
  • lymphoma or metastatic disease
    • persistent enlarged lymph nodes

79

anatomic etiologies of fecal incontinence

  • OB injury
    • damage to muscles/nerves (usually temporary)
  • surgery
  • pelvic fracture

80

types of hospice care

  • routine home care
    • routine visits usually 3x/week
  • continuous home care
    • 24/7
    • 8% of hospice care (usually right before death)
  • inpatient hospice care
    • 10-15% (not many beds)
    • for patients imminently dying in next 24-48 hrs
  • respite care
    • care for caregiver

81

types of BMT

  • allogeneic - family/unrelated
  • autologous - self
  • syngeneic - identical 

82

why use radiation in combo with chemo?

  • chemo affects G1, S, and G2
  • radiation affects M
  • increase cell kill
  • spread out side effects

83

principles of radiation therapy

  • use ionizing radiation
  • 60% of cancer patients will undergo
  • therapy goals
    • deliver a calculated dose of radiation to defined tumor site while sparing healthy surrounding tissue

84

types of hip fractures

85

urinary incontinence overview

  • involuntary los of urine
  • 17 million adults in US
  • 8-34% non-institutionalized elderly
  • 50-60% long-term care residents
  • 11% of elderly in acute care
  • usualy not life-threatening, but significant consequences 

86

acute toxicity r/t xrt of chest & lung

  • skin erythema
  • esophagitis, dysphagia, odynophagia
  • dysguesa, anorexia
  • GERD
  • pneumonitis (subacute)
    • decreased surfactant
    • low grade temp; congestion
    • chest fullness; dyspnea; pleuritic pain

87

sentinel lymph node biopsy

  • evaluates for metastasis in 1st lymph node closest to mass
  • eliminates unnecessary removal of healthy lymph nodes
  • requires njection of radiolabeled colloid near tumor
  • 2-6 hours later, lymphatic flow is assessed and 1st node is evaluated 

88

long-term Parkinson's management

  • effects can be managed with meds for quite some time
  • supportive care is goal when effects become severe
  • management of psychiatric Sx is priority
    • as is management of worsening tremors at peak med dosing
  • may require assisted living or subacute care/residential facility

89

chemotherapy toxicities

  • diarrhea
    • rule out C.diff
  • constipation
    • prevention is key; bowel regimens
    • prevent straining (increase risk of rectal abscess)
  • neuropathy
    • platinum based chemo
  • alopeca 

90

national guidelines for acute ischemic stroke

  • Designated Stroke Centers (DSC)
    • work with Stroke Ready Hospitals (SRH)
    • operate regionally in spoke-like system
  • public education on S/Sx
  • EMS standards
  • hospital standards
    • 24/7 capability to provide comprehensive stroke care
    • QI process for stroke care
    • provider w/in 10 min
    • CT w/in 30 min
    • fibrinolytics w/in 3 hrs

91

hospice care

  • for patients with life expectancy < 6 mo
    • two independent physicians w/ 80-90% certainty
  • covered by Medicare hospice benefit
    • replaces Medicare A & B
  • replaces curative therapies
  • home or inpatient
  • symptom management,c omfort, patient and family goals 

92

infertility caused by cancer tx

  • men
    • surgery (removal of testes)
    • high dose chemo
    • total body irradiation
  • women
    • surgery (hysterectomy, ovary removal)
    • age (fewer eggs after 35)
    • TBI
    • early menopause r/t drugs

93

acute toxicity r/t xrt of brain

  • alopecia
  • forehead erythema (manage dermatits)
  • auditory canal irraditation
    • resolves 1-2 weeks
    • steroid ear drops, nasal decongestants
  • transient increase in cerebral edema
    • start decadron

94

top five cancer deaths among women

  • lung and bronchus
  • breast
  • colon and rectum
  • pancreas
  • ovary

95

physical exam for urinary incontinence

  • abdominal
    • bladder fullness, tenderness, masses
  • genital
    • irritation, lesions, atrophic vaginitis, pelvic prolapse, vaginal muscle strength
  • rectal
    • tone, innervation, muscle strength, constipation, BPH
  • skin

96

goals/factors affecting cancer diagnostic approach

  • presenting S/Sx
  • clinical status, ability to tolerate procedures
  • anticipated goal of tx
  • biologic characteristics of cancer
  • available diagnostic equipment
  • sensitivity/specificity of tests
  • cost effectiveness of procedures
  • patient/family preferences

97

knee osteoarthritis

bone spur forms on outer portion of knee, reducing joint space and creating bowleggedness

98

neurological etiologies of fecal incontinence

  • DM
  • dementia
  • pudendal neuropathy
  • MS
  • spina bifida

99

what is cancer?

  • abnormal cells divide uncontrollably & invade other tissues and organs
  • > 100 types
  • damage occurs by disrupting normal cell & organ fxn
  • cancer cells can undergo angiogenesis
    • promotion of blood supply 

100

subdural hematoma

  • below dura, outside brain tissue
  • one of most common types of traumatic head bleed
  • can occur spontaneously in elderly or people with anticoag therapy

101

sexual abuse of elder

nonconsensual sexual contact of any kind with older adult

102

self-care strategies for urinary incontinence

  • products
  • frequent toileting
  • medication "rearrangement"
  • special clothes
  • avoid public transport
  • decrease/avoid carrying heavy objects
  • avoid intercourse
  • locate/stay near bathroom 

103

bladder retraining for urge urinary incontinence and overactive bladder

goal: regain bladder control by increasing bladder capacity and reducing OAB Sx

104

elder neglect

refusal or failure to fulfill any part of a person's obligations or duties to an older person

105

sexual activity during chemotherapy 

  • no pregnancy for up to 6 months after chemo d/t damage of DNA in sperm/eggs
  • barrier protection
    • drugs can be excreted in sperm/vaginal secretions

106

nursing management of hip fracture

  • pain - mobile s/p surgery (high risk of DVTs)
  • education - strengthening unaffected limbs
  • vitals - many vessels in hip/pelvis
    • huge increased risk of bleeding
  • respiratory - atelectasis
  • surgical site - hematomas, increased bleeding
  • neurovascular - catch DVT early
    • swelling post surgery can cause compartment syndrome
  • HIP precautions
  • prevent DVTs

107

DMARDs for rheumatoid arthritis

  • disease-modifying antirheumatic drugs - gold standard
  • methotrexate (most popular)
    • stops joint erosion and prevents deformities
    • bone marrow suppression and hepatotoxicity
    • consistent follow-ups

108

significance of a sore throat that does not heal as warning sign of cancer

  • oral cancer - new ulceration that will not heal
  • skin
    • delayed healing
    • change in skin lesion size, color, shape
  • vulvar - persistant sore or itching

109

decerebrate posturing

  • possible damage to brainstem
  • seen in
    • ponstine strokes
    • basilar aterial disruption
  • extremely poor prognostic indicator

110

clinical manifestations of osteoporosis

  • curvatures in bone structure - wedges
    • bones more porous, start to change shape
  • first manifestation is back pain 
  • second manifestation is spontaneous fractures or mild trauma

111

Parkinson's overview

  • affects ability to control voluntary movement
  • disrupts control of muscle cells through degeneration of dopamine production capabilities of neurons 
  • > 1 million Americans, most over 60
  • cause is unknown - suspected combo of environment and genetics
  • 10-15% have first-degree relative with disease
  • typically responds well to medical therapy
    • manageable until late stages
    • usually to treat side effects of meds

112

physical abuse of elder

use of physical force that can result in bodily injury, physical pain, or impairment

113

drug therapy for osteoporosis

  • bisphosphonates
  • salmon calcitonin
  • selective estrogen receptor modulator (SERM)
  • recombinant form of human PTH

114

Bouchard's nodes

swollen areas in proximal interphalanges r/t osteoarthritis

115

palliative care

  • relieving Sx and improving QOL
  • in conjunction w/ curative therapies
  • interdisciplinary
  • hospital or home

116

graft vs host disease

  • new (donor) immune system or graft reacts against HLA surface proteins in recipient
  • risk can be decreased by:
    • closely matching donor & recipient
    • providing appropriate myeloablative regimen to make room for new  graft
    • GVHD prophylaxis
      • cyclosporine
      • MTX
      • tacrolimus 

117

death rattle

  • d/t excessive oral or bronchial secretions
  • tx
    • anticholinergics
    • nebulized atropine
  • more for family - doesn't bother patient

118

lymphoma staging system

  • 1 - single lymph node region or single extralymphatic site
  • 2 - two or more sites, same side of diaphragm w/ contiguous extralymphatic site
  • 3 - both sides of diaphragm or with spleen or contiguous extralymphatic site
  • 4 - diffuse involvement of extralymphatic sites +/- nodal disease

119

principles of biotherapeutic agents

  • stimulate patient's own immune system
  • enhanced release of cytokines or chemical messengers that stimulate immune system
    • natural killer activity of T cells, etc.
  • result in immune response to fight cancer 

120

cystocele

dopped bladder - pushes back into vaginal vault

121

colony stimulating factors

  • epogen
    • sitmulates erythropoietin
    • black box warning in cancer patients (increase VTE)
  • neupogen
    • stimulates WBC growth after chemo

122

neurological theory overview

  • brain tissue needs constant oxygen supply
  • brain receives 15% of CO
    • emergency neurological care tries to ensure this is not interrupted
  • interventions are about relieving pressure on CNS structures
    • Munro-Kellie hypothesis
      • change in mass/volume - something else has to shift
      • cranium can compensate for 120 ml of volume change w/o damage

123

nursing diagnoses for strokes and TIA

  • ineffective cerebral perfusion
  • ineffective airway clearance
  • risk for aspiration
  • impaired physical mobility
  • activity intolerance
  • self-care deficit
  • impaired skin integrity
  • impaired verbal communication
  • impaired nutrition
  • ineffective coping
  • caregiver stress

124

bladder complications of allo BMT

  • hemorrhagic cystitis
    • 2/2 cytoxan chemo
      • treat with CBI
      • consult urology
    • re-activation of adeno or BK virus
      • consult ID for testing and anti viral selection

125

needle biopsy

  • fine needle
    • inserted into mass via palpation or assisted w/ imaging
    • local anesthesia
    • accurary 90%
    • negative does not rule out malignancy
  • core
    • spring load needle obtains core
  • both require open biopsy to confirm

126

interleukin 2

  • bio-therapeutic therapy
  • released by activated helper 2 cells & induces an inflammatory response to treat cancer 
  • FDA approved
    • metastatic renal cell
    • metastatic melanoma
  • each dose is a clinical decision
    • absolute criteria to hold
    • relative criteria to consider holding

127

signs of elder financial abuse

  • excessive financial gifts or reimbursements for care provided or companionship 
  • lack of amenitis the patient should be able to afford

128

types of N/V r/t chemotherapy

  • acute - wthin hour
  • delayed - within 24 hr
  • anticipatory - 25% incidence (Pavlovian response to seeing chemo)
  • prevention
    • serotonin antagonist; neurokinin 1 receptor antagonist; decadron
  • tx for breakthrough
    • lorazepam and benadryl; haldol and compazine; metoclopramide 

129

fatigue r/t xrt 

  • distressing, persistent, subjective sense of physical, emotional and/or tiredness or exhaustion r/t cancer or cancer tx that is not proportional to recent activity and interferes with functioning
  • most common side effect
  • peaks at 2-4 weeks
  • correct other causes
    • anemia; electrolyte imbalance; nutrition

130

long term considerations of ischemic stroke

  • goal of care is restoration of fxn to highest possible level
  • 14% of stroke survivors experience 2nd stroke in 1st year
  • rehab depends on:
    • damage done; areas involved
    • comorbidities (physical reserve)
    • rehab team experience/skill
    • timing of rehab
  • rehab can be acute, sub-acute (6-8 mo), inpt or oupt

131

cancer vaccines

  • cells removes from pt's blood
  • in lab, blood cells exposed to chemicals which turn them into dendritic cells
  • dendritic cells exposed to PAP (prostatic acid phosphatase)
  • dendritic cells will mount response against prostate cancer
  • infused back into body to treat cancer

132

Rome III constipation definition

  • two + of the following for past 3 months, with at least one symptom onset for past 6 months, occurring 25% of time
    • straining during BM
    • lumpy/hard stool
    • incomplete evacuation
    • feeling of anorectal blockage
    • use of manual manuevers to facilitate BM
    • less than 3 BM/week

133

indwelling catheterization for urinary incontinence

  • last resort
  • only in specific instances and for short periods
    • terminal/comfort
    • retention not treated by other means
    • acute management
    • skin breakdown

134

collaborative care of hip fracture

  • Buck's traction - keep hip in line until surgery
  • surgery - internal fixation device

135

stereotactic biopsy

  • non-palpable masses
    • insertion of small wire with curve to mark site for open biopsy
  • breast sterotactic biopsy
    • digital mamogram used to identify lesion
    • local anesthesia
    • needle or core biopsy

136

treating fecal incontinence

  • most cases are treatable
  • nursing interventions
    • dietary changes; bowel habit training
    • skin care
    • pelvic floor muscle strengthening
      • neuromodulation/Interstim
    • refer/collaborate
    • treat constipation/impaction
  • Solesta - injectable gel to optimize and strengthen pelvic floor muscles for those with chronic intractable fecal incontinence 

137

general criteria for end of life

  • multiple hospitalizations, ED visits or increased healthcare utilization
  • progressive illness
  • progressive functional deterioration
  • uninentional weight loss

138

nonpharm interventions for dyspnea at end of life

  • oxygen
  • cool air
  • pursed lip breathing
    • increase positive end expiratory pressure (PEEP)
  • positioning
  • cool compress
    • vasoconstriction (decrease oxygen demand)
  • pleurocentesis/pleurex catheter

139

principles of surgery in cancer care

  • 60% of cancers treated with surgery
  • surgical oncology is multidisciplinary
    • chemo given first to shrink surgical field
  • risk/benefit
    • will surgery result in loss of fxn
    • is tumor near vascular supply
    • will surgery impair body image
  • complete resection; resection with minimal residual disease; advanced cancer

140

pharmacological interventions for dyspnea at end of life

  • opioids - morphine
    • blunt pereptual response to dyspnea
    • decrease oxygen demand
  • anxiolytics
    • depress ventilation response (lorazepam, diazepam)
    • decrease secretions (thorazine, phenergan)
  • corticosteroids (decadron, pred)
  • bronchodilators
    • decrease effort of breathing

141

types of end of life documentation

  • healthcare power of attorney
  • durable power of attorney
    • who can speak for you if you are unable
  • living will/advanced directvie
    • wishes of patient
    • living will not legally binding
  • verbal advanced directives 

142

dyspnea at end of life

  • aggravates pain and anxiety
  • distressing for family
  • may potentiate delirium
  • among greatest fears r/t death

143

urinary continence overview

  • bladder is elastic muscle (detrusor) that stretches to hold urine send from kidneys via ureters
  • sphincter muscle remains tightly shut, preventing urine from leaking out
  • at ~100-150 cc (full) bladder signals brain and brain signals sphincter to relax and open
    • bladder contracts and squeezes urine out
    • sphincter closes so refilling can resume

144

affirmation of the whole person

  • desire to be understood as a person, not a disease including life values and preferences
    • need reassurance of ongoing value, that they are cherished
  • empathy from caregivers

145

signs of elder physical or sexual abuse

  • inadequately explained injuries
  • delay in seeking medical attention after injury
  • unexplained STD

146

planning palliative care

147

acute toxicity r/t xrt of abdomen/pelvis

  • N/V
  • diarrhea
    • small bowel more sensitive than large bowel
  • proctitis - inflammation of rectal mucous membranes
    • accompanied by tenesmus
  • cystitis - mucosal injury causing inflammation
  • mucositis of peri anal region
  • vaginal dryness, pruritis, dyspareunia 

148

other medications for Parkinson's

  • to increase dopamine fxn; enhance receptor functionality; mitigate side effects of lowered dopamine levels
  • dopamine agonists
  • anticholinergics
  • MAO-B inhibitors
  • COMT inhibitors 

149

elderly people might not report/admit abuse because:

  • fear of retaliation
  • fear of being placed in nursing home
  • fear of care provider getting into trouble
  • denial
  • blaming selves for being a burden
  • embarassment
  • poor self-esteem; abuse was deserved
  • inability to communicate effectively
  • no knowledge of resources

150

risk factors for osteoarthritis

  • trauma
  • obesity
  • mechanical stress
  • inflammation (autoimmune dx)
  • joint instability
  • neurologic dx (diabetic neuropathy)
  • skeletal deformities (congenital; dislocations; kyphosis/scoliosis)
  • hematologic or endocrine dx
  • drugs (corticosteroids)

151

types of radiation therapy

  • curative
    • primary therapy alone
    • Hodgkin's (early) and skin cancer
  • combination
    • chemorads
      • head & neck; breast; GI
  • palliative
    • painc ontrol of bony mets
    • Sx relief for cord compression
    • anticipatory palliation
      • large mediastinal tumor w/ potential for SVC syndrome

152

osteoporosis overview

  • osteoclasts break apart bone faster than ostebolasts can lay down fresh bone
    • porous bones (fragile bone dx)
  • chronic, progressive
  • 1 in 2 women; 1 in 4 men
  • majority of fractures over 50 yo

153

medical care providers might not report elder abuse because:

  • attribute medical condition to another cause d/t not recognizing it as abuse/neglect
  • constrained by time
  • concerned about offending patient an family
    • or in denial of abuse, esp. if abuser is a patient
  • unfamiliar with mandatory reporting laws
  • unfamiliar with resources
  • concerned about personal safety, fear of involvement
  • unfamiliar with screening tools
  • misinterprets patient's signs as indicative of another disease process

154

HIP precautions

  • hip remains straight and unbent so surgical site can heal w/o fracturing or dislocating
  • don't cross legs, bend legs inward, sit up quickly and bend hip at 90 degrees

155

intracerebral hematoma/hemorrhage

usually from either trauma or damge to vascular system

156

common symptoms at end of life

  • pain
  • dypsnea
  • anorexia
  • constipation
  • fatigue
  • depression/anxiety
  • delirium/agitation/confusion

157

constipation management

  • exercise
  • increase fluids
  • establish schedule
  • manage/increase fiber (two doses/day)
  • saline agent such as milk of magnesia
  • stimulant dulcolax, lactulose, miralax
  • saline laxative (osmotic retention of fluid)

158

salmon calcitonin for osteoporosis

  • inhibits osteoclastic bone resportion
    • normally secreted by thyroid gland
  • side effects: nausea, facial flushing
  • needs calcium to be absorbed

159

Sjogren's syndrome

  • autoimmune factor in rheumatoid arthritis attacks lacrimal glands and salivary glands
  • burning, itching eyes and dry mouth

160

bone marrow aspiration & biopsy

  • standard diagnostic test
  • prognostic value
  • chromosmal analysis
  • guides treatment plan
  • poor cytogenetic = BMT
  • favorable cytogenetics = conventional therapy
  • lidocaine - standard of care for pain 

161

dosing principle of radiation oncology

  • radio sensitivity of tumor
    • poorly differentiated; rapidly growing; high mitotic potential
  • normal tissue tolerance
    • amount of radiation surrounding tissue can tolerate
  • volume of tissue to be irradiated (target volume)
    • gross tumor volume - actual mass
    • clinical tumor volume - GTV + surround area w/ possible subclinical microscopie disease
    • planning target volume - margins are CTV to account for organ movement or artifact

162

hemorrhagic stroke presentation

  • focal neuro deficits and speech alterations
  • neuro signs depend on area/volume of hemorrhage
    • pushes structures out of the way
  • sudden osnet of severe headache
  • usually during routine activity
  • headache N/V occur in 1/2 of patients (b/c of increased ICP)
    • nuchal rigidity if intraventricular blood is present
  • early stupor or coma is ominous sign
    • usually requires emergent neurosurgical intervention 
  • surgical emergnecy if hemorrhage continues to expand
  • identify vs ischemic event

163

constipation assessment

  • acute vs chronic
  • diet; fluids; laxative use
    • ask for home remedies
  • straining; fecal soiling; incontinence
  • hemorrhoids, other anorectal disease
  • family hx colon cancer, IBD
  • consider additional workup 

164

diagnosing Parkinson's

  • thru HPI and ROS
  • no blood or imaging available; used to rule out other dx
  • 2/3 Sx must be present
    • tremors
    • dyskinesia
    • rigidity
  • dx supported by unilateral pattern of tremors and tremors at rest
    • starts unilateral; becomes bilatearl
  • dx supported if PD medications cause improvement 

165

motor strength scaling

  • 5 - full strength
  • 4 - not full; can overpower pt
  • 3 - movement against gravity
  • 2 - severe weakness; no movement against gravity or resistance, but can move purposefully
  • 1 - flicker
  • 0 - no resposne, voluntary or to pain

166

principles of biopsies re: cancer

  • cancer diagnosis requires tissue
  • treatment regimens differ depending on tissue type even in the same organ
  • cell of origin or primary cancer must be detected
    • lung cancer: adeno vs small cell
  • exception:
    • cervical cancer can be confimed with scraping of tissue

167

mucositis grading scale

  • 0 = none
  • 1 = mild (painless ulcers, erythema, mild soreness w/o lesions)
  • 2 = moderate (painful erythema, edema, ulcers but eating/swallowing possible)
  • 3 = severe (need IV hydration)
  • 4 = life-threatening (parenteral/enteral nutrition or ppx intubation)
  • 5 = death (r/t toxicity)

168

top five new cancer cases among males

  • prostate
  • lung and bronchus
  • colon and rectum
  • urinary bladder
  • melanoma of the skin

169

systems affected by GVHD

  • w/in first 100 days
  • organs affected
    • skin = most common
      • painful/pruritic maculopapular rash on palmar/plantar surfaces and spreads
    • liver = 2nd most common
      • hyperbilirubinemia; high alk phos; high transaminases; hepatometagly; confirm w/ liver bx
    • GI
      • massive diarrhea; bleeding; abd cramping; N/V

170

cytokine release syndrome

  • bio-therapeutic therapy
  • dose limiting factor
  • cytokine release causes:
    • profound capillary leak resulting in pulmonary edema and weight gain (15 lb)
    • profound vasodilation and hypotension
      • IVF, pressors
    • flu-like Sx

171

fractionation principle of radiation oncology

  • division of total radiation dose in equal fractions
  • facilitates tumor kill but more likely to spare healthy tissue than large single dose

172

reconstruction surgery s/p cancer

  • restoration of function
  • skin closure
  • cosmesis
  • enhance QOL

173

presenting clinical picture of rheumatoid arthritis

  • generalized systemic complaints - weakness, fatigue, stiffness
  • symmetrical joint stiffness, pain
    • pain in morning for 60+ minutes - does not ease after 30 min
    • stiffness after activity
  • deformities 

174

management of patient receiving BMT

  • blood product support
  • managing sx
    • N,V,D
    • constipation
    • mucositis
    • fluid, electrolytes & nutrition
    • psychosocial support

175

brachytherapy

  • targeted, localized high dose radiation applied directly to tumor
  • limits radiation to local tissues
  • in OR:
    • catheters placed into site 
    • seeds implanted into catheters for specific time (2 days usually)
  • prostate, cervical, breast, lung, esophageal, anal/rectal, head & neck

176

external beam radiation

  • LINAC - linear accelerator delivers high beam of radiation to targeted area
  • dose historically in Rads but now in Gray or Centigray
  • 1 rad = 1/100 Gy = 1 Gy
  • machine rotates around patient
  • session is painless
    • 10-30 min, 5x/week, 2 rest days

177

significance of change in bowel and bladder habits as warning sign of cancer

  • colorectal cancer
    • depends on location
  • bladder & prostate
    • hematuria
    • dysuria
    • frequency
    • retention

178

functional etiologies of fecal incontinence

  • impaction
    • pushes on bladder
  • physical disability
    • can't get to toilet and undressed fast enough 

179

signs of elder psychological or emotional abuse

  • unexplained changes in behavior
  • isolation from family and friends
  • caregiver who appears to be controlling, demeaning, overly concerned with spending money, verbally/physically aggressive towards patient

180

risk factors for elder abuse and neglect

  • decreased physical health
  • dementia or cognitive impairment
  • female
  • history of violence
  • increased age
  • shared living arrangments 
  • social isolation
  • victim or caregiver with mental health or substance abuse issues 

181

absolute contraindications to thrombolytic therapy during ischemic stroke

  • uncertain timing
  • hypertensive crisis (don't reperfuse weak vessel under high pressure)
  • hypercoagulable state
  • recent surgery or trauma
  • CT imagery indicating intracranial hemorrhage
  • physical findings indicating intracranail hemorrhage
    • battle sign; triple flexion reflex; nucchal rigidity
  • inability to treat intracranial hemorrhage if it occurs
    • need neurosurgical capabilities w/in reasonable distance

182

common causes of constipation

  • ignoring urge
  • low fiber; reduced fluid
  • immobility
  • medications (Ca, pain, antacids, iron, AED, antiparkinson)
  • depression (sedentary, affects self-care)
  • dementia (functional, neurologic component)
  • metabolic/endocrine (DM, hypothyroidism)
  • neurologic (stroke, Parkinson's, MS)
  • mechanical

183

clinical manifestations of hip fractures

  • external rotation
  • pain at site
  • muscle spasms
  • shortening of limb

184

GVHD treatment

  • steroids
  • dosed 1-2 mg/kg/day and taper when stable
  • long term steroids can increase infection rates

185

self-neglect 

person's refusal or failure to provide him/herself with adequate food, water, clothing, shelter, personal hygiene, medication, and safety precautions

186

fractures overview

  • elderly susceptible to long bone fractures
    • hip, femur, humerus, wrist
  • secondary fractures r/t osteoporosis or cancer
  • CDC - falls account for 86% of fractures among 65+

187

cardiac complications of allo BMT

  • high dose cytoxan - 5-10% cardiomyopathy risk
  • increased risk in setting of previous anti tumor abx
  • follow MUGA scans
  • tx is supportive 

188

falls overview

  • 1 in 3 adults fall each year
  • 1/2 of falls reported to HCP
  • 2-3X more likely to fall again

189

radiosensitizers

  • select cells b/c tumors outgrow blood supply and become hypoxic 
  • administration of chemo or other biologic agents
  • inhibit cell repair mechanisms --> increase # of cells in mitotic phase
  • increase in tumor cell death

190

nursing management of rheumatoid arthritis

  • rest
  • joint protection - canes/walkers
  • heat and cold
  • weight-bearing exercise
  • psychologic support

191

components of basic urinary incontinence evaluation

  • history
  • physical exam
  • urinalysis
  • post-void residual
  • +/- bladder diary

192

recombinant form of human PTH for osteoporosis

  • stimulates new bone formation
  • side effects: leg cramps and dizziness
  • needs calcium

193

drug therapy for osteoarthritis

  • NSAIDS and salicylates (ASA)
    • with food, report bleeding
  • corticosteroids
    • intraarticular injections to decrease inflammation
  • hyaluronic acid (HA)
    • found in normal joint fluid
    • helps with viscosity and moving joint smoothly over itself w/o pain and rubbing
    • 3 weekly injections

194

managing side effects of pain management

  • respiratory depression
    • naloxone/narcan at bedside
  • sedation
    • dosing schedule
    • nonpharm alternatives
  • constipation
    • abdominal massage
    • stimulant laxatives (biscodyl, senna)
    • NO fiber/bulk-forming supplements 

195

post-mortem care in general

  • ensure privacy
  • patient supine
  • close eyes
  • replace dentures/prosthetics
  • clean patient
  • change gown, linens

196

rheumatoid arthritis overview

  • systemic autoimmune dx that is chronic/progressive
  • inflammation in connective tissue surrounding synovial joints
    • around, not between joints
  • dependent on genetics
  • at any age (peak = 20-40 yo)
  • women 3x likely than men

197

types of acute urinary incontinence

198

acute toxicity r/t xrt of head & neck

  • skin erythema
  • oral mucositis
    • assess for candidiasis; HSV
  • xerostomia
    • major salivary glands are very radiosensitive
  • dysphagia; odynophagia
  • laryngitis
  • dysgeusa; hypogeusa (altered; decreased taste)

199

normal vs complicated grief

200

infection as complication of allo BMT

  • immune system recovery takes 6-12 months
  • prolonged neutropenia can last 2-3 weeks
    • in setting of broken mucosal barriers - bacterial can easily translate from GI to blood (sepsis!)

201

incisional biopsy

  • reserved when a piece tumor is needed for evaluation but removal of entire mass would require extensive surgery or risk of bleeding
  • tumor near organ or vasculature

202

sinuosoidal occlusive syndrome

  • complication of allo BMT
  • within first 21 days of BMT
  • major Sx
    • hyperbilirubinemia
    • hepatomegaly
    • RUQ pain
    • weight gain
  • treatment
    • fluid restriction
    • pain management
    • monitor renal failure

203

routes of chemotherapy administration

  • intrathecal
    • into CSF
  • intraperitoneal
    • into peritoneal space
    • ovarian ca with mets
  • central infusion lines
    • all terminate in caval atrial junction

204

characteristics of actively dying patient

205

musculoskeletal changes with age

  • decreased muscle strength
  • decreased find motor dexterity
  • slowed reaction times & reflexes
  • loss of height
  • increased risk of osteopenia and osteoporosis
  • increased rigidity
  • decreased agility
  • joint stiffness, limited ROM
  • loss of bone density
  • kyphosis 

206

Felty syndrome

  • autoimmune factor in rheumatoid arthritis affects spleen
    • splenomegaly and leukopenia

207

end of life definition

  • presence of chronic disease(s) or symptoms or functional impairments that persist but may also fluctuate and
  • the symptoms or impairments resulting from underlying irreversible disease require formal or informal care and can lead to death

208

preparing allo BMT donor

  • healthy donor receives high dose colony stimulating factor
  • healthy donor has marrow or peripheral cells collected
  • bone marrow filtered and given to patient or stem cells cryogenically frozen and given to patient when ready

209

AML morphological classification

  • M0 - minimally differentiated
  • M1 - without maturation
  • M2 - with maturation
  • M3 - hypergranular promyelocytic
  • M4 - myelomonocytic 
  • M5 - (a) monoblastic; (b) monocytic
  • M6 - erythroleukemia
  • M7 - megakaryoblastic 
  • rare types 

210

ischemic stroke survival chain

  • nursing impact:
    • education
    • PHRN, flight nurse, base hospital control team
    • rapid recognition of urgency
    • reperfusion therapy; hemodynamic stability
    • rehabilitation
    • care transitions 

211

cultural considerations in post-mortem care

  • care of body
  • attendance on body
  • organ donation
  • autopsy 

212

Circle of Willis

circulatory anastamosis that supplies blood to brain and surrounding tissue 

213

nursing management of skin toxicity r/t external beam radiation

  • routine skin assessment
  • patient education
  • burn is not proper terminology
    • radiation dermatitis 

214

risk factors for osteoporosis

  • A - alcohol use
  • C - corticosteroid use
  • C - calcium low
  • E - estrogen low
  • S - smoking
  • S - sedentary lifestyle

+ advanced age, caucasian/asian, family hx

215

complications of fractures

  • nonunion
    • two broken pieces don't connect/heal properly
  • avascular necrosis
    • vessels sheared, reducing blood supply
  • dislocation
    • hip precautions can prevent
  • degenerative arthritis

216

fiber recipe for constipation

  • 1 cup unproccessed bran
  • 1 cup applesauce
  • 1 cup prune/apricot juice
  • 4 oz water with every serving (tablespoon)
  • fiber is not a laxative
    • will normalize stool to #4 on Bristol Scale

217

basic neurological exam

  • orientation, mentation, speech
    • higher cognitive fxns
  • pupils; EOM; facial symmetry; tongue midline; shoulder shrug
    • presence/absence of intracranial swelling or focal injury affecting cranial nerevs
  • motor strength x 4 
    • focal injury affecting motor strip or spinal cord
  • balance, coordination, gait
    • cerebellar fxn
  • mood, affect, behavior
    • frontal lobe (emotion, mood, judgment) and limbic system

218

congenital etiologities of fecal incontinence

  • imperforate anus
  • rectal agenesis 

219

pulmonary toxicity r/t chemotherapy

  • as high as 40% incidence 
  • risk factors
    • above 30; pre existing renal failure; smoker
  • etiology
    • skin & lungs lack enzyme to break down bleomycin
    • mass inflamamtion and fibrotic changes d/t free radical release
  • prevention
    • monitor (pulm fxn tests)
  • treatment - steroids

220

top five new cancer cases among women

  • breast
  • lung and bronchus
  • colon and rectum
  • uterine corpus
  • thryoid

221

palliative care vs hospice care

222

ALL morphological classification

  • L1 - small, monomorphic
  • L2 - large, heterogenous
  • L3 - Burkitt-cell type 

223

principles of cytotoxic therapy

  • chemotherapy
  • given in cycles
    • induction - induce cure or remission
    • consolidation - control for microscopic disease
    • intensification - further control of microscopic disease
    • maintenance - maintain remission (leukemias)
  • primary curative tx vs neoadjuvant (before primary tx) vs adjuvant tx (after primary tx)

224

types of chronic urinary incontinence

  • stress
  • urge/OAB - leak all the time (detrusor contracts all the time)
  • mixed
  • overflow - bladder fills up but only trickles out
  • functional
  • iatrogenic 

225

determining cancer treatment plan

  • +/- clinical presenting symptoms
  • diagnostic imaging
  • tissue biopsy
  • performance status
    • can they tolerate treatment 

226

resident-to-resident aggression

negative and aggressive physical, sexual or verbal interactions between long term care residents

227

objectives of chemotherapy administration

  • achieve maximal tumor cell kill w/o excessive toxicity
  • provide cytotoxic drugs active against heterogeneous tumors
  • avoid tumor resistance
  • avoid drugs with overlapping toxicities
  • administer according to schedule and dose determined in studies
  • administer in cycles

228

eliminate/minimize bladder irritants

  • alcohol, nicotine
  • strawberries, citrus, guava, pineapple, cranberry
  • chocolate
  • tomatoes
  • vinegar, artifical sweeteners
  • chili, spicy foods
  • tea, coffee

229

preparing patient for radiation

  • simulation
    • additional imaging; contrast; site marks; molds to keep pt in position
  • localization
    • identify anatomical structures to avoid
    • external molds or shields
  • patient position
    • same every time - immobilization

230

selective estrogen receptor modulator (SERM) for osteoporosis

  • mimics effects of estrogen without breast/uterus stimulation
  • side effects
    • leg cramps, hot flashes, blood clots

231

patient has fallen - now what

  • do not lift patient alone
  • is patient ok? pain? something broken? hit head/lose consciousness? if so, keep them there and get help
  • if not hurt, ask them to roll onto side and into crawling position
    • move slowly to nearest furniture. don't have them use you to get up
  • tell them to step up on stronger leg, use chair, and sit in chair 

232

treatment for oral mucositis

  • normal saline rinses pre/post meals
  • oral balance moisturizer
  • assess/treat thrush
    • nystatin swish and swallow
  • systemic pain control
  • oral rinses
    • lidocaine; magic mouthwash?
  • prevention
    • cryotherapy
    • palifermin (increase growth of oral mucous membranes)

233

significance of persistent cough or hoarseness as warning sign of cancer

  • lung
    • persistent cough is most frequently reported Sx
  • lung, laryngeal, thyroid
    • hoarseness

234

NSAIDs and salicylates for rheumatoid arthritis

  • pain, stiffness, inflammation
  • fever (NSAID)

235

seven warning signs of cancer

  • Change in bowel/bladder habits
  • A sore that does not heal
  • Unusual bleeding/discharge from orifice
  • Thickening or lump in breast or elsewhere
  • Indigestion or difficulty swallowing
  • Obvious change in wart or mole
  • Nagging cough or hoarseness

236

physical examination for fecal incontinence

  • perianal skin
  • prolapse
  • impaction
  • nerve innervations
    • anal "wink"
      • scratch around anus and should "wink"
      • gross estimation that S3 and S4 are intact
    • perianal sensation

237

excisional biopsy

  • removal of entire biopsy
  • breast, melanoma 

238

hemorrhagic stroke overview

  • ruptured arteries lead to intracranial bleeding
    • rapid swelling and rise in pressure
  • 2nd most common cause of stroke
  • most common cause is aneurysms, arteriovenous malformations
  • 8-15% of all 1st time strokes in US; 25% in Japan (omega 3 in fish is an anticoagulant)
  • volume of intracranial hemorrhage directly related to severity and outcome

239

patient/caregiver barriers to pain management

  • fear of addiction
  • stigma with opioids
  • fear of side effects
  • cost of medication
  • cultural beliefs
  • cognitive/language impairments

240

emotional or psychological abuse of elder

infliction of anguish, pain, distress through verbal or nonverbal acts

241

treating intracerebral hemorrhage

  • early ID and transportation
  • priority shifts from admin of thrombolytics/restoration of fxn to prevention of damage
  • maintain airway and control HTN are top priorities
    • high BP forces blood out of damaged area and makes volume of bleed that much worse
  • emergent neurosurgical consult and admission to Neuro-ICU

242

Heberden's nodes

red swollen areas in distal inerphalanges r/t osteoarthritis

243

classification of liquid tumors

  • acute vs chronic
  • cell of origin
    • leukemia
      • myeloid
      • lymphoid
    • lymphoma
      • NHL vs HL
    • multiple myeloma
      • % of plasma cells
      • CRAB critera

244

tumor classification

  • biological behavior
    • benign
    • pre-cancerous
    • malignant
  • tissue of origin
    • most tumors have some of the characteristics of the cell in which they originated

245

significance of unusual bleeding or discharge as warning sign of cancer

  • endometrial or cervical cancer
    • vaginal bleeding most frequent sign
  • breast
    • clear, milky, bloody discharge is 2nd most common Sx
  • lung
    • hemoptysis
  • bladder, renal & prostate
    • hematuria

246

trajectory of organ failure

  • occurs in 80% of older adults
  • slow, steady decline in physical functioning with frequent crises until eventual death
  • "frequent fliers" - in and out of hospital/ED
  • hard to have end of life discussions because family thinks they are getting better

247

TNM classificaton system

  • primary tumor
    • Tx - cannot be evaluated
    • T0 - no evidence of primary tumor
    •  Tis - carcinoma in situ
    • T1-4 - size and/or extent of primary tumor
  • regional lymp nodes
    • Nx - cannot be evaluated
    • N0 - no involvement
    • N1-3 - degree of involvement (number/location)
  • distant metastasis
    • Mx - cannot be evaluated
    • M0 - no distant metastasis 
    • M1 - distant metastasis present

248

hx for urinary incontinence

  • goal: clear picutre of UI and how it affects life
  • tell me about the problems with your bladder
  • how often do you lose urine when you don't want to
  • what activities/situations are linked with leakage

249

managing urinary incontinence

  • treat acute causes: immobility, drug-induced, nocturia, constipation
  • behavioral
    • PME
    • bladder retraining
    • habit training; prompted voiding

250

epidemiology of ischemic stroke

  • 87% of all strokes in US
  • 2nd most common cause of mortality; 3rd in disability
  • higher mortality in low income areas; men; black and hispanic
  • SE U.S. has disproportionate amount of ischemic stroke (Stroke Belt)
  • outcomes depend on age; initial severity of stroke; vessel affected
  • caused by same factors that cause vascular disease in rest of body (HTN, HLD, genetic, DM, atherosclerosis, obesity)

251

anatomy and contributing factors to urinary incontinence

  • Men: BPH - pushes on bladder and urethra
  • Women: menopause; atrophic vaginitis/urethritis; vaginal stenosis
    • estrogen loss
  • Men and Women: increased PVR; delay in onset of desire to void; decreased bladder capacity; change in voiding patterns
  • other risk factors
    • DM, hysterectomy, stroke, obesity, functional impairments

252

anal sphincter

consists of internal & external anal sphincter plus puborectalis muscle 

253

puborectalis muscle

  • directly innervated by S3 and S4
    • incontinence often occurs b/c S3 or S4 are impaired or pelvic muscles not working/aren't strong enough
  • sensatioin provided by receptors in muscles of pelvic floor 

254

Bristol Stool Chart

255

differentiating grief and depression at end of life

256

intracranial arterial vasculature

  • vertebral arteries are back-ups to carotids (blood flow to brain)
    • collateral circulation
  • larger arteries flow into smaller arteries
    • lower pressure to higher pressure
  • major arteries
    • anterior and posterior communicating arteries
    • middle cerebral artery

257

Rheumatoid nodules

  • sucutaneous, firm, nontender
  • usually fingers and elbow joints

258

medications for urinary incontinence

  • meds
    • urge: anticholinergic, antispasmodic
    • stress: alpha-agonist
    • estrogen for stress, urge, mixed, UTI prevention
  • surgery: stress UI, prolapse, BPH
  • devices: pessary

259

hip fractures overview

  • 20,000/year admitted 
    • most common - subcapital neck fracture r/t osteoporosis
  • 50% of seniors hospitalized with hip fractures cannot return to previous living situation
    • complicated and severe injury
    • lack of physical reserve
    • comorbidities complicate healing
    • providers don't understand what pts need to go home
  • need PT/OT assessment of home

260

assessment of fecal incontinence

  • passive - unconscious loss of stool
  • urge - inability to control impending BM
  • functional, cognitive, environmental assessments
    • can they recognize toilet? (dementia)

261

decorticate posturing

  • possible damage to
    • cerebral hemisphere
    • internal capsule
    • midbrain
  • poor prognostic indicator

262

goals of therapy for rheumatoid arthritis

  • manage pain
  • minimize loss of fxn
  • patients tend to isolate themselves b/c of embarrassment

263

rectocele

  • rectal prolapse/dropped rectum - rectum pushes through vaginal canal
  • hard to have BM b/c gets caught in pocket