exam 3 Flashcards
(353 cards)
1
Q
oliguria
A
decreased urine output, less than 400 mL / 24 hours
2
Q
anuria
A
urine output of less than 100 ml in 24 hours
Normal urinary output for adult: 30 ml / hour
3
Q
azotemia
A
syndrome that results from increased BUN & creatinine together
4
Q
polyuria
A
increased urine output, more than 2000 mL in 24 hours
5
Q
uremia
A
a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys
Manifestation of renal failure
6
Q
normal specific gravity
A
1.000 - 1.030
7
Q
range of urine ph
A
4-8
8
Q
serum creatinine normal level
A
0.2-1.0 mg/dl
9
Q
normal BUN
A
8 - 20 mg/dl
10
Q
is 50% of your kidney function is compromised, what will be elevated?
A
creatinine
11
Q
urethral stricture
A
Narrowing of urethra
Causes obstruction of outflow of urine → can lead to urine stasis and UTI
Can develop overflow incontinence
12
Q
how to tx urethral stricture (surgery)
A
urethroplasty - repair urethra
13
Q
which is worse, AR or AD PKD
A
AR - 100% of nephrons are involved
14
Q
4 common side effects of UTIs
A
Dysuria = painful when voiding
Frequency - peeing continuously
Urgency - have to go right now
Nocturia - have to go in the middle of the night
15
Q
if BUN is rising more than creatinine…
A
may not be a renal issue
16
Q
KUB films
A
kidney, ureter, and bladder x-rays
Aka flat plate of the abdomen
A to P view of what’s going on in abdomen
17
Q
when would you use cystoscopy/cystography/VCUG (4)
A
Done to diagnose bladder or urethral trauma
Done to see why frequent UTIs
Remove tumor in urinary tract
Examine enlarged prostate
18
Q
process for cystoscopy/cystography
A
Ask patient to void
Catheter
Sterile saline → fill bladder
Get pictures
19
Q
Voiding cystourethrography (VCUG) process
A
have person stand, remove saline, and watch how bladder contracts to empty
Shows if there are problems with motion of bladder wall
20
Q
do cystoscopy/cystography/VCUG require consent
A
yes
21
Q
when you remove a foley, is it normal for first void to sting
A
yes
if it stings after that, need to call provider
22
Q
causes of cystitis
A
Usually d/t infection but not always
Usually e.coli ascending urethra into bladder → infection
Can also be virus, fungus or parasites
Catheter related infections are common
23
Q
what is the most common cause of sepsis
A
cystitis
24
Q
what can cause non infectious cystitis
A
can be d/t chemo or chemical irritation
25
what is interstitial cystitis
unknown cause, not infectious
| could be an allergic response
26
how to dx cystitis
Urinalysis with culture and sensitivity
27
for chronic, recurring infections of cystitis, how do you tx
long term antibiotics
28
what is urethritis
inflammation of urethra that causes s/s of UTIs
29
in what population is urethritis common in and how do you treat them
post menopausal women, especially if sexually active
| tx with estrogen cream
30
what is urethral stricture and what type of incontinence can it lead to?
Narrowing of urethra
| Causes obstruction of outflow of urine → can lead to urine stasis and UTI and overflow incontinence
31
stress incontinence cause
Due to weakening of the bladder neck, often associated with childbirth
32
stress incontinence s/s
Incontinence when sneezing, coughing, laughing, exercising
| Small amounts leaked
33
stress incontinence tx
Pelvic floor exercises = Kegels
Spacing fluid during the day
Incontinence diary
Topical estrogen therapy for postmenopausal therapy
Reconstructive surgery for uterus or bladder prolapse
Implanted sacral nerve stimulator - reminder to kegel
Tens units
34
urge incontinence definition and cause
- Loss of urine r/t strong need/desire to urinate and inability to suppress signal for same = overactive bladder
- May be secondary to Parkinsons, MS, stroke
35
interventions for urge incontinence
Behavioral interventions
Diet therapy - stay away from caffeine, alcohol, stimulants
Drugs - anticholinergics for smooth muscle relaxation, antihistamines, etc.
Bladder training
Pelvic floor exercise
Interval training
Space fluid intake, and limit fluid after dinner
36
what causes overflow incontinence
Detrusor muscles fail to contract so bladder over extends --> Constant dribbling of urine to avoid bladder rupture = underactive bladder
Can be associated with meds
Diabetes, spinal cord injuries, MS, BPH, uterine prolapse
37
overflow incontinence interventions
Intermittent catheterization (maybe for spinal injury)
Surgery if outflow is obstructed (like BPH)
Meds - depends on cause
BPH - flomax
38
functional incontinence cause
Caused by factors other than urinary tract issues like
Loss of cognitive function
See this in Alzhemiers and other dementias but never assume dementia is the reason (could be BPH)
39
functional incontinence interventions
```
Treat any reversible causes first
Skin protection
Urine containment
Caregiver would need the urinary training - i.e. walk patient to bathroom, etc.
Condom caths at night, Diapers for women
Intermittent catheterization
```
40
mixed incontinence
We don’t always figure out the reason for incontinence
| Features of more than 1 type of incontinence
41
what is urolithiasis
Presence of calculi (stones) in urinary tract
| Majority of stones are made of calcium but not all (some can be bacterial)
42
can stones damage the lining of the urinary tract
yes
43
risks d/t urolithiasis
Retention from retained urine
Hydronephrosis - stone in kidney
Can be seen in ureter
44
what can contribute to urolithiasis
```
Metabolic defects
Immobilization
Urinary retention
Loop diuretics
Antacids, steroid therapy, fiofelan
```
45
is a high calcium diet associated with urolithiasis
no - high calcium diet should not promote stone formation
46
s/s of urolithiasis
```
Sudden onset of extreme pain
Hematuria
Oliguria
Ureteral spasm
N/V secondary to pain
Pallor and diaphoresis
Potential for shock d/t nearby SNS nerves
Potential for hydroureter &/or hydronephrosis = obstructive stone
```
47
does a stone that isn't moving cause pain
no
48
what labs/tests do you do for urolithiasis
Lab assessment - chemistries, hematology, UA
Elevated WBC - infectious process
KUB x ray can see stones
CT scan w/o contrast
49
how do you treat urolithiasis pain
Opiates, injectable NSAIDs (toradol), antispasmodics
Complementary and alternative therapies
Heat → dilation
walking helps pass the stone
50
Shock wave lithotripsy (SWL) w/ stents
| What type of sedation, how is it done, etc.
```
fluoroscopic procedure
Under moderate sedation
IV
Cardiac monitoring
Aim a shock wave at location of the stone and blast it with sound/shock wave so they can pass it
```
51
what are 2 other surgical ways to treat urolithiasis
Retrograde ureteroscopy
| Open surgical procedure (if the above and the shock waves don't work)
52
pt teaching post surgery for urolithiasis (3)
Strain urine
stay hydrated
antibiotics
53
which PKD is more common: AR or AD and when does it manifest
AD, manifests later in life
54
how many nephrons are involved in AR PKD
100% of nephrons are involved from time they are born
| Children usually die early in childhood
55
how does PKD impact the kidneys
Fluid filled cysts in nephrons → prone to rupture → pressure in kidney area
Pressure within kidney causes nephrons to become not functional
Grossly enlarged kidneys - look like grape clusters
Cysts damage glomerulus and tubules
56
where else can you get cysts from PKD (3)
Berry aneurysms
Liver cysts
Cardiac vasculature cysts
57
PKD pain: acute
when cysts rupture, sharp pain over flank, pain is worse
58
PKD pain: chronic
all the time because of cysts, pressure, discomfort
59
s/s of PKD
Distended abdomen - enlarged kidneys press on bowel
constipation
Hematuria/cloudy urine
Kidney stones are common
Nocturia & proteinuria
HTN b/c of renal ischemia → can lead to aneurysms
Edema b/c of high sodium levels (d/t renal ischemia)
N/V, anorexia
pruritis
60
what is an early sign of PKD
nocturia
61
how do you treat PKD
- treat chronic and acute pain - can needle aspirate through the back to the cyst
- antibiotics for infection
- stool softener
- BP medications
- diet therapy - increase fiber and decrease Na+
62
are ASA or NSAIDs encouraged for PKD
no
63
self teaching for PKD (3)
Take temp if feel ill
See MD for unremitting headache or visual changes (could be cyst elsewhere)
Call MD for foul smelling urine = sign of infection
64
what can Hydronephrosis, hydorturerer and urethral stricture result in
overflow obstruction
65
causes of Hydronephrosis, hydroureter and urethral stricture
```
Tumors
Stones
Trauma to renal system
Congenital defects
Scar tissue
Radiation therapy for urological cancers
```
66
how to dx Hydronephrosis, hydorturerer and urethral stricture
CT or US
67
interventions for Hydronephrosis, hydroureter and urethral stricture
Catheterization as needed
Double voiding
Monitor bladder distension - gentle palpation
Bladder scan
68
nephrostomy tube
If huge stone is obstructing - undergo fluoroscopy and drain ureter through the patients back→ reroute urine to decrease pressure
*do not have patient lie on their back
69
what to be mindful of before nephrostomy tube placement
NPO before
Clotting studies or correct if not normal before procedure
Pain control before procedure
70
how long is bloody urine expected for after nephrostomy tube placement
24 hours
71
if there is recurrence of pain after nephrostomy tube, what might that mean
tube could have been displaced
| Check urine output and report to provider
72
acute pyelonephritis: cause
Bacterial infection of the kidney
Can be primary of urinary tract Or can be obstruction
Usually a bladder infection that has ascended!
73
s/s of acute pyelo
```
Fever, chills, tachycardia and tachypnea
Flank or back pain
Abdominal discomfort
Significant N/V
May not be able to take PO antibiotics
May have urgency, frequency, nocturia
General malaise or fatigue
dehydration
```
74
chronic pyelo: 4 causes
numerous episodes of acute pyelo in the past
Stones
Neurogenic impairment of voiding
Kinked ureter
75
s/s of chronic pyelo
HTN!
Very dilute urine/nocturia - can’t concentrate
hyponatremia, hyperkalemia, acidosis
76
tx for chronic pyelo
Urinary diversion surgery
Unkink ureter via surgery
Antibiotic but might be long term
77
what is the leading cause of ESRD
diabetic nephropathy
78
what is the 1st manifestation of diabetic nephropathy
albuminuria
79
how do you prevent diabetic nephropathy
Manage glucose levels!
| Check eyes yearly! Retinal changes parallel renal changes
80
how to tx diabetic nephropathy
Avoid nephrotoxic agents
Avoid dehydration
Might need to reassess insulin requirements because failing kidneys can lead to hypoglycemia
81
BPH population
Men, age 50, decrease in male hormones, Increase in DHT
82
physiologic manifestations of BPH
Detrusor muscle hypertrophies - can’t contract effectively
| Prostate swells and puts outflow obstruction on urinary tract
83
what can BPH lead to
```
Leads to UTI d/t retained urine
Acute or chronic urinary retention
Kidney stones, bladder stones
Hydroureter or hydronephrosis
Urinary overflow incontinence → dribbling
Can go into renal failure
```
plus lower urinary tract symptoms (hesitancy, difficulty maintaining stream, decreased force of stream, dribbling, hematuria, nocturia, etc.)
84
what is severe BPH
Higher levels of protein made by androgen related gene
| bladder damage and more renal involvement
85
is there a link b/w BPH and ED
Coexist together in people with BPH
86
tx for BPH
Lifestyle: more frequent intercourse
meds:
- 5 alpha reductase inhibitors (procar)
-alpha antagonists (flomax) (don't take w/ viagra!)
others: saw palmetto, botox, viagra (in testing)
87
PSA level less than 4 is..
normal
88
PSA greater than 10
associated w/ prostate cancer
89
should labs be drawn before or after digital exam
Labs need to be drawn and sent off before digital exam
| If not before, you can have falsely elevated PSA
90
general characteristics of surgery for BPH
All can be done outpatient
Local anesthesia
No foley, few complications
Removes excess prostate tissue
91
what is thermotherapy and what is it used for
BPH
destroy tissue and stents are placed to keep prostate patent
ex: tuna, tunt, and Ilc
92
when would you use more traditional therapies for BPH
Used when other complicating issues are involved
| Acute urinary retention, hematuria, chronic UTIs, high urinary residuals, hydroureter, hydronephrosis
93
Transurethral resection of the prostate = TURP
Excess prostate issue is removed via endoscope under epidural or spinal anesthesia
Stricture, might need repeat surgeries
No surgical incision line
Long term sexual function should not be affected
94
adverse effect of the TURP
Can have retrograde ejaculation for some time → into bladder
95
2 other surgeries for BPH w/ other factors
TUIP - transurethral incision of prostate
| Open prostatectomy. -Entire prostate is removed under general
96
after BPH surgery, how long do you have CBI for
24 hours
97
characteristics of foley for post BPH surgery
```
3 way catheter w/ 30-45 ml balloon (Normal foley = 10ml balloon)
Tape to leg
Run irrigant (NS) into bladder
```
98
how often should you look at urine outputs post BPH surgery while foley is in
hourly
| need to get out what you've put in plus a little more!
99
what is the most common cancer in men
prostate cancern, slow growing, predicatble
100
when do you screen for prostate cancer
over 50, annually
101
risk factors for prostate cancer
Diet high in animal fats
Age
Vietnam vets d/t agent orange
102
what is EPCA-2
early prostate cancer antigen
| New serum marker just for prostate cancer
103
prostate cancer surgery: types and indication
Can be indicated if cancer is resistance to radiation
MIS - usually minimally invasive
Open radical surgery
Laparoscopic radical prostatectomy (LRP)
104
what are complications post radical prostatectomy
Usually sterile after
Urinary incontinence - might be permanent
Impotence (ED) - lasts 3-18 months
105
what are non surgical options for prostate cancer
Radiation seed implants
External radiation
hormonal therapies - androgen deprivation
chemotherapy
cryotherapy —> can lead to ED and incontinence
106
what are precautions for radiation seed implants
Anyone under 3 should not be in lap
| Less than 5 mins per day per child
107
what are s/s of androgen deprivation therapy
LH releasing hormone agonists to release more testosterone
| s/s: onset of ED, hot flashes, gynecomastia
108
what is a fistula and where is it located
Attaching artery to vein
| forearm, upper arm or thigh
109
what to know about a AV fistula, graft or shunt
No BP readings in the affected extremity
No venipuncture
Palpate for thrills; auscultate for bruits
Assess distal pulses - want to ensure good blood flow
Encourage routine ROM of extremity
Check for bleeding at the site
Assess for manifestations of infection
Teach patient how to guard their graft/shunt
110
for patients w/ renal failure, how do you manage excess fluid volume
Daily weights!
Fluid restrictions
Assess for overload/crackles and JVD
111
what are dietary considerations for renal failure patients
Protein - restrict as renal failure worsens
Fluid (urine output + 500 ml/day usually for all input)
K+
Na+ - limit b/c of thirst and HTN
Phosphorus - limit
Water content of foods
112
does hemodialysis or peritoneal dialysis have more dietary restrictions
hemodialysis
113
what are neuro changes in the elderly
Intellect does not decline with age
Perceived changes are related to drug interactions, less sleep
Response time - can take longer for older adults to learn or process something new
114
what causes memory changes in the elderly
Decreased number of neurons
Brain size atrophies
Recent memory is less clear than distal memories
115
sensory changes in the elderly (3)
Touch sensation is diminished with age
Hearing is less acute
Pupils are smaller in general - need more light to see
116
motor changes in the elderly (4)
Movement is slower
Balance changes
Coordination changes
Postural changes
117
before doing a neuro check on a patient, what must you know
their baseline
118
what could cause acute changes in mental status
infectious process elsewhere in the body
119
what is the first sign CNS function has declined
changing LOC
120
stuporous characteristics
can be roused with vigorous painful stimuli
121
comatose
cannot increase LOC no matter what
122
PERRLA
Equal, round, reactive to light and accommodate
123
what can alter the shape/appearance of pupils
```
Surgeries
Eye meds
Cataracts
Dry eye syndrome
Traumatic injury
```
124
what is a late sign of neuro deterioration
can have dilated pupil or non reactive pupils
125
lowest score of glasgow coma
3
126
highest score of glasgow coma
15 = higher functioning
127
when do you test response to painful stimuli
GSC score of less than 6
128
1st way to get test response to painful stimuli
use normal voice, then go to loud voice then give gentle tap or shake (not for trauma pt)
Supraorbital pressure: Feel ridge of eye socket - gentle pressure
Trapezius squeeze - thumb in juncture of neck and chest and squeeze
Sternal rub w/ knuckles - should be last
129
2nd way to test pain response
peripheral pain assessment
Test all extremities for responsiveness
Press pencil on cuticle
130
how to assess motor function
MAE - moving all extremities
Assessment of strength in each extremity
Grasps
Push on the gas, pull your toes up to toward your head
131
how to test sensory function
Sharp vs dull
| 2 point discrimination - close their eyes and ask them to tell you which toe you’re touching
132
what does a CT look at
w/ or w/o contrast
Contrast is iodinated
Looks at structural changes
133
what is a magnetic resonance spectroscopy used for
alzheimers
| strokes
134
what is an MRI used for
Looks at soft tissues
Also MRA/MRV
Uses gadolinium (not iodine)
135
what is a PET scan used for and how do you prep a patient for it
Malignancies
Cerebral blood flow
Prep:
- NPO 6 hours before
- Should not get insulin 6 hours before and no metformin to avoid lactic acidosis
136
what does an EEG do (6)
```
Evaluate brain activity
Determine site of seizure origin
Diagnose sleep disorders
Monitor activity during anesthesia
Determine brain death
Degenerative brain disease
```
137
how to stimulate brain for EEG
Photo stimulation
Auditory stimulation evoked potential to assess hearing loss or auditory nerve damage
Somatosensory evoked potential - delivery tiny shocks to check for nerve degenerative disease/disorders
138
what are migraines
Associated w/ spasm of cerebral arteries
Chronic, episodic disorder, usually 4-72 hours
Pain usually worse behind one eye or ear
139
if someone has a migraine new onset after 50
have neuro imaging done
140
s/s of migraine
Unilateral, fronto temporal throbbing pain, with phonophobia, photophobia, N/V, sensitive scalp
141
what are triggers for migraines
Dietary - cheese, chocolate, nuts, caffeine, yeasts, smoked foods, artificial sweeteners, red wine
Physiologic changes: sudden drops in blood glucose, skipping meals, anger, mood changes, fatigue
Meds: missed medications, nifedipine, nitroglycerin, estrogens
Big changes in barometric pressure and weather
142
stage 1 of migraine: prodrome
mood changes, cravings, behavioral changes
143
stage 2 of migraines: aura
warning sign that something is coming
Visual changes associated with it (i.e. flashing lights, double vision)
Paresthesia sometimes
Phonophobia, photophobia
144
stage 3 of migraine: headache
wanes in intesnity over time
145
stage 4 of migraine: post prodrome
Exhaustions, muscle pain, irritation, no appetite
146
how to relieve pain w/ migraines
ice packs
head elevated
dark room
147
meds for migraines
NSAIDs, tylenol, or OTC preps w/ caffeine
Ergotamine derivatives - nasal sprays or injections (DHE or cafergot)
Triptans - Imitrex, Relpax, Zomig, Maxalt, Frova
Opiates and barbs
Antiemetics and antidpressants
148
preventative therapy for migraines and when is it indicated
more than 2x in a week
Avoid triggers: Eating regularly, rest, diet
Beta blockers (timolol, propranolol)
Antiepileptics (topamax, depakote)
149
other therapies for migraines (CAMs and herbs)
Acupuncture
Massage
Willow, ginger, valerian, lavender, peppermint
150
when do cluster headaches onset
Onset with relaxation, nap or REM
| -Seasonal
151
how long do cluster headaches last
30-90 minutes but recur q 8-12 hours for 4-12 weeks followed by a period of remission (9-12 months)
152
s/s of cluster headaches
Excruciating, boring, non throbbing frontal or oculo temporal pain which may radiate
Pt may sit and rock or pace during episode
Ipsilateral tearing of eye and diaphoresis on one side
Rhinorrhea
Ptosis - drooping eyelid
Eyelid edema and bilateral pupillary miosis (constriction)
N/V
153
tx for cluster headaches
Triptans, ergotamines, antiepileptic drugs
Verapamil, lithium, corticosteroids, and OTCs (melatonin, glucosamine)
Oxygen mask x 10-15 mins during headache to decrease cerebral blood flow until headache gets better
Sunglasses, avoid direct light
avoid precipitating factors
154
surgery for cluster headaches
last resort
Deep Brain stimulation (DBS) - stimulate subthalamus and implanted unit
Percutaneous stereotactic rhizotomy (PSR) - needle into trigeminal nerve
155
what is the most common chronic headache
tension headaches
156
s/s of tension headaches
-present w/ neck, shoulder, muscle tenderness
-bilateral pain at base of skull and forehead
-lasts > 4 hours
- different presentations
can also have N/V, photophobia and phonophobia
157
how to tx tension headaches
NSAIDs, ASA, muscle relaxants, OTCs
| Prophylaxis is similar to migraines
158
what is a seizure
abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain
is A SYMPTOM
159
epilepsy
chronic disorder with recurrent unprovoked seizures; may be caused by abnormality in electrical neuronal activity and/or imbalance of neurotransmitters
160
what can trigger epilepsy
```
Physical activity
Stress
Fatigue
Alcohol
Caffeine
Specific food intolerances (wheat, soy, sugar, dairy)
Medication intolerances
Flashing lights (strobe)
```
161
primary/idiopathic epilepsy
Not associated with anything identifiable
162
Secondary epilepsy
d/t another disorder like...
Metabolic disorders
heart disease
Brain lesions/tumors, stroke or head injury
Acute alcohol withdrawal or substance abuse
163
generalized seizures
involve entire brain and both hemispheres
| tonic, clonic, tonic-clonic, absence, myoclonic, atonic
164
tonic seizure
abrupt increase of sig muscle tone
| Stiffening of the muscles
165
clonic
rhythmic jerking of all extremities
166
tonic-clonic
both tonic and clonic
167
absence seizure
brief, blank stare, no postictal period, (avg 10-30 seconds), automatisms (like lip smacking, or patting)
168
myoclonic
brief, involves extremities either singly or in groups, symmetric or asymmetric
Can happen after brain injury
169
atonic
drop attack, sudden loss of muscle strength
| Resistant to drugs
170
postictal period characteristics
pt is confused, disoriented, silent, awaken over time, gargled speech, emesis
171
partial seizures
Less responsive to treatment
Begin in one cerebral hemisphere (can progress to general)
2 types exist: complex and simple
172
complex partial seizures
```
(psychomotor):
Lose LOC
May have automatisms
Unaware of environment
Might wander
Involves temporal lobe
```
173
simple partial seizures
```
Remains conscious
May have aura
May have deja vu phenomenon
May have unilateral limb movement
Automatisms potentially
Autonomic symptoms - increased HR, flushing, GI discomfort
Fear, anger, sadness
Difficult speech
Hallucinations but aware it's a hallucination
```
174
unclassified seizures
no known reason, don’t fit into category, idiopathic
| Half of all seizures
175
drug drug concerns w/ seizures
antibiotics will alter anticonvulsant levels
more than one anticonvulsant will affect another
Ginkgo decreases anticonvulsant level
176
drug food concerns w/ seizures
Phenytoin blocks absorption of folic acid
| Folic acid, vitamin D - can be interfered w/ by anticonvulsants
177
can you administer warfarin and phenytoin - what does warfarin do to phenytoin
no - warfarin Increases serum half life of phenytoin
178
what should you have in the room of an epileptic pt
airway, suction and O2 available, IV access, side rails up and padded
No tongue blades or restricting movement!
179
seizure mgmt
```
Stay with pt
Time seizure
Observe
Document
Prevent injury
Bed in lowest position
Prevent aspiration
Contact MD
```
180
pt education for seizures
Need to take meds daily even if seizures stop
No ETOH can interfere w/ medications & lowest seizure threshold
Medic alert bracelet
Employment concerns - do they put others at risk
Driving - may have to be seizure free for a specific amount of time to get license back
Acceptance
Family should be involved as to what pt. can and can’t do
181
parkinsons
progressive neurodegenerative disease affecting motor ability
- cause: exact cause unknown, but suspect combo of environment and genetics (maybe well water?, over 40, decreased estrogen levels, exposure to chemicals or heavy metals)
- can be secondary to other things
- involves dopamine and NE loss
182
early signs of parkinsons (3)
Loss of sense of smell
Constipation
Sleep disorders
183
4 cardinal signs of parkinsons
1. tremor at rest
2. Rigidity - muscles are stiff and don’t fully relax
3. problems with motor and fine movement: Akinesia or bradykinesia
4. Postural instability: Freezing gait while walking
184
stage 1 of parkinsons
Initial presentation - mild symptoms, unilateral and one limb involved, minimal weakness w/ tremors
185
stage 2 of parkinsons
Mild parkinson’s disease - bilateral limb involvement, mask like face, slow shuffling gait
186
stage 3 of parkinsons
Moderate - postural instability, increased difficulty with gait, need cane or walker
187
stage 4 of parkinsons
Severe - akinesia and rigidity of muscles
188
stage 5 of parkinsons
Dependent on caregiver for everything - can’t perform ADLs
189
s/s of parkinsons
muscular rigidity, change in facial expression, difficulty chewing, swallowing, uncontrolled drooling, increasingly cognitively demented, can’t initaite volutnary movemements, orthostatic hypotension, perspiration
Forward tilted
Reduced arm swinging
190
goal of tx for parkinsons
improve mobility for self care
191
medications for parkinsons
```
Anticholinergic drugs for tremor (Cogentin - helps move but doesn’t help cognitively)
Dopamine agonists
levodopa/carbidopa (take w/ meals)
Bromocriptine (parlodel)
Amantadine (symmetrel)
Tasigna - tyrosine kinase inhibitor
COMT inhibitors
```
192
concerns for parkinsons meds
Hallucinations
Over time, less effective
Doses have to be reduced over time b/c AE gets so bad
Medications have to be changed over time
“Drug holiday” and then restart at lower dose
193
ways to manage parkinsons
exercise and ambulation for mood and mobility
need thickened liquids so they don't aspirate
communication boards or speech therapy
psychosocial support
surgery as a last resort - deep brain stimulation or stereotatic pallidotomy
194
dementia
syndrome of slowly progressive cognitive decline. Pt is chronically confused.
Most common dementia (60%) is Alzehimer’s disease
Second most common (20-25%) is multi-infarct dementia
195
delirium
acute state of concussion which is reversible. Often seen in patients who are in an unfamiliar setting. Up to 50% of older pts who are hospitalized experience this.
May have physical and emotional components as well as cognitive
196
hyperactive delirium
may climb out of bed, or become agitated, restless and aggressive
197
hypoactive delirium
quiet, apathetic, withdrawn
198
mixed delirium
may have a combo of both hyper and hypo manifestations
199
unclassfiable delirium
cannot fit into any category
Can be d/t medications, infection, electrolyte imbalance, fecal impaction/diarrhea, hypoxia, nutritional deficiencies, relocation, major loss or disorders of any system
200
nursing interventions for delirium
Assess patient with Confusion Assessment Method or similar tool
Verify pt’s baseline LOC with family/facility
Provide for pt safety
Speak in calm voice
Frequently re-orient pt
Provide with a fidget instrument
Have family provide a familiar item to patient
201
lumbosacral back pain
Lower back pain
- pain d/t muscle strain, spasm, ligamentous injury, spinal stenosis, spondylothesis
- can be d/t herniated nucleus pulposus = herniated disk, bulging disc
202
s/s of lumbosacral back pain
```
Sciatica
Continuous acute pain
Altered gait
Vertebral alignment
Paresthesia
Change of position is painful
```
203
how to do you dx lumbosacral back pain
MRI or CT
204
nonsurgical mgmt for lumbosacral back pain
Standing or lying rather than sitting
Williams position for comfort - lying down with knees to chest
Firm mattress
Exercise
Drug therapy
Heat and ice therapy
Diet therapy - more than 10% overweight - losing weight will help
Other pain relief measures ie TENS, ultrasound
CAMs - acupuncture, music therapy, bean bags you can heat
205
surgical mgmt of herniation
Minimally invasive - percutaneous laser disk decompression
Diskectomy and laminectomy - open procedures
Spinal fusion may be done with open procedures if unstable
206
risks for surgical mgmt of spine herniations
```
Nerve injury
Discitis
Dural tears
Infection
Chronic pain d/t nerve injury
```
207
where is cervical neck pain usually
Herniation of cervical disk, usually laterally
| Usually C5 -C6
208
how does cervical neck pain present
Radiating pain with neck movement
Headache
Numbness in arm
209
how do you dx cervical neck pain
MRI
210
surgery for cervical neck pain
anterior cervical disk, resection
| Concern about swelling and bleeding for airway, swallowing
211
post op mgmt for herniation surgery
```
Distal neurovascular checks
Check patient’s ability to void
Pain control
wound/dressing checks
Positioning and mobility
Check sensation and mvmt
Log roll
```
212
MS
- chronic autoimmune disease affects the myelin sheath and conduction pathway of the CNS
- characterized by periods or remission and exacerbation
- inflammatory response results in demyelination of sheath, and decreased transmission of nerve impulses
213
what can trigger ms
onset: virus, genetic predisposition, colder climates
exacerbations: Fatigue, stress, overly exerting oneself, temp extremes
214
s/s of MS
Weak, fatigued, and activity intolerant
Muscle spasms at night, intention tremors in the day
Tinnitus and vertigo
Dysmetria
Visual changes - blurred or double vision, ↓ acuity, nystagmus
↓ hearing ability
Hypalgesia - ↓ ability to feel pain
Bowel or bladder dysfunction
May have personality and behavioral changes, poor decision making, attention loss
Cognitive changes appear later in disease
215
relapsing/remitting MS
most common
Mild to moderate form of dz, decreasing fxn and development of new symptoms
Symptoms for weeks to months but can return to baseline functional level
216
Progressive-relapsing MS
Frequently relapse, only partially recover, no remission
| Never return to baseline
217
primary progressive MS
Slowly deteriorate neurologically over time, no remission
| Doesn’t have acute exacerbations
218
secondary progressive MS
Starts as relapsing-remitting but progressively deteriorates
219
tx for MS
Treat symptoms and slow progression
Biological response modifiers: Interferon beta-1a, Tysabri (*Significant side effects)
Immunosuppressives (steroids and antineoplastics)
Steroids
Antispasmodics
Adjunctive therapy
220
is Guillain barre more common in men or women
women
221
what kind of disorder is guillain barre
Acute autoimmune disorders, follows acute illness
222
s/s of GB
Varying degrees of motor weakness and paralysis
| Starts in legs and spreads to arms and upper body
223
GB presentation
```
Ascending symmetric muscle weakness
Decreased or absent DTRs
Respiratory compromise may be a problem
Paraesthesias and pain, muscle cramping
Labile blood pressure
Tachycardia and arrhythmias
Facial weakness and dysphagia
Diplopia
Bowel and bladder control issues in some
Cerebral function or pupillary signs are not affected
```
224
are Cerebral function or pupillary signs affected in GB
no
225
tx for GB
plasmapheresis to remove antibodies
Immunoglobulin (IVIG) - lessens immune attack on nerve system
NO STEROIDS
226
GB outcomes
highly variable - can be months or years until recovery
| Usually have residual muscle weakness up to 3 years later
227
myasthenia gravis (MG)
Chronic autoimmune disease of neuromuscular junction
228
characteristics of MG
fatigue and weakness
Primarily in muscles innervated by cranial nerves, skeletal and respiratory muscles
Progressive paresis of affected muscle groups partially resolved by resting
229
cause of MG
formation of autoantibodies to Ach receptors
230
complication of MG
thymus tumor
| rare
231
how does MG affect the eyes
Ocular palsies or ptosis
Diplopia
Weak or incomplete eye closure
232
s/s of MG
```
Resp distress
Facial expression change
Fatigue and poor posture
Speech change
Difficulty chewing
Limb weakness
Bowel and bladder function
Muscle weakness worsens when patient is fatigued
Decreased sense of smell and taste
```
233
why is eye protection imp for MG
they cannot close eyes well → dryness, abrasions
| Artificial tears, lubricant gels at night
234
drugs for MG
Cholinesterase inhibitor drugs - drugs that include anticholinesterase drugs for increased muscle strength (Mestinon - pyridostigmine)
Immunosuppressants to decrease immune response: Chemo & steroids
IVIG (block harmful antibodies)
Plasmapheresis (to remove harmful antibodies)
235
when should ACHE inhibitors be given
Administer within an hour before eating and on time
236
Myasthenic crisis and tx
exacerbation of symptoms caused by undermedication of anticholinesterases
Tx: Tensilon given IVP
237
Cholinergic crisis and tx
acute exacerbation of muscle weakness caused by overmedication of anticholinesterase drugs:
Tx: pt. Would not improve after Tensilon → give atropine IVP (antidote to tensilon)
238
tensilon test
diagnostic test used to evaluate myasthenia gravis, which is a neuromuscular condition characterized by muscle weakness. The test involves an injection of Tensilon (edrophonium), after which your muscle strength is evaluated to determine whether your weakness is caused by myasthenia gravis or not.
239
how long does improvement from tensilon last
5 mins
240
priority nursing mgmt for MG
maintain adequate resp function
241
what can exacerbate MG
```
Infection
Stress
Heavy physical exercise
Surgery
Sedatives or analgesics, enemas, cathartics
```
242
what causes Facial Paralysis/Bell’s Palsy (CN and virus and who do you see it in?)
```
Acute inflammation of 7th cranial nerve
r/t dormant HSV-1 virus
Unilateral facial muscle paralysis
See in diabetics
Peaks in 48 hours
```
243
medical mgmt of facial paralysis/bells palsy
Steroids (prednisone)
Analgesics for discomfort in face
Antivirals (acyclovir) not consistently
Anticonvulsants (neurontin)
244
other mgmt for bells palsy/facial paralysis
Protection of eye
Nutrition
Massage, warm, moist heat, facial exercises
245
can facial paralysis/bells palsy be permanent
yes
| Most patients fully recover within a few weeks but not all, can be permanent
246
bone changes with aging (3) and result
↓ bone density
Synovial joint cartilage less elastic
Muscle tissue atrophy
Result: ↓ coordination loss of strength, gait changes
247
effusion
collection of fluid in a joint
248
serum calcium normal
9.0-10.5
249
serum phosphorous normal
3.0-4.5
| inversely related to Ca
250
serum alkaline phosphatase normal
30-120
| elevated in bone cancner
251
what muscles enzymes elevate in response to muscular damage
CK and LDH
252
osteoporosis
Disease of demineralization of bones
| Continue to break down but not rebuilding
253
primary osteoporosis
Post menopausal w/ women
| r/t to decreased estrogen
254
secondary osteoporosis cause
```
corticosteroids, alcohol, heparin, antidepressants, anticonvulsants, high levels of exogenous thyroid hormone
Other conditions:
Hyperthyroidism, hyperparathyroid and adrenal gland
Prolonged immobilization
Uncontrolled DM
Cushing’s
Metabolic acidosis
RA
Marfan’s
Cirrhosis
Bone cancer
Low vit D or low Ca levels
Carbonated beverages
Caffeine and tobacco smoke
Exercissive exercise in females
```
255
risk factors for osteoporosis
```
Women
Age >60
Family hx
White or asian race
Thin, lean body type
Low lifetime Ca intake
Estrogen deficiency
Smoking history
High alcohol intake
Lack of physical exercise or immobility
```
256
drug therapy for osteoporosis
```
HRT
Parathyroid hormone (forteo)
Ca supplement + vitamin D
Biphosphonates (Boniva, Fosamaz, Actonel)
SERMs (evista)
Calcitonin
```
257
how does PTH help treat osteoporosis
increases bone density and strength, decreases osteoporosis
258
diet therapy for osteoporosis
```
Adequate protein, Mg, Vit K, trace minerals
Minimize alcohol and caffeine
Vit C and iron
Calcium
Dietary consultation
```
259
what is important for osteoporosis
fall prevention
260
osteomyelitis: causes
Bacterial, fungal, viral
Cyclic process in bone ischemia/abscess/necrosis
```
Bacteriemia of any origin
Poor dental hygiene or gum disease
Non or penetrating trauma/bone necrosis, puncture wounds
Animal bites
Bone surgery
```
261
acute osteomyelitis: s/s
```
Fever > 101F
Localized swelling
Erythema, tenderness of area
Bone pain is constant, localized, pulsating, worse w/ movement
WBCs ↑
```
262
chronic osteomyelitis s/s
```
Ulceration of the skin
Sinus tract formation
Localized pain
Drainage from affected area
WBCs may be normal
```
263
drug therapy: osteomyelitis
prevention = best option
prolonged antibiotic therapy
hyberbaric o2 therapy
264
surgical therapy: osteomyelitis
Debridement of necrotic bone (sequestrectomy)
Bone grafts or bone segment transfers
Muscle flaps
amputation
265
what are signs of neurovascular compromise
is an emergency!
```
Pain intractable
Paresis or paralysis of extremity
Paresthesias
Pallor
Pulselessness
```
266
types of fractures
```
Complete or incomplete
Closed (simple) or open (compound)
Displaced vs. nondisplaced
Comminuted (fragmented)
Pathologic (spontaneous) d/t to another disease process
Stress (fatigue) fracture
Compression
```
267
how long can bone healing take
6 weeks - 6 mos
268
For assessing fractures of the shoulder and arm
Sitting upright
| Support affected arm to promote comfort
269
For assessing distal areas of the arm:
Assess in supine position
270
Fractures of lower extremities or pelvis
assess in supine
271
musculoskeletal assessment
```
Observe for change in bone alignment
Alteration in the length of extremity
Rotation of a limb
Change in bone shape
Pain w/ mvmt/inability to move
Decreased ROM
crepitation/ecchymosis/swelling
Amount of soft tissue damage
```
272
EBL: ankle fracture
250-1000 ml
273
EBL humerus fracture
500-1500 ml
274
EBL elbow fracture
250-750 ml
275
EBL radius/ulna fracture
250-500 ml
276
EBL tibia/fibula
250-2000 ml
277
EBL femur
500-3000 ml
278
EBL pelvis
750-6000ml
279
fat embolism syndrome and s/s
```
Syndrome resulting from release of fat globules into bloodstream from yellow marrow
First: altered LOC
Resp distress
Tachycardia, tachypnea
Fever
Chest pain
petechiae
```
280
nonsurigcal mgmt: fracture
Early immobilization for best outcomes
Closed reduction and immobilization
Splint, bandage, cast, traction
Neurovascular checks hourly for 24 hours then every 4-8 hours as needed
Elevated injured extremity above level of the heart
Apply ice on/off for the first 24-48 hours
Watch for signs of Acute Compartment Syndrome
281
what does eearly immobilization of an injury do
decreases pain, and negative outcomes
282
complications of rigid devices
Infection
Circulation impairment
Peripheral nerve damage
Complications of immobility
283
Open reduction and internal fixation = ORIF
Direct visualization
Permits early mobilization
Hardware may need to be removed in the future
284
external fixation (EF)
self drilling pins implanted in bone, held in place by an external metal frame to prevent bone mvmt
285
Types of hip fracture (2) and how to tx
Intracapsular (inside joint capsule of hip) vs. extracapsular (outside joint capsule)
Tx by ORIF usually
-Allows older client to get out of bed sooner
-May involve rod, pins, fixed plate or a prosthesis
286
Is surgery required for a Non weight bearing pelvic fracture
surgery is not required
287
weight bearing pelvic fracture
involves multiple fractures or pelvis or pelvic ring itself - will need ORIF or EF
May not be able to bear weight for 12 weeks
288
second most common cause of death from trauma
pelvic fracture
289
negative nitrogen balance and why it's important
delays healing!
protein breakdown exceeds protein anabolism (buildup)
When trying to heal, metabolism increases - might break down nonessential organs and tissues
Healing won't occur if negative nitrogen balance occurs
290
kyphoplasty
insert bone cement to restore
| used for compression fractures of the spin
291
vertebroplasty
for compression fractures of the spine
| Balloon catheter into vertebral body to restore height of vertebrae
292
how to deal with traumatic amputations
Digit or part is wrapped with cool, dry cloth and just moistened with NS or bottled water
Placed in a sealed plastic bag which is placed in ice water
293
when is surgical amputation indicated
d/t disease
294
complications from amputations
```
Hemorrhage
Infection
Phantom limb pain
Problems associated w/ immobility
Neuroma
Flexion contracture
```
295
neuroma
cluster of nerve cells that grow after amputation
296
what is phantom limb pain like
burning, crushing, cramping
297
how to treat phantom limb pain
Opioids not as effective for PLP
| Tx: calcitonin (IV infusion 1st week post op), beta blockers, anticonvulsants, antispasmodics
298
levels of amputation
```
Above knee
Below need
Mid foot amputation
Syme amputation - top of the foot below the leg
Toe amputation
```
299
what is rheumatology
study of conditions or disease involving musculoskeletal system
300
characteristics of osteoarthritis
```
Weight bearing joints and hands/feet
Not systemic
Not inflammatory
Most common arthritis
Nodal (involving hands)
Non nodal (no hands)
```
301
primary osteoarthritis
idiopathic
| Triggered by age, obesity, genetic factors, smoking
302
secondary osteoarthritis
```
caused by something else
Other metabolic disorders (ex: DM)
Hemophilia
Sickle cell
Motor vehicle accidents
```
303
manifestations of osteoarthritis
```
Chronic pain
Loss of function d/t loss of cartilage
Not symmetrical
Not bilateral
Not progressive to other parts of the body
```
304
will lab tests be normal or abnormal for osteoarthritis
normal
305
what would pain be like early in osteoarthritis
Pain with mvmt
| No pain in rest
306
what would pain be like late in osteoarthritis
May not have pain relief when activity stops
307
how would pt describe osteoarthritis pain
pain radiates down extremities
| crepitus
308
Herberden’s nodes (DIP)
distal joint nodules
309
bouchard's nodes
proximal nodules
310
osteoarthritis: pt lived experiences
```
Perm lifestyle changes
Pain, muscle spasm, crepitus
Quality of life changes
Role change
Body image and self esteem changes
Immobility and joint enlargement
Inflammation can result if synovitis has developed
Behavior changes: anger, depression
```
311
heath promo for osteoarthritis
```
Keep weight WNL
Limit activities that stress the joints
Shoes
Avoid repetitive activities
Avoid risk taking activities
Stop smoking
```
312
drug therapy for osteoarthritis
OTCSs, Rx, injectables
| Tylenols, NSAIDs, Cox 2 inhibitors, antispasmodics, hyaluronate, steroids, lidocaine patches, topical salicylates
313
is heat or cold better for osteoarthritis
heat
314
how to manage post op total joint arthroplasties
H&H every 4 hours
keep pt midline
hip: prevent dislocation w/ riser and abduction pillows
knee: CPM machines to maintain mobility, to decrease risk of scar formation or clots
315
CIs for osteoarthritis surgeries
Severe osteoporosis
Active infection
Uncontrolled DM
316
osteotomy
Part of bone is resected to correct bone or joint deformity
Less invasive
Endoscopic
317
Q ball
pinned to pt gown, filled w/ topical anesthetic - inserted by tube into surgical site and slowly released
*under osteoarthritis section
318
how to prevent dislocation
No leg crossing, no hip flexion, use toilet risers
| Progression of activity - up and out of bed
319
RA
A chronic, systemic, progressive autoimmune process that destroys primarily the synovial joints
Inflammatory process!
Autoantibodies = RF
Affects synovial and other tissue anywhere in the body
320
early RA disease s/s
```
Fatigue
Morning joint stiffness, swelling, pain
Anorexia and small weight loss
Low grade fever
Symmetrical and bilateral in multiple joints (Usually upper body first)
Joint inflammation
```
321
late RA disease s/s
Joint deformities
Moderate to severe pain + morning stiffness
Exacerbations: Moderate to severe weight loss, Anorexia, Fevers, Extreme fatigue, Peripheral neuropathy and paresthesias
Vasculitis (Ischemic skin lesions)
322
lab test for RA
```
CBC, anemia, increased WBCS
RF
Antinuclear antibody
ESR
Serum complement (C3 and C4); decreased usually
```
323
RA respiratory complications
Pleurisy
Pneumonitis
Fibrotic lung disease
Pulmonary HTN
324
RA cardiac complications
Pericarditis
| Myocarditis
325
RA opthalamologic complications
Iritis or scleritis
326
arthocentesis
```
Aspirate of synovial fluid
Evaluated for RF, WBCs, etc
Local anesthesia only
Ice and rest the joint for 24 hours
Tylenol
```
327
RA psychosocial issues
Depression, frustration, helplessness, isolation
Reality based fears b/c they will be dependent
Quality of life issues
328
drugs for RA
NSAIDs
DMARDs
biologic DMARDs to decrease inflammation
glucocorticoids (steroids)
329
3 other treatments for moderate to severe RA
Narcotic analgesics
Nonpharmacologic: heat and cold
Plasmapheresis
330
goal of RA therapy?
Promotion of self care to limit the patient’s abilities - May lose fine motor skills first
Mgmt of fatigue
Enhanced body image
Teaching
331
DLE
discoid - involves skin
332
population most commonly impacted by SLE
More common with women 15-40 y.o onset
333
SLE characteristics
autoimmune
Chronic, progressive, inflammatory connective tissue disorder
Can be fatal if not treated
Major organ systems may fail over time - kidney failure is leading cause of death
334
SLE manifestations
```
Characteristic butterfly rash - can see face or elsewhere, Sun exposed areas
Alopecia - head and body
Polyarthritis - can be seen early stages
Polymyalgia - muscle aches everywhere
Joint inflammation
Osteonecrosis
```
335
why can SLE result in osteonecrosis and where?
can be side effect b/c of steroids - lack of oxygen and blood flow
Hip or tibia
336
DLE manifestations
round, scarring lesions only - can be seen in sunlight or UV
337
complications of SLE
```
Pleural effusion or pneumonia in 50%
Pericarditis - most common cardiac complication
Abdominal pain from multiple etiologies
serositis = peritoneal involvement
Lymphatic enlargement
Raynaud’s phenomenon
Paresis
Seizures
Migraines
Peripheral neuropathy
Marrow involvement - anemias, thrombocytopenia, pancytopenia, leukopenia
Psych issues
```
338
how to assess for DLE
skin biopsy
339
SLE lab assessments
```
VDRL = can have false positive
anti-Ro, anti-SS- a (or - b), anti DNA
Higher titers w/ SLE but not diagnostic
*Anti nuclear antibody test (ANA)- more consistent with SLE
ESR rate might be elevated
CBC
RF might be drawn
```
340
how to tx DLE
topical cortisone and hydroxychloroquine (plaquenil)
| Prevents further skin lesions
341
how to tx SLE
Aggressive steroid therapy until remission
Hydroxychloroquine to decrease inflammation and slow progression
Immunosuppressants (renal and CNS symptoms)
plasmapheresis if don’t respond to other treatments
Pregnancy is not advised
Renal transplant
342
Fibromyalgia Syndrome: is it inflammatory?
Chronic pain syndrome, but not an inflammatory disease
343
who do you see fibromyalgia in
women from 30-50 y.o and on
344
what can contribute to fibromyalgia
```
chronic fatigue,
lyme disease,
significant trauma,
certain meds,
flu like illness
```
345
secondary fibromyaglia
often seen in combo w/ other connective tissue disorders
| w/ Lupus, or RA
346
characteristics of fibromyalgia
Fatigue and sleep disturbances
Paresthesias in extremities
Headaches and jaw pain
GI pain with diarrhea or constipation
GU discomfort
CV complaints - dysrhythmias, chest pain, dyspnea
Visual disturbances: Vertigo, Dizziness, Dry eye
Neurologic complaints: Forgetfulness, Problems with concentration
depression and anxiety
Muscle tenderness r/t inability to tolerate pain
Trigger points
347
what are trigger points for fibromyalgia
burning, gnawing characteristic
When palpated
Neck, upper chest, trunk, low back
348
how is fibromyalgia pain exacerbated
Stress
Increased activity
Changes in weather
349
how to tx fibromyalgia
```
Limit anything that can interfere with sleep: Alcohol, Caffeine, Other meds
Nerve pain - pregabalin
Antidepressant - duloxetine
Physical therapy
Low impact exercise as tolerated
NSAIDs
CAMs
```
350
chronic fatigue syndrome: who does it affect
mostly women, no specific age group
351
dx: chronic fatigue syndrome
severe fatigue for >6 months post flu like symptoms
need to meet 4 criteria:
Sore throat
Impaired short term memory
Poor concentration
Tender lymph nodes
Myalgias
Multiple joint pain w/ redness or swelling
Headaches of new type, pattern or severity
Post Exertional malaise for more than 24 hours
Unrefreshing sleep
352
is there a lab to verify chronic fatigue syndrome
no lab
353
how to tx chronic fatigue syndrome
Supportive tx!
Antidepressants can be helpful
Improved health practices: Sleep, energy conservation, nutrition, regular exercise, stress mgmt
Complementary and alternative therapies may be useful
