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Flashcards in Misc Med Deck (15):

Insomnia: Pathophysiology

  • Physiology:
    • The older you get, the less sleep you need
  • Medical and psychiatric disorders
  • Drugs that cause sleep disturbance
  • Recognize depression
    • Lots of little complaints, anxiety
    • Depression is one of those disease that uses everybody elses symptoms. Sleeping, can’t sleep, not interested in doing anything, backpain, no appetite, headache, 
  • Sleep hygiene
  • OTC sedative profiles


Sleep Disturbance Etiology: Medical, Psyche, Misc.

  • Medical
    • Arthritis*
    • Pain*
    • CHF
      • lots of pillow, feel like being strangled
    • GERD*
      • if eating late, non adherant to acid reflux disease
    • Asthma, COPD
      • allergic to pillows/air ducts
    • BPH*
    • Diabetes
      • Hyperglycemia, pee in night
      • Hypoglycemia, wake up 
    • RLS
      • restless leg syndrome
    • OSA*
      • obstructive sleep apnea
      • obesity (neck circ., waist to hip ratio), craniofacial or upper airway abnormality, FH, smoker, DM
      • Hypertension, male, overweight, big neck
  • Psyche
    • Anxiety*
    • Depression*
      • anxious, complain about little things
    • Bipolar disorder
    • Psychosis
    • Substance abuse
  • Misc.
    • Shift work


Insomia: Causative Drugs

  • Alcohol
    • short half-life, wake up, rebound
  • Antidepressants
  • Antihypertensives
  • Nicotine
  • Stimulants
  • Steroids
    • hungry, talk alot, not sleep
    • prednisone
  • Theophylline


Sleep Hygiene

•Don’t go to bed if you are not sleepy.
•Bed is for intimacy and sleeping
•If you’re not sleeping get up
•Don’t watch clock
•Don’t take daytime naps
•Don’t take caffeine after supper
•Caution with stimulants in evening
•Establish regular pattern


OTC Sedatives

  • Best chance of taking something to put you to sleep, diphenhydramine, some daytime sedation might occur
  • Not the greatest OTC choices, for a night or two they are fine.
  • Antihistamines
    • Diphenhydramine
    • This patient, not good to recommend because prostate worse, age (oldsters can fall and then die)
    • Anticholinergic side effects
    • Acute narrow glaucoma
    • Cognitive effects
    • 1st generation antihistamines, benadryl, unisom, etc. 
  • Melatonin
    • Not very effective
    • Some people are melatonin defficient, made in pineal gland, will help melatonin deficient people
    • May help track back to cycle for travelers, getting back to cycle faster is better than sliding in slowly
    • Not overnight
    • Very safe
  • Alcohol
    • rebound
    • short half-life and wake up 
    • sleep disturbance later
  • Valerian
    • Go to sleep 1 min earlier
  • L-tryptophan
    • Not on market because of eosiophil myophalgia syndrome deaths
  • Other herbals (passion flower, etc.)
    • Not effective


Exclusions for OTC Sleeper

  • Frequent nocturnal awakenings or terminal sleep disorder
  • Chronic : more than 3 weeks, nightly
  • Secondary to medical or psychiatric disorders



  • Get more sleep
  • Reinforce sleep hygiene
  • Treat underlying cause
  • Caffeine
    • Physiological effects:
    • Adverse effects:
      • addictive, headaches


7 Reasons Why Coffee is good for you

1.Makes you smarter
2.Burns fat and improves physical performance
3.Lowers risk of diabetes
4.Lowers risk for Parkinson’s, Alzhiemer’s.
5.Good for your liver
6.Decrease risk of dying
7.Loaded with nutrients and antioxidants


Caffeine: Physiolgic and Adverse Effects

  • Physiologic effects
    • Bronchodilator
    • CNS stimulant
    • Incr. gastric acid & pepsin
    • Incr. renin
    • Incr. metabolic rate
    • Incr. blood glucose
    • Incr. cortisol
    • Decr. LES tone
    • Diuretic
  • Adverse Effects
    • Cardiovascular (BP, P)
    • Psychiatric
      • (anxiety, panic)
    • Fertility
    • Pregnancy


Obesity: Class Notes

  • Obesity
    • Patient knows that he needs to lose weight
    • Exercise and diet, fruits
    • Burn more than taking in, how to do it is the question,
      • Set reasonable goal, 0.5-1 pounds a week, maybe 2 lbs a week in the beginning
    • Support groups, family/friends, weightwatchers,
    • Gadgets: Pedometer, Fitbit, use smartphone, make practical suggestions
    • Smaller plates 


Treatment of Obesity 

  • Behavior modification
  • Dietary
    • 2200-3000 – male/1800-2800-female Kcal/day to maintain a 30 year old in temperate climate
    • Nobody can maintain on 1000 Kcal/day
  • Exercise
  • Drugs
    • sibutramine (no longer),orlistat, phentermine, diethylpropion, buproprion, topiramate
  • Liposuction
  • Bariatric Surgery
    • BMI >40;   BMI >35 with co-morbidities


Tobacco Use: Addictions

  • Give clear cut, unambiguous advice "Single most powerful thing to preserve quality and quantity of life"
  • Nurse who continually goes back to it.
    • Cigarettes will never get back to the pharmacy. Would you sell cigarettes to a patient. Don’t do it.
  • Physical: take away drug and get withdrawls, need to maintain a blood level, crabiness, tachycardia, headache, bitchiness, blood level dependent
    • A lot of people have this
    • Overcome in a couple of days
  • Psychological: goes to brain, bathed with dopamine, (pleasure, fun, enjoyment), very addictive and powerful
    • Virtually everybody has this
    • Cravings, I wish I had
    • Hardest to over come
    • Takes months to overcome
  • Behavioral: in a ritual
    • Triggers
  • Modality needs to match the type of addiction that the person has
  • Hospital woman addiction: behavioral (always shopping for cigarettes), psychological (craving), not physical
  • Nurse woman addiction: behavioral and psychogical, not much physical
  • How do you figure out physical addition
    • Use fagersome scale
    • 2 questions: when do you smoke cigarette (in first 30 min) and how many to do you smoke (more than 20)
    • 2 pts is physically addicted


5 A's 

  • Ask
  • Advise
  • Assess
  • Assist
  • Arrange
  • Not counseling technique
    • A way to manage smoking
    • Manage smoking on a constant basis
  • Knowing if a person smokes is probably one of the most important vital signs
    • Flag profiles for smoking
    • So can have an opportunity to ask them
    • Can’t help anybody that you don’t know
  • Advice: your blood-pressure could be better if you didn’t smoke
    • Clear cut unambiguity advice
  • I’d like to quit but I can’t, can swoop in for asses
    • Figure out the type of addiction
  • Assist, pick the best NRT
  • Arrange for followup


Smoking Schpiel

  • History:
    • Positives and negatives of smoking
    • Motivation for quitting
    • Past quit attempts
    • PMH, risk factors
    • Fagerstrom Score​
  • Decide who is ready to change
    • Ask to come back
    • Are they contemplative, if not, don’t waste your time
      • Go to ask and advice
  • Ask what they like about smoking? A lot of people have a hard time coming up with positives. Don’t like about it smell, kisses, expensive, teeth. Bring up all their health problems
  • Have you ever quit before? How long? What did you use? Did it work?
  • Cover medical problems and risk factors
  • Calculate Fagerstrom Score
    • More when angry
    • Activities associated with smoking
    • When wake up


Smoking Quit Plan

  • Plan:
  • Quit Date:
    • A couple weeks out so can get psyched, pick a significant date so they can keep track of it
    • Enroll support (including 877-270-STOP)
    • Smoke Log
      • date, time, activity, rate how important (1-10)
      • Less than 5, skip that cig
      • 8-10, behavioral trigger that need to be careful around
  • Pharmacotherapy: 
    • bupropion (physical and psychological)
      • 1 tablet a day, after 3 days to 1 twice day, can still smoke until quit day, 3 months
  • Gimmick
    • detail car, start bank account, dry cleaners etc.
  • Follow-up:
    • phone call on quit date;
    • visit @ 2 weeks post quit date