Traumatic Brain Injury and Dementia: Symptoms, Management, and Diagnostics, Exams of Nursing

Download Traumatic Brain Injury and Dementia: Symptoms, Management, and Diagnostics and more Exams Nursing in PDF only on Docsity! NRNP Finals 6560 NRNP 6560 FINAL EXAM REVIEW 1. coup-contrecoup injury: Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. 2. Scalp laceration: what, effect, management: Primary head injury profuse bleeding - signs of hypovolemia Apply direct pressure Suture/ staple laceration Lidocaine 1% with epi to control bleeding, not close to nose/ ears 3. Skull fracture: types, effect, management: Primary head injury Simple: no displacement of bone. Observe and protect spine Depressed: bone fragment depressing thickness of scull Surgery for debridement. Give tetanus and seizure precautions Basilar: fracture at floor of skull Raccoon eye - periorbital bruising battle's sign: mastoid bruising otorrhea/ rhinorrhea - halo sign: do not obstruct flow Give Ab's Oral intubation and oral gastric instead of nasal 4. Brain injury: types, effect, management: Primary head injury Concussion: reversible change in brain functioning loss of consciousness, amnesia Do not give opioids, admit for unconsciousness greater than 2min Contusion: bruising to surface of brain with edema Frontal and temporal region Brainstem contusion: posturing, variable temp, variable vital signs N/V, dizziness, visual changes seizure precautions 1 / 63 NRNP Finals 6560 5. Hematoma - neuro: types, effect, management: Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into epidural space Loss of consciousness Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation CT scan (non contrast) Treatment based on Brain trauma foundation. Surgical if greater than 30cm Subdural hematoma most common type of intracranial bleed Acute (hours): drowsy, agitated, confused, headache, pupil dilation, CT scan (noncontrast) surgery for 10mm thickness or 5mm midline shift or for worsening GCS Chronic (days): headache, memory loss, incontinence CT scan (noncontrast) Surgery: burr holes/ crani 6. Cerebral edema/ ICP elevated/ herniation: symptoms, management: decreased level of consciousness Blown pupil Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased intracranial pressure) 7. Neuro exam components: AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive GCS: 8 or below is comatose Posturing: decorticate = arms, legs in decerebrate = arms, legs out 8. Electrolyte imbalances in brain injury: Hyponatremia: SIADH and cerebral salt wasting Hypernatremia: DI (give mannitol) 9. Management of traumatic brain injury: - Consult neurosurgery - Limit secondary injury - Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion. 2 / 63 NRNP Finals 6560 Knee extension (L2-L4): extend knee with hip/ knee flexed 16. key signs of spinal cord injury - various levels: C2-C3: resp paralysis, flaccid paralysis, deep tendon reflexes loss C5-C6: diaphragmatic brething, paralysis of intercostal muscles, quadriplegia, anaesthesie below clavicle, areflexia, fecal/ urinary retention, priaprism T12-L1: paraplegia, anesthesia legs, areflexia legs, fecal/ urinary retention, priaprism L1-L5: flaccid paralysis, ankle/ plantar areflexia 17. Multisystem impact of spinal cord injury: Cardiovascular: - hypotension/ spinal shock. Fluid resuscitation (LR) - bradycardia; oxygenate well, normothermia, atropine - vasovagal reflex: limit suctioning length- Poikilothermy - venous thrombosis: dvt prophylaxis- orthostatic hypotension GI: - abdominal injuries: assess for abd distention - curling's ulcer: stress ulcer. Give ranitidine - gastric atony and ileus: NG to LIS - loss of bowel function: initiate bowel program GU: - autonomic dysreflexia: HTN crisis from distended bladder or other noxious stimulu. Decompress bladder. - UTI Musculoskeletal: - paralysis- wounds Psychological: - ineffective coping, powerlessness, denial/ anger/ depression. Be honest with positivity, include pt, interdisciplinary approach 18. Spinal cord lesions/ syndrome: Anterior cord syndrome: weakness/ paralysis with loss of sense of pain and temp 5 / 63 NRNP Finals 6560 Posterior cord syndrome: can't feel touch and vibration Central cord syndrome: greater loss in upper extremities than lower Brown sequard syndrome: one side of spinal cord is damaghed by stab/ gun wound. Ipsilateral motor loss and contralateral loss of pain and temp sense. Extremities that can move have no feeling and that have feeling can not move. 19. Spinal cord injury: diagnostics: Cervical vertrebrea: lateral xr, then AP (swimmer view) Thoracic vertebrae: lateral and AP xr, view all 12 Lumbar: lateral and AP, view all 5 CT to check for bony fragments Films in flexion. extension to check for fractures Myelogram: detects compression of cord by herniated disks, bone or foreign matter MRI: cord impingement, hematoma, infarct, contusion, hemorrhage. 20. Spinal cord management: - Consult neuro - Airway maintenance (do not hyperextend neck when intubating) - immobilization (cervical collar/ spine board) - intravascular fluid (neurogenic shock: warm, dry, brady) - monitor bp (avoid hypotension: keep MAP 85) - Foley - NG - AB for penetrating injury - room temp - good skin care - fixation of spine - fusion: attaching injured vertebrae 21. Key features of dementia: - General decrease in level of cognition - thinking, memory, reasoning - Behavioral disturbance 6 / 63 NRNP Finals 6560 - Interference with daily function and independence Not a disease, but group of symptoms by various diseases 22. Alzheimer's disease: most common form of dementia Neuritic plaques, neurofibrillary tangles, degeneration of cholinergic neurons causing irreversible neuronal damage. B-amyloid present in high levels. Effect: cerebral atrophy. 23. Causes of brain degeneration: Alzheimer's Parkinson's Huntington's Vascular: stroke, arteritis Infectious: HIV, Syphilis, Meningitis, Encephalitis CNS/ toxic: drug overdose Nutritional deficiency: Vit B12, folate deficiency Chronic seizures Lewy body dementia 24. symptoms of dementia: - Slow onset - memory loss and confusion - problems with language - impaired abstract reasoning - aphasia, apraxia, agnosia - disorientation - poor judgement - emotional problems - sleeplessness 25. Dementia labs/ diagnostics: - History: family/ spouse report - Physical: neuro, cognitive examz: Mini mental State exam (score 23 or less is cognitive impairment), document in 3-6mo intervals - Labs: glucose, electrolytes, magnesium, calcium, liver tests, BUN/ creat, thyroid, Vit B12, HIV, CBC, ABG, cultures, drug screen - CT head/ MRI: for tumor/ infarction - PET scan: differentiate dementia type - EEG 7 / 63 NRNP Finals 6560 - double vision, dysarthria, dysphasia, vertigo (brain stem) - visual deficits - gait ataxia, tremor, uncoordinated movements (cerebellum) - cognitive dysfunction: memory, processing - fatigue (common!) - sleep disorder - bladder, bowel dysfunction- seizures Objective: - decreased sensation of pinprick, vibratory, temp - Reflex changes: abnormal deep tendon, pos babinski, pos hoffman's - brain stem changes: nystagmus, hearing loss, tinnitus - Cerebellar: ataxia, tremor, poor coordination - visual field changes - frontal lobe: cognitive dysfunction, emotional changes 33. MS diagnostics: - neuro exam - MRI (white matter lesions, lesions spinal cord, T1 and T2 lesions) (diagnostic!) - CSF analysis: elevated igG and oligoclonal bands in CSF but not serum 34. MS management: - consult neuro - no intervention for mild attack - Acute intervention for relapse with Glucocorticoid (po or iv) - symptom management meds - disease modifying meds: to reduce relapse, delay disability, and decrease MRI lesions: - Fingolimod. For relapsing. May cause brady, AV-block, HTN, diarrhea - Betaseron. For relapsing. May cause depression/ suicidality - Avonex. For relapsing. May cause flu-like symptoms - Rebof. For relapsing. May cause flu like symptoms - Glatiramer acetate. For Relapsing/ remitting. - Mitoxantrone. For sec progressive, progressive, or worsening relapsing/ remitting.35. Parkinson's disease: what, etiology: Neurodegenerative disorder caused by depletion of dopamine-producing cells causing resting tremor, rigidity, slowness of movement. 10 / 63 NRNP Finals 6560 Age onset: 60 more men than women caucasians Environmental (metals such as copper) and genetic factors. Gene: PARK1 36. Symptoms and diagnostics of Parkinson's: - Classic triad: resting tremors, rigidity, bradykinesia - Motor symptoms: postural instability can cause falls - Classic gait: diminshed arm swing, shuffling steps, bent forward, frozen gait - neuropsychiatric: depression, dementia, anxiety, psychosis, sleep disruption- autonomic dysfunction: urinary incontinence, sexual dysfunction, constipation, impaired thermoregulation - Craniofacial: masked face/ expressionless, dysphagia, impaired sense of smell, drooling - H&P - CT and MRI to assess for differential 37. Parkinson's treatment: - consult neuro - Pharm to relieve symptoms and improve functioning: Carbidopa-levodopa standard treatment. - Can on/off phenomona with working/ not working of meds. Add catechol-O- methyltransferase - Adequate nutrition - Exercise 38. Dopaminergic agents and Parkinson's: Carbidopa-levodopa. Most effective drug. Use with rasagiline. May cause on/ off phenomena, dyskinesia, confusion, headache, hallucinatinos. 39. Dopamine agonists and Parkinson's: Pramipexole and Ropinirole May reduce risk for complications and alleviate symptoms. Mono or dual theraoy with levodopa. May cause N/V, dyskinesia, confusion. 40. MAO-B inhibitors and Parkinson's: Rasagiline Adjunct therapy May cause serotonin syndrome, dyskniesia, arthralgia, ataxia 11 / 63 NRNP Finals 6560 41. Amyotrophic lateral sclerosis (ALS): what and etiology: Disease of motor neurons causing asymmetric weakness, in upper or lower extremity. Less likely to present with resp weakness, dysarthria or dysphagia Onset age: 50 Men more likely Familial is 10% of cases unknown Average survival: 2-5 yrs 42. Symptoms and diagnostics ALS: Classified by number of upper and lower motor neurons in regions of brain Progressive weakness over weeks/ months Sensation intact Muscle atrophy Small muscle fasciculations Hyperreflexia Spasticity Serum CK elevated EMG: denervation Muscle biopsy: atrophic muscle fibers MRI: no abnormality 43. Management of ALS: Supportive and palliative: - Immobilty - Altered resp function: ventilation/ suction - Dysphagia/ poor nutrition - pain: pain management - Anxiety - Meds: riluzole. Can extend life by months but not cure. 44. Low back pain - major syndromes: 1. Back strain 2. Disk herniation 3. Osteoarthritis/ disk degenration; osteophyte (bone spur) 4. Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment 12 / 63 NRNP Finals 6560 51. Stroke: what, etiology: Rapid onset of neurological deficit lasting longer than 24hours. Leading cause of disability. Ischemic or hemorrhagic. 80% ischemic. - HTN - Cardiac disease (afib) - smoking - obesity - hyperlipidemia (ischemic, low cholesterol hemorrhagic) - elderly - DM - alcohol, recr drugs - female on contraception and smoking 52. Education on stroke - five "suddens": Sudden: weakness speech difficulty visual loss dizziness severe headache 53. ischemic stroke: what, etiology: Thrombus in blood vessel in head or neck Predisposing: - atherosclerosis/ hyperlipidemia - HTN - DM - hypotension - smoking - trauma - afib, endocarditis, mitral stenosis (embolism) 54. Ischemic stroke symptoms, based on location: Middle cerebral artery: - Hemiplegia (upper and face mostly), hemianesthesia, heminopia - aphasia - neglect Anterior cerebral artery: 15 / 63 NRNP Finals 6560 - hemiplegia (lower mostly), primitive reflexes, confusion, behavioral changes if bilateral anterior Vertebral and basilar arteries: - LOC - vertigo - dyshpagia, diplopia - ipsilateral CN findings - Contralateral sensory deficiency Deep penetrating branches of major cerebral infarction (lacunar infarction): - associated with poorly controlled HTN and DM - contralateral pure motor and sensory deficits - ipsilateral ataxia - dysarthria 55. ischemic stroke diagnostics: - CT head without contrast initially, preferable to MRI to rule out hemorrhage. Appears as area of density. - xr chest: possible cardiomegaly, neoplasm (metastasis brain suspicion) - Labs: CBC, Pt, PTT? INR, lipid profile, drug screen, alcohol level - ECG/ holter - MRI/ MRA (diffusion weighted more sensitive to detect cerebral ischemia) - CTA: vascular anatomy. Combine with CT perfusion which can show old infarct and salvageable areas. 56. Ischemic stroke treatment: - appropriate time goals - BP control: Only treat if higher than 220 syst and 120 diast., aortic dissection, or receiving t-PA. For t-PA goal goal is less than 185 syst/ 110 diast, before t-PA and less than 180 syst/ 105 diast. after. Use repeat labetolol or nicardipine drip. - Anticoagulation: IV Heparin, bridge to Warfarin (PTT 1.5-2.5 baseline). But newer meds better: Dabigatran, Apixaban (Eliquis - for stroke prevention in afib), Rivaroxaban (stroke prevention afib). No routine labs necessary for those. Not for hemorrhage, cautino after GI bleed - Antiplatelet: Aspirin or Clopidogrel - Mannitol and hypertonic saline for cerebral edema, on second on third day. Monitor serum osmolality. - Corticosteroids to reduce cerebral edema from tumor burden. - surgery for high grade extracranial carotid artery disease (greater than 70%) 16 / 63 NRNP Finals 6560 57. Time goals of stroke: - ED eval within 10min - notify stroke team within 15min - CT scan within 25min - CT scan interpretation within 45min - Thrombolytic (if appropriate) within 60min - Transfer to bed within 3 hrs 58. t-PA: - Pt needs to be in 3 - 4.5 hr window - Prior CT to assess for hemorrhage - need to have "last well known" - older than 18 - ischemic stroke - neurochecks q15min for 2hrs, q30min for 6 hrs, q1h till 24hrs Contraindications: - age greater than 80 - previous hemorrhage - previous stroke within 3mo - major surgery last 14 days - Urinary/ GI hemorrhage within 24 days- seizure - PTT and PT elevated - oral anticoag/ heparin with elevated PTT/ PT - glucose less than 50/ greater than 400 - SBP greater than 185 or DBP greater than 110 - active internal bleeding last 22 days 59. Hemorrhagic stroke; what, etiology: Resulting from bleeding into subarachnoid space or brain parenchyma SAH: ruptured saccular aneurysm arteriovenous malformation ICH: HTN Predisposing: 17 / 63 NRNP Finals 6560 - CPP: keep at 50 - 70 - pressors if SBP less than 90: Dopamine, epi, levo - maintain ICP less than 20 - mannitol for cerebral edema. For 5 days or less. check serum osmolality. Or 3% saline. - ventricular drain for hydrocephalus - keep euvolemia - seizure precautions (phenytoine, levetiracetam) - control fever - surgery if hemorrhage greater than 3cm 66. cerebral vasospasm: - cerebral vasospasms: between day 7 - 10 after aneurysm lasting till day 21 - symptoms: confusion, ams, neuro deficits, ha, increased icp. May cause infarction. - treat: calcium channel blocker: nimodipine. Symptomatic: tripe H. Hypervolemia, hypertension, hemodilution. 67. Meningitis, what and etiology: inflammation of arachnoid, dura mater, pia mater or spinal cord due to viral, bacterial, or fungal infection - predisposing: sinusitis, otitis, pneumonia, trauma, congenital malformation68. Bacterial meningitis: Bacterial: - may be fatal in hours - exudate in subarachnoid space, thus thickened CSF and decreased flow Most commonly caused by: - streptococcus pneumoniae (infants) - neisseria meningitidis (school, college, spread of drainage/ blood) - haemophilus influenzae (daycare children - vaccine) - Escherichia coli/ emterobacter/ klebsiella (infants, elderly, immunocompromised) - Atypical: mycobacterium, listeria 69. viral meningitis, what and etiology: Pia and arachnoid space filled with lymphocytes but not with exudate. benign and self-limited. In late summer/ early fall. Transmission via cough, saliva, fecal matter Caused by: 20 / 63 NRNP Finals 6560 enterovirus, mumps, varicella, herpes, rubella, cmv, epstein barr, HIV 70. Fungal meningitis, what and etiology: Most common in immunocompromised Causes: candida cryptococcus histoplasma aspergillus 71. Meningitis findings and diagnostics: - severe ha - stiff neck/ nuchal rigidity - phtophobia - fever - ams - cranial nerve palsy- seizures - kernig's sign: flex at knee, then hip, and extend knee. Causes pain and spasm of hamstring muscles - brudzinski's sign: flex head and neck to chest. Causes legs to flex at hips - n/v - purpura/ petechiae on trunk and le - exaggerated deep tendon reflexes - LP - CT before LP, for ams or focal neuro signs or for CSF bacterial meningitis signs but no organism - bld culture, sputum cult, cbc, bmp - antigen tests and HIV testing 72. LP in bacterial versus viral meningitis: Bacterial: - Appearance: cloudy - Opening pressure: elevated (more than 180) - Cells: increased WBC's (100-5000, polynuclear) - Protein: increased (100-500) - Glucose: decreased (5-40) - Culture: bacteria present Viral: 21 / 63 NRNP Finals 6560 - Appearance: clear - Opening pressure: normal (less than 180) - Cells: increased WBC's (100-5000, mononuclear) - Protein: normal or slightly increased (less than 200) - Glucose: normal (greater than 45) - Culture: no bacteria 73. Meningitis management: AB's: - 2 -50 yrs: vancomycin plus ceftriaxone - older than 50 yrs: vancomycin, plus ampicillin, plus ceftriaxone - Meningococcal meningitis (college): penicillin or ceftriaxone if pcn allergy - H.influenzae: ampicillin or ceftriaxone - tuberculosis: isoniazid plus pyridoxine, rifampin - s. pneumoniae (infants): add dexamethasone - no hypotonic fluids - amphotericin B for fungal meningitis 74. Cerebral abscess, what and etiology: Infected space occupying lesion, from bacterial or fungal source (sinusitis, lung infection, skin infection, trauma) 75. Cerebral abscess findings, diagnostics: - ill appearing/ lethargic - signs of increased ICP (n/v, confusion/ ams) - stage 1: ha, chills, fever, confusion, speech disorder - stage 2 (expanding cerebral mass): signs and symptoms of brain tumor: ha, confusion, drowsy, stupor - Lab: increased WBC and ESR - LP (CT prior to LP): elevated opening pressure, mildly elevated protein- CT - MRI: reveals necrosis vs edema 76. Cerebral abscess treatment: - AB based on microbiology - surgery and debridement when abscess is greater than 2.5cm 77. Encephalitis, what and etiology: Acute inflammation of the brain - most commonly caused by herpes simplex virus - tick infestation - west nile virus 22 / 63 NRNP Finals 6560 - LP if CT or MRI did not show anything - CBC, BMP - ua: drug screen - elevated prolactin 88. Seizure management: - supportive - open airway, left side laying, do not force anything in mouth (airblade) - IV with NS - ECG, bp - benzodiazepine first treatment: ativan, diazepam, midazolam (may give midazolam IM if no IV present) - Phenytoin, loading dose 20mg/kg - Fosphenytoin, can be given faster than phenytoin - if still seizing after 1hr: propofol - taper drugs, never stop abruptly 89. Dermatitis Medicamentosa (Drug Eruptions): Abrupt, widespread, and symmetric eruption. If exposed before, it may take only very little to elicit response again. 90. Predisposing factors for dermatitis medicamentosa - classification: Type 1: immediate-type immunologic reaction: by IgE. Looks like: urticaria and angioedema of skin and mucosa, and fall in bp (anaphylactic shock) Type 2: cytotoxic reaction. drug causes lysis of cells or produce antibodies. Type 3: serum sickness, drug-indiced vasculitis. Looks like: vasculitis, urticaria-like lesion, arthritis, nephritis, alveolitis, hemolytic anemia, thrombocytopenia type 4: morbiliform. Cell-mediated. Drug erruption with eosinophilia and systemic syndromes (DRESS). Allergic reaction causing systemic reaction, presenting as hepatitis, pneumonia, lymphadenopathy, nephritis. May last 2-6wks after start med. Often: anti-epileptocs, B-blocker, allopurinol. 91. General points for dermatitis medicamentosa: - Amoxicilllin/ ampicillin/ penicillin: common cause urticaria and maculopapular allergic skin reaction 25 / 63 NRNP Finals 6560 - Cephalosporin can cause reactions to pcn allergic patients. Third generation less likely than first generation. - Red man syndrome caused by vancomycin. Responds to slowing of rate. - ACE-inhibitors associated with chronic cough and angioedema - B-blocker can precipitate asthma. - Anticonvulsants and sulfonamides most common cause of toxic epidermal necrolysis and Stevens-Johnson syndrome. - May give Prednisone and hydrocortisone before IV contrast is suspected allergy 92. Dermatitis medicamentosa: symptoms and diagnostics: - abrupt onset - bright erythema - facial edema/ involvement - swelling tongue - itching - fever/ chills - symmetric distribution of skin reaction - arthralgia - possible: sob, wheezing, hypotension - if urticaria and angioedema present, then mast cell degranulation, so repeat reaction is likely. - maculopapular rash, most often on trunk - ecxematoid rash - photodermatitis - may have: hemolytic anemia, liver/ kidney dysfunction, serum sickness (rash, fever, malaise) - clinical diagnosis - blood work no value - eosinophil count greater than 1000 - skin biopsy 26 / 63 NRNP Finals 6560 - challenge dosing - if anaphylactic reaction not likely - serum renal/ liver if indicated 93. Dermatitis medicamentosa, management: - Withdraw drug - may be only thing necessary - Epi0.5-1ml IV or SQ relief from urticaria and angioedema. Repeat after 20min up to three doses - Oral/ IV antihistamine: benadryl or Ranitidine - Severe cases: Prednisone, taper slowly - Bronchodilators for wheezing 94. Cellulitis: what: Infection of dermis and subcutaneous tissue. Caused by gram Pos cocci and staph. aureus (for dm) as well as gram neg. E.coli. Fungi for neutropenic patients. H. influenza for facial and upper extremities. 95. Cellulitis, general comments: - break in skin precedes cellulitis, - Risk factors: trauma, underlying skin lesion, diabetes, pedal edema, venous/ lymphatic compromise, IV drug use - may be next to necrosis or abscess - often lower extremities - complicated by DVT 96. Cellulitis findings: - tenderness, pain, swelling, erythema, warmth - rapid increase intensity and spread - fever, chills, malaise - sepsis possible - erythema with indistinct margins; warmth and tenderness - enalargement and tenderness of regional lymphnodes - red streaks from site (lymphatic spread: lymphangitis) - erythema and tenderness few cm from site - Lymphnode enlargement and lymphangitis: cellulitis. - Blood culture and wound culture - Rule out: DVT and necrotizing fasciitis, which should be suspected in very sick pt with bullae, crepitus, anesthesia of involved skin, skin necrosis, rhabdo, DIC 97. Cellulitis treatment: - AB: cover streptococci and staphylococci, with penicillin, Cephalexin, Dicloxacillin. If allergy to pcn: erythromycin or clindamycin. - Inpt AB: nafcillin, Cefazolin, Vanco for MRSA suspicion, 27 / 63 NRNP Finals 6560 - prophylaxis therapy: 5- Fluorouacil or Imiquimod - sunscreen 104. Melanoma: what, etiology: Tumor with dark pigmentation, flat or raised, irregular borders, greater than 6mm - Leading cause of death from skin disease - avoid blistering sun radiation - age: between 30 and 50 - fair skin, blue eyes, blond - twice risk if sunburned young - twice the risk with many nevi - head/ neck/ trunk for males, lower extremities for females 105. Melanoma: findings and diagnostics: - change in pigmented lesion: - bleeding/ ulceration bad sign - scaling - texture change, irregular border - bigger than 6mm - color change- itching ABCDEE changes: Assymetric shape Border irregularity Color change Diameter greater than 6mm Elevation Enlargement/ increase in size Surgical biopsy: full thickness total excisinoal biopsy. Do not shave, curette, or electrodesiccate melanoma 106. Melanoma staging: Clark staging: Level 1: epidermis - in situ Level 2: invasion of papillary dermis Level 3: invasion of interface of papillary, reticular dermis 30 / 63 NRNP Finals 6560 Level 4: invasion of reticular dermis Level 5: invasion subcutaneous fat Breslow staging: Thin: less than 0.75m depth Intermediate: 0.76 - 3.99mm depth Thick: greater than 4mm depth 107. Melanoma Management: - dermatologist - follow up q3-6mo - Based on stage: Less than 1mm: wide excision 1mm. No lymphnode dissection 1-4mm thick: wide excision 2mm. Nodal biopsy recommended. Lymphatic mapping. 4mm thick: wide excision more than 4mm - Adjuvant therapy: hem/ onc. Alpha-interferon 108. Types of wounds: Acute: Acute surgical: clean/ contaminated Traumatic wound: clean/ contaminated Chronic: Arterial: ischemia from arterial occlusive disease Venous: venous return disorder Diabetic: from hyperglycemia and per neuropathy Pressure: prolonged pressure 109. Factors that delay wound healing: - pressure - decreased tissue perfusion/ oxygenation - incontinence - infection - dm - poor nutrition - steroids - immunusuppression - aging 110. Wound findings, specifics: - Pain 31 / 63 NRNP Finals 6560 - Arterial: claudication - Venous: lower extremities heavy and sore - Neuropathy: numbness, tingling - Arterial, venous, diabetic: poor healing 111. Wound depth, levels: - Superficial - Partial thickness: through epidermis, partially into dermis - Full thickness: through epidermis and dermis and some subcut layer. Muscle/ bone may be involved. - Undermining and tunneling 112. Wound colors: Red: healthy Yellow: debridement/ cleaning needed Black: necrotic 113. Findings arterial and diabetic ulcers: - On toes and below ankles (arterial) - plantar surfaces of feet (diabetic) - diminished pulse - shiny, cool le skin - no leg hair - thick toe nails - deep ulcer with smooth wound margins, small amount of drainage/ necrosis114. Findings venous ulcers: - lower legs, above ankle - varicoses present - edema of le- warm le - superficial, granulating ulcer with irregular margins, with heavy drainage 115. Findings pressure ulcer: - On bony prominences - Stage 1: skin intact, but skin non blanchable - Stage 2: partial thickness loss - Stage 3: full thickness loss, deep craterlike - Stage 4: full thickness and extensive destruction with tissue necrosis 116. Diminished arterial and venous flow diagnostics: - Doppler, reduced PVR waveforms - Digital plethysmography: systolic toe pressure. Normal is 80-90% - Transcutanous oxygen measurements: higher than 30, wound will heal. Lower than 20, will not heal 32 / 63 NRNP Finals 6560 - Give crystalloids (NS/ LR), no colloids (albumin, plasma) - Urine output should be 30-50ml/hr - Monitor for hyperkalemia first 24-48 hrs, after that hypokalemia. 126. General burn management rules: - rinse chemical injuries in water, no other products - wrap area in clean, dry towel (not wet, to keep body temp) - dressing before treatment: wrap in ns and sterile towels - maintain normothermia (warming blankets, etc) - analgesics (morphine), only iv - topical ab options: silvadene, sulfamylon, collagenase - intubate for one of these: burn to face, singed nares/ eyebrows, dark soot from nares, hoarseness, drooling, difficulty swallowing. AND bronchoscopic laryngeal edema 127. Transport to burn center for: - 2nd degree, more than 10% TBSA - 3rd degree - electrical burn - chemical burn - inhalation injury - burned children - burn injury is big risk for mortality 128. carbonmonoxide poisoning: - CO replaces Hgb - Cause: home furnace/ gas and car exhaust - signs: ha, dyspnea, confusion, n/v, tachy, seizures, coma, death - Give 100% O2 - potential hyperbaric oxygen chamber 129. Laceration treatment: Cleanse (NS) Debridement (for contaminated wound) (potential excision) Control of hemorrhage - pressure, elevation, ligation, tourniquet Closure (do not close contaminated wound) 130. Suturing: - not too tight - choose smallest suture size - remove after 5-7 days or 10 days on trunk and extremities 131. Nerve block for laceration: - 1% lidocaine with epinephrine, do not exceed 7mg/kg or 4mg/kg without epi 35 / 63 NRNP Finals 6560 - or Procaine - choose small needle (30gauge) 132. Aneurysm: what and types: Dilation of arterial wall because of abnormal weakening, often from sudden increase in bp Types: Berry (saccular) - congenital aneurysm of cerebral vessel. - Common in adults - Asymptomatic Fusiform - tapered at both ends - common in vertebrobasilar system Mycotic - bacterial cause/ infection Traumatic 133. Locations of intracranial aneurysms and effect of rupture: - Most in carotid system: anterior communicating artery, posterior communicating artery, middle cerebral artery - some in posterior circulation: basilar and vertebral Rupture result: - subarachnoid hemorrhage - intraventricular hemorrhage - intracerebral hemorrhage - subdural hematoma 134. Risk factors for intracranial aneurysm: - hereditary/ familial - smoking - women above 50 (postmenopausal) - alcohol use - 7mm risk for rupture 135. Intracranial symptoms and diagnostics: - asymptomatic until rupture, then 36 / 63 NRNP Finals 6560 SAH - warning leaks (small amount of blood) hours prior to rupture: headache, neck stiffness, nausea - eye hemorrhage on ophthalmologic exam - aneurysm with mass effect (bigger than 25mm): headache, palsy of CN 3 (pupils), brain stem dysfunction - CT . Very sensitive within 24hrs. Less after 5-7 days. - CTA - MRI best for detecting thrombus in aneurysmal sac - CTA, help in therapeutic decision making - WBC and ESR up in ruptured aneurysm 136. Intracranial aneurysm management: - Surgery: consider for warning symptoms (headache, neuro signs) and salso consider comorbodities. - early surgery (within 72hrs of bleed) is desirable - clipping, wrapping, embolization - or manage nonsurgically as SAH 137. Aneurysm complications: Vasospasm - 3 or 4 weeks after tx - give calcium channel blockers (nimodipine) Rebleeding - risk within 2-24hrs of 1st hemorrhage - prevent htn - give antifibrinolytic agents: transexamic acid. If given in first 2 wks after bleed reduces risk for rebleed. Hydrocephalus - may require shunt placement, ext ventricular drain, lumbar drain Seizures Increased intracranial pressure 138. arteriovenous malformation (AVM): a vascular malformation that is a tangle of abnormal blood vessels connecting arteries and veins in the brain; 37 / 63 NRNP Finals 6560 - corticosteroids: dexamethasone (start H2-blockers simultaneously) - mannitol for sever cerebral edema - anticonvulsants for repeated seizures 149. Guillain-Barre syndrome, what, etiology, prognosis: Acute, rapidly progressive inflammatory demyelinating radiculoneuropathy: motor greater than sensory resulting in increased msucular weakness, mild sensory loss, auronomic dysfunction. Often following an infection. Cause: myelin destruction or complexes attacking axons and nerve conduction Max deficit by week 4. - possible autoimmune - antecedent infection - incidence increases with age- more men Improvement may take months. May keep mild disability. 150. Guillan Barre signs and diagnostics: - symmetric, rapidly progressive muscle weakness and parasthesia, beginning in legs and moving up. Can lead to total paralysis/ death - reduced deep tendon reflexes - more weakness than sensory loss - may have hyperesthesia - dysphagia - respiratory paralysis - autonomic dysfunction: tachycardia, bp fluctuations, cardiac arrythmia - CSF: elevated fluid protein, but may be only after couple of weeks- leukocytosis - may require lp - will find: demyelatino of peripheral nerves or inflammation of myelin sheath - antibodies: GM1 or amti-GQ1b - slowed conduction on electromyography 151. Guillan barre management: - no known cure - consult neuro - icu - intubation - immunomodulating treatment and plasmapharesis (first line!) - no corticosteroids 40 / 63 NRNP Finals 6560 - prevent thromboembolic events (hep sq q8h) - pain control (especially during reinnervation) - GI prophylaxis - H2 blocker - protect skin - rom - nutrition management- rehab 152. Myastenia Gravis (MG): what and etiology: Disorder of neuromuscular junction resulting in pure motor syndrome: fluctuating muscle weakness most notable after prolonged muscle use Cause: autoimmune attack on acetylcholine receptor at the postsynaptic membrane. Mild and intermittent or sudden severe onset more women early adulthood, equal later in life 153. Myastenia Gravis symptoms and diagnostics: - Ptosis - Diplopia - facial weakness - fatigue from chewing - neck weakness - more upper than lower limb weakness - resp weakness - may cause severe quadriparesis - Antibody testing: ACHR and MUSK pos - increased jitter on electromyography - Edrophonium test (Tensilon): in MG will have brief improvement when given Edrophonium. No improvement if cholinergic crisis - MRI/ C - Thyroid function tests: may have thyroid disease - Vit B 12 low, pernicious anemia - ANA, RA factor pos- normal LP 154. Myastenic crisis: Defined by resp failure, requiring mechanical ventilation, following increasing muscle weakness and diplopia. More likely in MUSK positive. This often follows an infection, stress, steroid change, drug exposure 155. myastenia gravis treatment: - neuro -Symptom mamagement with: Pyrodostigmine bromide - slows down degradation. Monitor for cholinergic adverse effect: n/v, diarrhea, bronchial secretions, cramps. 41 / 63 NRNP Finals 6560 - Immunomodulating therapy: Prednisone, taper to low maintenance. Azathriopine. - Management of impending crisis: intubate. And give rapid immunomodulating therapy: IVIG. Can also do plasmapharesis. Removes antibodies. 156. GCS measures: The GCS measures the following functions: Eye Opening (E) 4 = spontaneous 3 = to sound 2 = to pressure 1 = none NT = not testable Verbal Response (V) 5 = orientated 4 = confused 3 = words, but not coherent 2 = sounds, but no words 1 = none NT = not testable Motor Response (M) 6 = obeys command 5 = localizing 4 = normal flexion 3 = abnormal flexion 2 = extension 1 = none NT = not testable 157. GCS outcomes: Severe: GCS 8 or less Moderate: GCS 9-12 Mild: GCS 13-15 158. Ectopic pregnancy: what, etiology: Implantation of fertilized ovum in other place than endometrium, often fallopian tube Could be caused by: 42 / 63 NRNP Finals 6560 - ruq abd pain (with Fitz-High and Curtis Syndrome) - assess last period - STI hx - contraception use - sexual hx - pregnancy test - drug allergy - CDC criteria 163. CDC PID/ salpingitis criteria: Needs to have one of these: - uterine/ adnexal tenderness- cervical motion tenderness And potentially: - fever - purulent vaginal discharge - elevated ESR - gonorrhea or chlamydia - WBC up Definite: - evidence from endometrial biopsy - tuboovarian abscess on US - lap.scopic abnormalities consistent with PID 164. PID/ salpingitis management: - Early and aggressive tx of STIs will prevent PID - Admit for: surgical emergencies, coexisting pregnancy, failure to respond to tx- notify sexual partners - test for cure after 7days - rescreen for gonorrhea and chlamydia after 4-6 wks - remove IUD - test for HIV - no douching - no sex - bed-rest semi-fowlers- Tylenol Inpatient: - Cefotetan or Cefoxitin 45 / 63 NRNP Finals 6560 - Doxycycline - Clindamycin or Metronidazole with Doxy for abscessOr: - Clindamycin - Gentamicin Continue till 24-48hrs after improvement Outpt: - Ceftriaxone - single dose - Doxycycline- Metronidazole Or: - Cefoxitin - Doxycycline with Metronidazole 165. Vaginitis - what: Most commonly: bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis 166. Vaginitis, findings: - vaginal discharge - vulvar itching/ irritation - vaginal odor - asymptomatic On speculum exam: - Bacterial vaginosis: adherent, thin, milky foul/ fishy smelling discharge - Candidiasis: thick, clumpy, white cottage cheese discharge. Inflammation, erythema - Thrichomoniasis: frothy, gray/ yellow/ green discharge. Cervical petechiae: strawberry cervix. 167. Vaginitis, diagnostics: Bacterial vaginosis: Amsel criteria: - vaginal PH greater than 4.5 - clue cells on wet mount - whiff/ fishy odor test - milky- white discharge, adherent to vaginal wall Candidiasis: wet mount: pseudohyphae and or budding yeast Thrichomoniasis: 46 / 63 NRNP Finals 6560 - wet mount: motile trichomonads seen - vaginal PH greater than 4.5 - culture - nucleic acid amplification test 168. Vaginitis treatment: - Enclose to partner and treat - no sex Bacterial vaginosis: - Metronidazole PO or intravaginally- Tinidazole Candidiasis: - Fluconazole PO - Butoconazole intravaginally Thrichomoniasis: - Metronidazole While pregnant: Metronidazole or Clindamycin 169. Chlamydia, what and etiology: Parasidic STI producing reproductive tract complications. Caused by: C. trachomatis. Transferred by body fluids - both sexes, younger than 25 - annual screening for sexually active adolescents and not using contraceptives, pregnant, or abortion May cause: Women: - PID - ectopic pregnancy - infertility - late onset postpartum endometritisMen: - Epididymitis - urethritis, conjuctivitis, arthritis, skin lesions Newborn: - conjunctivitis - pneumonia 47 / 63 NRNP Finals 6560 - fever - Abd pain: guarding, referred, rebound - Hyperperistalsis - Painful, enlarged Bartholin and Skene glands - urethral discharge - red vaginal wall -purulent drainage from cervix - adnexal pain and masses - cervical motion tenderness - red and swollen penile shaft 175. Gonorrhea diagnostics: - Corner stone diagnosis: perform throat and endocervical culture for oral/ vaginal sex - rectal exam for anal sex - check for Chlamydia and syphilis and HIV - leukocytosis - ESR up - males: one hour after voiding 176. Gonorrhea management: - Ceftriaxone single - Azithromycin or Doxy 7 days Pregnant: - Azithromycin - Tell sexual partners and treat, and screen also for chlamydia- no sex - test for cure after 3mo - hospitalize for disseminated gonococcal infection - report to health department 177. Herpes simplex virus: what and etiology: Recurrent, incurable viral infection of genital or orofacial skin, with fluid containing eruptions on red base. two strains: HSV-1 and HSV-2. HSV-1: - herpes labilialis (cold sores) and herpes keratitis 50 / 63 NRNP Finals 6560 - gingivostamitits: children and adults - healing of lesions after 3 wks- more common HSV-2: - mostly genital - later in life, more severe and recurrent - lesions heal in 2-3 wks - Transmitted by vaginal, anal, oral contact/ very close physical contact - improper use of condom 178. genital herpes findings: - Flulike symptoms - pharyngitis - itching, pain - urinary retention and dysuria - le weakness - hyperparesthesia - small, multiple painful vesicles over external genitalia - painful ulcerating papules - white necrosis on cervix - inguinal lymphadenopathy - extragenital cutaneous lesions on hips/ buttocks Recurrent: - precipitated by trauma, period, stress, illness, fever, sun - local burning, itching, tingling - lesions in 3 days, resolve in 7 days 179. genital herpes diagnostics: - Tzanck smear: immediate results and sensitive - collect specimen from vesicular lesion - HSV culture (test of choice). Results in 7 days - Western blot also accurate 180. Herpes management: - No cure First episode: 51 / 63 NRNP Finals 6560 - AcyclovirPregnant: - Doxycycline Recurrent: - Acyclovir - suppressive tx if more than 6/ year Teaching on sexual transmission 181. Human Papillomavirus (HPV), what and etiology: Infection at basal cell layer that causes genital warts, cervical abnormalities, and cancer Low risk for ca: HPV 6 and 11 and low grade cervical changes High risk for ca: HPV 16 and 18 Incubation: week to months for warts, years for cancer Most common STD 182. HPV findings and diagnostics: - no findings often - genital warts: cauliflower like, smooth/ flat papules, warts in areas of coital friction - visual inspection of genital warts - biopsy for: uncertain diagnosis, immunocompromised, worsening lesions despite tx, persistent ulceration 183. HPV management: - Pap smear for all sexually active women - tx will treat infectivity but not cure - sinecatechins ointment or imiquimod on warts until gone - Cryotherapy - Partner exam not necessary - all women age 9-26 should get vaccine 184. Syphilis, what and etiology: Systemic STI with 4 stages: primary, secondary, latent, tertiary. caused by treponema pallidum. Incubation period: 21 days. Infection at site of inoculation: small sore. 185. Syphilis findings: Primary: - Chancre (painless, indurated ulcer). heals in 1-5 days.- regional lymphadenopathy 52 / 63 NRNP Finals 6560 - cardiovascular collapse - tinnitus - delirium/ psychosis - serum levels may confirm overdose - bradycardia with AV block - prolonged QRS - ventricular arythmia's - Torsade's - Acute lung injury- low blood counts - drug induced lupus with procainamide 193. Antidysrhythmic drug overdose management: - ECG - Charcoal with NG - For bradycardia: atropine or pacing - Isoproterenol to maintain HR greater than 60 194. Barbiturate overdose: what, findings, diagnostics: Phenobarbital - confusion - slurred speech - ataxia/ impaired coordination - CNS depression/ stupor - Drowsiness/ coma - Hypothermia - Resp depression - absent reflexes - miosis (pupil constriction) 195. Barbiturate overdose management: - airway/ ventilation - charcoal for cooperative/ stable pt's - hemodynamic support/ vasopressors 196. Benzodiazepine overdose: what, findings, diagnostics: Clonazepam, Diazepam - Drowsiness - confusion - slurred speech- unsteady gait 55 / 63 NRNP Finals 6560 - resp depression - hypoactive reflexes 197. Benzodiazepine overdose management: - monitor BP and respiration - Flumazenil - gastric lavage 198. Betablocker and calcium overose: what, findings, treatment: Labetolol, metoprolol Amlodipine, Nicardipine, Diltiazem Bradycardia, hypotension, rhythm changes - Give Gluconate/ Glucagon and calcium chloride - Atropine for bradycardia - Monitor and treat electrolyes (K) - charcoal - ECG and possible pacing 199. carbon monoxide poisoning findings: - SOB - HA - confusion/ ams - n/v - weakness - blurred vision - parkinsonism - dysrythmia's - cardiac arrest - HF - resp depression - hypoxia - elevated carboxyhemoglobin level - Sinus tach - ST depression and PVC's - metabolic acidosis 56 / 63 NRNP Finals 6560 200. carbon monoxide poisoning management: - 100% O2 with mask or intubation - may require hyperbaric O2 if carboxyhemoglobin levels are greater than 25%, or pregnant, or ams 201. Opioid toxicity: what, findings, treatment: Codeine, heroin, methadone, opium, morphine, oxycodone - hypothermia - ams/ drowsiness/ coma - resp depression - miosis - ECG - ventilatory support - Narcan 0.4-2mg q2-3min 202. Lithium toxicity findings: - n/v - muscle weakness/ tremor/ rigidity - ataxia - dementia/ delirium - lithium level greater than 1.5 - hyperglycemia - AV-block/ prolonged QT - DI - seizures - leukocytosis - stupor/ coma 203. Lithium toxicity management: - bolus NS - charcoal ineffective - gastric lavage for acute ingestion - within 1 hr - diuretics for lithium greater than 2-2 mEq - hemodialysis - benzodiazepine for seizures 204. Hymenoptera stings: what and findings: Bees, wasps, ants 57 / 63 NRNP Finals 6560 - treat pain (HR, RR, expression): morphine, fentanyl, versed - remove mechanical ventilation in stepwise fashion, while assessing and treating pain 214. ANA Code of Ethics for Nurses: -In all professional relationships, practices with compassion & respect -Primary commitment is to patient, family, group, community -Promotes, advocates, protects health, safety, & rights of patients -Responsible & accountable for his/her own patient care practice -Owes same duty to self as to others, with integrity, competence, growth -Participates in improving ethical and safe, high quality health care environments -Participates in advancement of profession with research -Collaborates with other health professionals & public to protect human rights, reduce health disparities -Profession of nursing, as represented by associations/members...responsible for values & integrity & shaping social policy 215. Autonomy: the right to make their own decisions based on their own beliefs and values, for the patient 216. Veracity: being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress 217. Beneficence: Action should promote good 218. Non-malfeasance: Ethical concept requiring that an action do no harm, or do less harm than good 219. Justice: All patients have a right to be treated fair and equally by others. 220. AACN Clinical Standards for Acute Care Nurse Practitioners: • perform comprehensive advanced health assessments • order and interpret the full spectrum of diagnostic tests and procedures • formulate a differential diagnosis to reach a diagnosis, and • order, provide, and evaluate the outcomes of interventions. The ACNP provides comprehensive advanced nursing care across the continuum of health care services to meet the individualized needs of patients with acute, critical, and/or complex chronic health conditions. 60 / 63 NRNP Finals 6560 ACNPs do not require physician supervision or oversight as may be defined in collaborative practice arrangements to fulfill their role. - The ACNP elicits relevant data and information concerning patients with acute, critical, and/or complex chronic illnesses or injury - The ACNP analyzes and synthesizes the assessment data in determining differential diagnoses for patients with acute, critical, and/or complex chronic illnesses or injury. - The ACNP identifies individualized goals and outcomes for patients with acute, critical, and/or complex chronic illness or injury - The ACNP develops an outcomes-focused plan of care. - The ACNP implements the interventions identified in the interprofessional plan of care for patients with acute, critical, and/or complex chronic illness or injury. - The ACNP evaluates the patient's progress toward the attainment of goals and outcomes 221. AACN professional standards for Acute Care Nurse Practitioners: - The ACNP evaluates his or her clinical practice in relationship to institutional guidelines, professional practice standards, and relevant statutes and regulations. - The ACNP maintains current knowledge of best practices. - The ACNP collaborates with the patient, family, and members of the interprofessional team across the continuum of care. - The ACNP integrates ethical considerations into all areas of practice congruent with patient and family needs and values and the ANA Code of Ethic - The ACNP engages in organizational systems and processes to promote optimal outcomes. - The ACNP incorporates evidence-based diagnostic strategies, therapies, and complementary health alternatives to achieve optimal fiscally responsible outcomes. - The ACNP leads in the practice setting and in the profession. - The ACNP promotes respect for colleagues and the interprofessional team through the implementation of standards supporting a healthy work environment. - The ACNP evaluates and enhances the quality, safety, and effectiveness of care across the continuum of acute care service - The ACNP enhances knowledge, attitudes, and skills through participation in research, translation of scientific evidence, and promotion of evidence-based 61 / 63 NRNP Finals 6560 practice. 222. ICD 10 vs CPT: The ICD-10 procedural coding system (ICD-10- PCS) is used by facilities (e.g., hospital) to code procedures. CPT codes are, and will continue to be, used by physicians (and other providers) to report professional services. 223. credentialing vs privileges: Credentialing is a formalized process that incorporates established guidelines to confirm that a health care provider possesses sufficient qualifications, licensure, training, and abilities to practice at a nationally approved standard of care. Privileging is a process that authorizes a provider to perform a specific set of care services that the agency determines the provider is qualified to perform 224. Macule: A circumscribed, flat area of discoloration that is less than 10 mm* in diameter. Example: Freckle 225. Patch: A circumscribed, flat area of discoloration that is greater than 10 mm* in diameter. Slight scale may or may not be present. Example: Vitiligo 226. Papule: A circumscribed, elevated, solid lesion that is less than 10 mm* in diameter. Example: Wart 227. plaque: A circumscribed, elevated, solid lesion that is greater than 10 mm* in diameter and is usually broader than it is thick. Example: Psoriasis 228. Weal: Transient, circumscribed, edematous papules or plaques caused by swelling in the dermis. Wheals may manifest with erythematous borders and pale centers and/or a narrow peripheral zone of pallor or vasoconstriction. Example: Urticaria 229. Ulcer: A circumscribed loss of the epidermis and at least upper dermis. Ulcers are further classified by their depth, border, shape, edge, and the tissue at its base. Example: Venous stasis ulcer 230. Bulla: A large, raised, circumscribed blister that is greater than 10 mm* in diameter and is fluid filled. The fluid can be clear, serous, hemorrhagic, or purulent. Example: Pemphigus vulgaris 231. Cyst: A closed cavity or sac containing fluid or semisolid material. A cyst may have an epithelial or endothelial lining. Example: Epidermal inclusion cyst 62 / 63