TWU FHN 3 Test 1
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| Chronic illnesses are characterized by one or more of the following: | duration > 6 months
permanent or residual disability
nonreversible pathological changes
need for special rehabilitation
long term medical and/or nursing care
🗑
|
||||
| Some chronic illnesses have acute exacerbations resulting in: | loss of control of illness
times of instability with need of medical/nursing assistance
increased dependence on family members
🗑
|
||||
| Disability: | a limited functional ability as the result of an impairment; it is the term preferred over “handicap”
🗑
|
||||
| Sequelae of chronic conditions: | Limitation of functions; disfigurement
Dependence on medications or special diet
Current need for medical care/ related services
Special ongoing treatments at home, work
🗑
|
||||
| Major Chronic Conditions | Chronic sinusitis
Allergic rhinitis
Asthma
Chronic bronchitis
Heart disease
Hypertension
Diabetes
Psoriasis
Arthritis
Orthopedic impairments
Migraine headache
Visual impairment
Hearing impairment
🗑
|
||||
| What % of adults have 1 or more chronic diseases | 50
🗑
|
||||
| Each chronically ill person has average of 2 chronic diseases | Related--HTN and CHF
Unrelated--HTN and arthritis
🗑
|
||||
| 1/3 of those with chronic illness have limitations in performing ADL’s | Arthritis
Cancer
Coronary artery disease
Spinal cord injury
Highest incidence in people > age 65
🗑
|
||||
| Exact number of children with chronic illness unknown; estimates differ by definition of chronic illness in children | 31% of children under 18 years have chronic health condition
Incidence of chronic conditions have not changed (CDC, 2008)
Prevalence of children affected increased due to increasing survival and enhanced recognition
🗑
|
||||
| Maternal and Child Health Bureau Division of Services for Children With Special Needs created definition of “special health needs” for federal and state programs: | Children who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.
🗑
|
||||
| Children affected by large number of rare diseases , genetic, or prenatal conditions | Not stable; subject to acute exacerbations
🗑
|
||||
| Adults affected by relatively small number of common diseases that increase in morbidity with age. | Generally stable conditions
🗑
|
||||
| Any loss of physical/mental function has major impact on a person’s life | Changes in family roles
Drains major power sources (income, self esteem, autonomy)
Taxes coping abilities of the person
Grief over loss of normal function
🗑
|
||||
| Engel’s Theory of Loss Shock and disbelief over diagnosis | Unable to accept facts of illness
🗑
|
||||
| Engel’s Theory of Loss Development of awareness | Aware of lifelong implications of illness
Depression
🗑
|
||||
| Engel’s Theory of Loss Restitution | Family and patient provide mutual support in coping with reality of disease
🗑
|
||||
| Engel’s Theory of Loss Resolution | Responds to loss with psychological coping
Roles are adjusted to normalize activities of daily living
🗑
|
||||
| Individual Response to Chronic Illness Depends on: | Pattern of coping strategies used in the past
Pathophysiology causing the disease
Visibility of disease
Degree and type of limitations
Relationship between the disease and person’s functioning in social roles
family support
Pain, fatigue, and fear
🗑
|
||||
| Societal Response to Chronic Illness | Members of society tend to avoid persons with chronic disease
Impact on patient:
social isolation
lack of social support
🗑
|
||||
| Living With Chronic Illness Managing a medical crisis | Delegation of control to others
Can result in damage to patient’s self concept and body image
🗑
|
||||
| Living With Chronic Illness Carrying out prescribed regimens | Family and/or family must learn regimens of care
Timing of interventions
Coping with side effects
Learning how to use equipment
Pain management
🗑
|
||||
| Living With Chronic Illness Controlling symptoms | Learning acceptance of limitations on lifestyle imposed by disease
Redesigning/timing activities and hobbies
🗑
|
||||
| Living With Chronic Illness Dealing with lack of monetary resources for treatment | Costly treatments
Limitations on ability to work
Worry, anxiety, depression
🗑
|
||||
| Living With Chronic Illness Managing the trajectory (disease pattern) | Variable, depending on predictability of illness and ability of patient to cope
🗑
|
||||
| Living With Chronic Illness Preventing social isolation | Dependent on patient response to his/her tendency to withdraw from friends and society
Patient response to societal withdrawal from her/him
🗑
|
||||
| Living With Chronic Illness Normalizing | Not focused on seven problems of the disease itself
Involves working through above tasks
Occurs when patient and family accept new, realistic identities and roles
Achieves normalization-optimal level of functioning within the limits imposed by illness
🗑
|
||||
| Corbin & Strauss | Trajectory Framework describes the experience of chronic illness
🗑
|
||||
| Further refinement of Strauss’s earlier theory is applicable to | Cardiac illness
Cancer
Multiple sclerosis
Diabetes
Elderly with chronic illness
🗑
|
||||
| Corbin & Strauss Common phases Pre-trajectory | prior to diagnosis
emphasize prevention
🗑
|
||||
| Corbin & Strauss Common phases Trajectory onset | signs and symptoms
🗑
|
||||
| Corbin & Strauss Common phases Crisis phase | life threatening
inpatient care
🗑
|
||||
| Corbin & Strauss Common phases Acute phase | interventions carried out
illness/complications
🗑
|
||||
| Corbin & Strauss Common phases Stable phase | planned interventions
🗑
|
||||
| Corbin & Strauss Common phases Unstable phase | plan not working
managed out-patient
🗑
|
||||
| Corbin & Strauss Common phases Downward phase | deterioration
🗑
|
||||
| Corbin & Strauss Common phases Dying phase | terminal illness
🗑
|
||||
| Psychosocial adaptation to a chronic illness is optimally achieved by maximizing | self-control and independence
🗑
|
||||
| General Management of chronically ill | Evaluate the patient’s self-care abilities
Help the patient adjust to limitations imposed by illness
Help the patient adjust to changes in body image
Work to increase self-esteem
Assist the patient to express feelings
🗑
|
||||
| Assess coping & help the patient practice new coping mechanisms Facilitate the grieving process Promote social interaction Teach the family about the illness Participate with the health care team to devise a comprehensive plan of care | General Management of chronically ill
🗑
|
||||
| Care at the End of Life Most persons will carry a chronic illness diagnosis at the end of life | Role of the FNP:
Pain management
Facilitator of hope
Explore patient expectations about the end of life
Patient/family communication about care/prognosis
Clarification of limits of care
Caring for the family
Follow-up and grieving for family
🗑
|
||||
| Confusion: Alteration in mental status | Common term used to describe impaired cognition resulting in disturbed behavior and/or emotions
Symptom of underlying condition
Diagnostically challenging
🗑
|
||||
| Confusion: Alteration in mental status Important early sign in elderly of : | Disease
Of the brain itself
Other organ systems
Medication problems
🗑
|
||||
| Confusion: Alteration in mental status Need to determine | How abruptly it started
How long it has been going on
If the situation is progressing, and if so, how fast
🗑
|
||||
| Delirium or acute confusional state is | a syndrome of a disturbance in consciousness with reduced ability to focus, sustain, or shift attention that occurs over a short period of time and tends to fluctuate over the course of the day
🗑
|
||||
| Acute Delirium: A Medical Emergency | Acute effect of physical illness on brain function
Affects 10-52% of hospitalized elderly
Of those with dementia, the incidence of delirium is 32-82%
Often neglected as medical emergency
no history available, best to assume confusion is of new onset
🗑
|
||||
| Acute Delirium: Brain maladaptive reaction to acute stressor | Infection
Hypoxia
Hypoperfusion
Trauma
Surgeries
🗑
|
||||
| Acute Delirium: Pathogenesis: Metabolic changes | Alter availability of amino acids from plasma to the brain
Modify cerebral neurotransmission
Increased secretion of cytokines
Induces neurotransmission state of cholinergic deficiency and dopaminergic excess
🗑
|
||||
| Acute Delirium: DSM-IV Diagnostic Criteria | not accounted for by a dementia
Develops over hours to days
Fluctuates during the course of the day
Impaired ability to focus, sustain, or shift attention
Cognition impaired
or perceptual disturbance (misinterpretations, illusions, hallucinations)
🗑
|
||||
| Associated with sleep-wake cycle disturbance, disturbed psychomotor behavior, emotional disturbance,(EEG) abnormalities Evidence that disturbance is caused by a general medical condition, substance intoxication or withdrawal, or multiple etiologies | Acute Delirium: DSM-IV Diagnostic Criteria
🗑
|
||||
| Acute Delirium: symptoms | Acute change in mental status
Sleep disturb
Fluctuating course
Attention disturb
Memory disturb
Orientation disturb
Perceptual disturbance
Thought disturbance
Consciousness disturbance
Speech disturbance
Psychomotor activity disturbance
🗑
|
||||
| Main differentiating feature between Delirium and Dementia | symptom fluctuation that occurs with delirium
🗑
|
||||
| Acute Delirium Mandatory search for underlying cause(s): | Intracerebral disease
More often due to acute illness or physiological change elsewhere
Treatment of several interacting diseases (medication)
🗑
|
||||
| Acute Delirium Common causes | Acute systemic infection
Pneumonia, Urinary sepsis, Cholecystitis, Diverticulitis, Meningitis, Encephalitis
Head injury, subdural hematoma
Acute myocardial event
Rarely is one single factor responsible for onset of delirium
🗑
|
||||
| Risk factors for acute delirium | Predisposing or vulnerability factors (See Ham & Sloan Chap 16)
Precipitating or trigger factors
🗑
|
||||
| Precipitating Factor for acute delirium | use of anticholinergic drug
Anticholinergics play a dual role
Both a predisposing and a precipitating factor
total anticholinergic burden Reflects cumulative anticholinergic (antimuscarinic) actions of all medications taken by an individual
🗑
|
||||
| Several methods used to determine anticholinergic action | In-vitro affinity to muscarinic receptor
Opinion of clinical expert regarding adverse effect
Serum anticholinergic activity
🗑
|
||||
| Definite Central Anticholinergics | Ipratropium Bromide Inhaler
Meclizine
Oxybutinin
Meperidine
Paroxetine
Hydroxyzine
Chlorpheniramine
Amitriptyline
🗑
|
||||
| Diagnosis of Delirium | Acute change in mental status
Accompanying attention deficit
Disorganized thinking or change in alertness status
🗑
|
||||
| Acute and Fluctuating Changes in Mental Status as demonstrated by one of the following | Family member interview
Nurse interview
Chart review
> 2 pts acute drop in MMSE during hospitalization
Discrepancy between different examiners regarding pt’s mental status
🗑
|
||||
| Attention Deficit as demonstrated by one of the following | Nurse interview
Patient inability to spell first name backward
Patient inability to repeat a phone number
Patient inability to count backward from 20 to 1
🗑
|
||||
| Disorganized Thinking as demonstrated by one of the following | Nurse interview
Patient incoherent speech
Patient illogical speech
🗑
|
||||
| Hypoalert or Hyperalert Status as demonstrated by one of the following | Nurse interview
Chart review
Patient sleepiness
Patient restlessness
🗑
|
||||
| Agitation | Consider professional sitter
Assess impact of agitation on patient safety and d/c Foley and other tethers if possible
Consider trazodone po q 6hr PRN
If h/o ETOH consider Lorazepam PO/IM/IV q 4-6 hr PRN
🗑
|
||||
| Decreasing burden of delirium requires implementation of specialized delirium programs | Active screening to identify patients with high vulnerability (Delirium vulnerability scale)
Educating clinicians on recognizing and diagnosing delirium and identifying triggers
🗑
|
||||
| Alzheimer’s Disease A progressive, neurodengerative condition characterized by memory loss and cognitive decline. | Most common form of dementia in the older population
Insidious onset
Slow and progressive
An array of behavioral and emotional behaviors
Accounts for about $100 billion per year
Approx. $27,000 per year per patient (Dunphy, 2011)
🗑
|
||||
| According to the American Psychiatric Association, AD is characterized by the impaired ability to learn new information or recall previous learned information and one or more additional cognitive disturbances: | Language (aphasia)
Function (apraxia)
Perception (agnosia)
Executive function-interpersonal relationships, ADL’s
🗑
|
||||
| Pathologic markers for AD have been identified; however, these features also occur in the brains of cognitively intact persons | Affects in general about 1 in 10 person over the age of 65
Affects as many as half of those age 85 and older
Estimated to be 16 million affected in 2050
🗑
|
||||
| AD affects the 3 processes that keep neurons healthy | Communication, metabolism, and repair.
🗑
|
||||
| Brain Changes in Alzheimer’s Amyloid Plaques | one of the hallmarks of AD
protein fragments that the body produces normally
Healthy brains are able to break down and eliminate the protein fragments. In AD the fragments accumulate for form hard insoluble plaques
🗑
|
||||
| Brain Changes in Alzheimer’s Neurofibrillary Tangles | Insoluble twisted fibers found inside the brain’s microtubules in neurons.
In a healthy brain these microtubules are a transport system in the brain.
In AD, the tau protein is abnormal and the microtubule structures collapse.
🗑
|
||||
| Alzheimer’s Genetic Factors | Less than 10% of cases are familial
🗑
|
||||
| Alzheimer’s Risk Factors | Advancing age
Family history of APOE genotype
Obesity
Insulin Resistance
Dyslipidemia
Hypertension
Inflammatory Markers
Traumatic Brain Injury
🗑
|
||||
| Trisomy 21 predisposes to Alzheimers in late life Down’s syndrome (late 40’s or 50’s) | Chromosome 1, 14, and 19 implicated in both familial and sporadic forms
🗑
|
||||
| Mild Alzheimer disease Signs of mild AD can include the following: | Memory loss
Confusion of familiar places
Taking longer for normal, daily tasks
Trouble handling money and paying bills
Compromised judgment, often leading to bad decisions
Loss of spontaneity and sense of initiative
increased anxiety
🗑
|
||||
| Moderate Alzheimer disease | Increasing memory loss confusion
Shortened attention span
Problems recognizing friends and family members
Diff with language; reading, writing,numbers
diff organizing thoughts and thinking logically
Inability to learn new things or situations
🗑
|
||||
| Restlessness, agitation, anxiety, tearfulness, wandering, especially in pm Repetitive statements or movement; Hallucinations, delusions, suspiciousness or paranoia, irritability Loss of impulse control: Perceptual-motor problems: | Moderate Alzheimer disease
🗑
|
||||
| Patients with severe AD cannot recognize family or loved ones and cannot communicate in any way. They are completely dependent on others for care, and all sense of self seems to vanish. Other symptoms of severe AD can include the following: | Weight loss
Seizures, skin infections, difficulty swallowing
Groaning, moaning, or grunting
Increased sleeping
Lack of bladder and bowel control
🗑
|
||||
| History for Dementia 5 areas that require assess/reassessment | Ability to perform ADLs and Instrumental ADLs
Cognitive functioning
Comorbid medical and mood disorders
Caregiver status
🗑
|
||||
| Functional Activities Questionnaire (FAQ) | Bill paying
Assembling records relating to business
Shopping alone
Playing a game of skill
Performing multi-step task (writing letter, stamping, and mailing)
🗑
|
||||
| Preparing balanced meal Awareness of current events Understand/discuss TV program, book, article Remembering and keeping appointments Driving, taking bus, walking to familiar places | Functional Activities Questionnaire (FAQ)
🗑
|
||||
| Screen for depression (US Preventive Services Task Force) | Over the past 2 weeks have you felt down, depressed, or hopeless
Over the past 2 weeks have you felt little interest or pleasure in doing things?
🗑
|
||||
| Identify primary caregiver and assess for | adequacy of family support
other support services availability
🗑
|
||||
| No true treatment for Alzheimer Disease | cholinesterase-inhibiting drugs may improve function and slow decline, however in clinical trials these drugs benefits fewer than 50% of patients.
🗑
|
||||
| The glutamate antagonist memantine (Namenda) has been shown | to prolong daily function in patients with moderate-to-advanced AD
🗑
|
||||
| Acetylcholinesterase inhibitors Reversibly bind and inactive the enzyme that degrades acetylcholine, which is involved in memory. | Used as first line agents
Most trials have found no difference in effectiveness among the agents in this class.
The most common side effects are nausea, vomiting and diarrhea and dose related.
Rivastgmine (Exelon) patches my be better tolerated
🗑
|
||||
| Used as first line agents Most trials have found no difference in effectiveness among the agents in this class. The most common side effects are nausea, vomiting and diarrhea and dose related. Rivastgmine (Exelon) patches my be better tolerated | The most common side effects are nausea, vomiting and diarrhea and dose related.
Rivastgmine (Exelon) patches my be better tolerated
🗑
|
||||
| Cholinestrase Inhibitors Donepezil (Aricept) Longer duration of inhibitory action; greater specificity for brain tissue Treatment of mild, moderate, and severe Second generation cholinesterase inhibitor | Initially 5 mg/day--increase to 10 mg/day after 4-6 weeks
May have initial increase of agitation; subsides in 2 weeks
Side effects: Nausea, diarrhea
Reduce by taking with food
🗑
|
||||
| Cholinestrase Inhibitors Rivastigmine (Exelon) Treatment of mild to moderate | 1.5 mg twice daily
Can increase by 1.5 mg twice daily (3 mg/day) every 4 weeks
Max 6 mg bid
Side effects: Nausea, vomiting, diarrhea, h/a, abdominal pain, fatigue, anxiety, agitation
Reduce by taking with food
🗑
|
||||
| Cholinestrase Inhibitors Galantamine (Razadyne, previously Reminyl) Treatment of mild to moderate | 4 mg bid taken with bid with meals for 4 weeks
After 4 weeks, increase to 8 mg bid for 4 weeks
Consider 12 mg bid if tolerated and benefit noted
Advantage: no sleep disturbance
Side effects: nausea vomiting, diarrhea
Reduce by taking with food
🗑
|
||||
| NSAIDs should be avoided with cholinesterase inhibitors | (additive effective for ulcer formation)
🗑
|
||||
| NMDA Receptor Antagonist Memantine (Namenda) New class of medications N-methyl-D-aspartate (NMDA) receptor antagonists Indicated for moderate to severe AD | In AD, abnormal glutamatergic activity may cause neuronal toxicity and impair learning
Namenda (memantine HCl) permits activation of NMDA receptor
🗑
|
||||
| Memantine (Namenda) May be used in conjunction with donepezil (Aricept) for additive effect | Dosing—
Use to be a gradual titration
Now changing to extended tabs: Namendia XR 28mg once a day-same apporx. Cost $300/month
May consider stopping in 3-6 months if no improvement-taper over 4 weeks to prevent rebounds
🗑
|
||||
| Monoamine oxidase type B inhibitor selegiline (Eldepryl 5 mg bid) | In some studies some improvement seen for 4-6 wks, no improvement after 6 weeks.
Rationale: slows progression of AD
Possible association of free radicals and oxidative stress contribute to neural degeneration.
🗑
|
||||
| Anxiety in AD | Buspirone 5-7.5 mg bid up to 30 mg/day
🗑
|
||||
| Depression in AD | SSRIs are first line
Zoloft (sertraline) less effect on metabolism of other meds
Tricyclic antidepressents NOT recommended due to anticholinergic activity
🗑
|
||||
| Sleep disturbances and insomnia in AD | Good sleep hygiene
Pharmacologic as last resort
🗑
|
||||
| Treatment of Agitation In AD Warnings in the elderly: | Older patients with dementia who are treated with atypical antipsychotics have a 2x higher mortality rate.
Federal law states that if antipsychotics used in treatment in nursing homes, drug reduction efforts must be made every 6 months or less
🗑
|
||||
| Antipsychotics: | Evidence suggests that olanapine (Zyprexa) and risperidone (Risperdal) reduce aggression and risperidone reductes psychosis in patients with AD.
🗑
|
||||
| AD Management: Behavioral | Balance environmental stimulation
Familiarize routines for security and predictability
Art and expressive recreation can improve mood
Exercise outdoors to improve mood and behavior
🗑
|
||||
| Ten Warning Signs of AD | Memory loss affects job skills
Difficulty with familiar tasks
Problems with language
Disorientation to time and place
decreased judgment
Problems with abstract thinking
Misplacing things
Changes in mood/behavior/personality
Loss of initiative
🗑
|
||||
| SIMPLE LINEAR SKULL FRACTURES | Small breaks in the skull that are not associated with depressed bone fragments and underlying brain injury.
🗑
|
||||
| CONCUSSION | Trauma-induced alteration in mental status that may or may not involve loss of consciousness
🗑
|
||||
| CLASSIFICATION OF HEAD INJURIES Minimal | No loss of consciousness or amnesia.
Glasgow Coma Scale of 15.
Normal alertness and memory.
No focal neurological deficit.
No palpable depressed skull fracture.
🗑
|
||||
| Classification of Head Injuries Mild | Brief (<5 min.) loss of consciousness.
Amnesia for the event.
Glasgow Coma Scale score of 14.
Impaired alertness and memory.
🗑
|
||||
| CLASSIFICATION OF HEAD INJURIES Moderate to severe | Prolonged (>5 min.) loss of consciousness.
Glasgow Coma Scale score < 14.
Focal neurological deficit.
Post traumatic seizure.
Intra-cranial lesion detected on CT scan.
🗑
|
||||
| The Most Common Cause of Traumatic Head Injuries in All Ages is | Falls
🗑
|
||||
| Head injuries in infants | These head injuries are most often associated with falls and abuse.
ALWAYS CONSIDER “shaken baby syndrome.
🗑
|
||||
| How long after a head injury should an unhospitalized patient be observed? | 48 hours
🗑
|
||||
| What s/s are the hallmarks of a Concussion? | Confusion, amnesia
🗑
|
||||
| normal BMI | 18-24.9
🗑
|
||||
| overweight: | 25-29.9
🗑
|
||||
| Class I: Obesity BMI | 30-34.9
🗑
|
||||
| Class II: Obesity BMI | 35-39.9
🗑
|
||||
| Class III Obesity BMI | 40+
🗑
|
||||
| Distribution of fat differs in individuals Apple-shaped (upper body obesity) | More common in men
Associated with greater risk of most complications of obesity
🗑
|
||||
| Pear-shaped (lower body obesity) | More common in women
Tend to accumulate more fat in gluteofemoral region.
🗑
|
||||
| Visceral fat in abdominal cavity | more hazardous to health than subcutaneous fat around abdomen
🗑
|
||||
| Health risks are increased when: Waist circumference | Men: >102 cm (40 in)
Females > 88 (35in)
🗑
|
||||
| Health risks are increased when: Waist : Hip ratio | > 1.0 in men
> .85 in women
🗑
|
||||
| Waist circumference and waist to hip ratio are both a better predictor than BMI for health risk | Diabetes mellitus
Stroke
Coronary artery disease
Early death
🗑
|
||||
| relative risk associated with obesity decreases with age | Weight no longer risk factor in adults >75 years of age
🗑
|
||||
| Increased weight results in increased incidence of | CVD
Type 2 diabetes
Degenerative joint disease (Osteoarthritis)
Hypertension
Hyperlipidemia
Certain cancers:
suppressed immune function
Digestive tract disease
Increased surgical and obstetric risks
Endocrine abnormalities
Proteinuria
🗑
|
||||
| 40-70% of obesity explained by | genetic influences
🗑
|
||||
| Obesity results from | genetic predisposition, environmental factors, and psychological behaviors
🗑
|
||||
| Visceral abdominal adipose tissue associated with obesity appears to be act as an endocrine gland | releasing several atherogenic, inflammatory, proteins associated with increase diabetes and CVD risk.
🗑
|
||||
| Plasminogen Activating Inhibitor 1 (PAI-1) | PAI-1 decreases with caloric restriction, exercise, weight loss and metformin treatment
🗑
|
||||
| Retinol-binding protein 4 (RBP-4) Reported to be associated with visceral-fat accumulation and parameters of the metabolic syndrome (MetS). | Studies of bariatric surgery weight loss patients show marked decreases that correlate with loss of visceral fat
🗑
|
||||
| Adipokinases affect insulin action in obesity: Tumor Necrosis Factor alpha | Secreted from adipose tissue proposed as a molecular link between obesity and insulin resistance.
Inactivates insulin receptors
Correlates with BMI, percentage of body fat and insulin resistance.
Weight loss decreases TNF
🗑
|
||||
| Peptide resistin | Interferes with insulin action on glucose metabolism
Levels elevated in obese animal models
🗑
|
||||
| Leptin (1994) protein (leptin = Greek for thin) Leptin is released from fat cells in response to changes in body fat | Crosses the blood brain barrier-receptors in the hypothalmus
Increases sensitivity to insulin by increasing hepatic responsiveness
Appears to affect appetite: decreased levels of leptin are associated with obesity
🗑
|
||||
| Leptin replacement | has shown improved glycemic control, decrease in triglycerides, decrease in caloric intake
🗑
|
||||
| Adiponectin | Also seems to increase sensitivity to insulin by increasing hepatic responsiveness
🗑
|
||||
| Angiotensinogen | Major risk factor for CVD
Associated with obesity---adipose tissue is the major extrahepatic source of AGE
Appears to increase new adipose formation
🗑
|
||||
| Serotonin | Regulates food selection
Increases mood
Increases carbohydrate cravings/food addiction
🗑
|
||||
| Thermogenesis alterations in obesity | Normal process involves use of calories by converting food to heat
In obese, energy is stored, not converted to heat
Less sympathetic nervous system activity
🗑
|
||||
| 60% of obese individuals have metabolic syndrome as defined by NCEP ATP III: | Elevated abdominal circumference
Men > 102cm (40 inches)
Women >88cm (35 inches)
Elevated blood pressure >130/85
Elevated blood triglycerides > 150 mg/dl
Elevated fasting blood sugar >110 mg/dl (others >100mg/dl)
Lo HDL cholesterol
🗑
|
||||
| WHO criteria for Metabolic Syndrome slightly different: | High insulin levels
Elevated FBS or post prandial glucose
+2
Of the NCEP ATP III Guidelines
🗑
|
||||
| patients with Metabolic Syndrome have | Decrease in tissue (liver, muscle, adipose) sensitivity to insulin or “insulin resistance”
This produces an increase in circulating insulin levels
Increased insulin produces more fat cells
Fat and glucose metabolism impaired
Desire to eat more
🗑
|
||||
| Most obesity is the result of | overeating/decreased exercise with the accompanying cascade of metabolic changes
🗑
|
||||
| Major endocrine disorders that may manifest with obesity are: | Pituitary and adrenal dysfunction
Thyroid disease
Polycystic ovary syndrome
Hypothalamic disease
🗑
|
||||
| OBESITY IN CHILDREN | Overweight before age 3 not prediction of future obesity, unless parents obese
After 6, the chance that obesity will persist increases 50%
Approximately 70% of obese adolescents will remain so as adults
🗑
|
||||
| Overweight in Children: | defined as a sex and age specific BMI at or above the 95th percentile based on revised growth charts by the CDC
🗑
|
||||
| Obesity in Children | defined as a mean weight above the 120th percentile for height. Some sources use the 125th percentile and some use 130th. BMI >85 percentile.
🗑
|
||||
| Obese children should be evaluated for presence of associated co-morbidities | Cardiovascular disease
Type 2 Diabetes-
Weight related orthopedic problems
Skin disorders
Psychiatric problems
Sleep apnea
🗑
|
||||
| Factors influencing weight in Children | Heredity
Overeating
Emotional and Psychological Factors
Body Changes and Puberty
Medications/Medical Conditions
Community Factors
🗑
|
||||
| What % of overweight children can achieve optimal weight with intervention | 80-90
🗑
|
||||
| Childhood Obesity intervention Plans incorporate | Modification of child and family’s diet
Regular exercise
Family-based behavior modification programs
Establish treatment plan with the family
🗑
|
||||
| Obesity assessment | required at every well child exam
🗑
|
||||
| Childhood Obesity Goals | Normalize child’s weight within his genetic potential
Reduce health risks through improved diet and activity
Support treatment of underlying biological and psychosocial contributors.
View obesity as a symptom with diverse contributors
🗑
|
||||
| Contraindications to weight loss | Pregnancy
Anorexia nervosa
Terminal stages of illness
Medical or psychiatric illnesses should be stable
🗑
|
||||
| MANAGEMENT OF OBESITY Goals of treatment: | Lowest weight the patient can comfortably maintain- initial goal is 5-10% of total body weight
Cosmetic goals should be discouraged
Prevention of weight gain
🗑
|
||||
| Alternative goals for management of obesity: | Improvement in comorbidities, mobility, and feelings of well-being, reduction in waist circumference and adherence to a diet and exercise regimen.
🗑
|
||||
| Weight loss requires creating a calorie deficit | To lose 1 pound-must ingest 3,500 fewer calories than expended
Most lose weight if ingest fewer than 1,500 calories per day and do aerobic exercise regularly
🗑
|
||||
| Fats: | body uses only 3 calories to store 100 calories of fat.
🗑
|
||||
| Body uses 25-40 | calories to convert 100 calories of protein into body fat
🗑
|
||||
| Daily fat intake should not exceed ____ of total caloric intake | 30%
🗑
|
||||
| Fiber: | Improves blood glucose levels through enhancing insulin effects and reduces number of calories absorbed by the body
🗑
|
||||
| EXERCISE | Raises metabolic rate
Helps keep weight down that was lost
Walking briskly for 20-30 minutes a day
🗑
|
||||
| SUPPLEMENTS | Not all that on market are safe and effective
Herbal products still largely unregulated
🗑
|
||||
| Chromium: | Mineral-key role in increasing cell sensitivity to insulin
Lowers body wt, yet increases lean body mass
Recommended dosage 400-600 mcg/day.
no reported significant adverse effects
Refined sugars, white flour, and lack of exercise deplete chromium
🗑
|
||||
| Thermogenic Formulas Ephedrine ( also ma huang) | Data conflicting, weight loss rarely permanent, esp after drugs disc.
SE: insomnia, irritability, jitters, elevated BP
Products have been removed from the market 2004!!
🗑
|
||||
| Guggul: | Herb used in ancient Indian system of medicine
Increases HDL and lowers total cholesterol and trig.
Dose for wt loss is 25 mg TID
No adverse effects noted
🗑
|
||||
| Pantothenic Acid (vit B5) used in energy production of fats and carbohydrates | 1 study demonstrated wt. loss in subjects on 10 gms/day followed by maint. 1-3 gm/day
🗑
|
||||
| Coenzyme Q10: | Can improve energy production at cellular level, increasing thermogenic response to meals
No serious SE
Statins and beta blockers lower body’s CoQ10 levels
Supplementation may be helpful in pts taking these
🗑
|
||||
| FORMULA DIETS | Called supplemented fasts
Optifast, HMR, and Medifast
Provide superior weight loss and rapidly reduce severity of number complications of obesity
Close medical supervision
Must be used with support and behavior, nutrition, and exercise education.
🗑
|
||||
| Obesity PHARMACOTHERAPY | May be used as adjunct
Indications for use of FDA approved drugs:
Patients with a BMI >30
Patients with BMI >27 in presence of concomitant obesity-related risk factors or diseases
🗑
|
||||
| Orlistat (Xenical) approved for long term use <2 years | Prevents absorption of 30% of fat
Reduces LDL and increases HDL, reduces BP, and fasting insulin levels
Causes diarrhea, flatulence
Encourage use of multiple vitamin
120 mg TID with meals
No significant adverse reactions
🗑
|
||||
| Belviq: a serotonin 2C receptor agonist FDA approved 2012 Schedule IV 10 mg BID for up to 12 weeks Contraindicated in pregnancy | Warnings
Serotonin Syndrome/Neuroleptic Malignant Syndrome reaction
Valvular heart disease
Cognitive impairment
Monitor for depression/suicidal thoughts
Antidiabetic meds: Hypoglycemia with wt loss
Priapism: seek treatment for erection > 4 hrs
🗑
|
||||
| Qsymia (ku-si-mia) is an extended release combination of two drugs (FDA approved 9/2013) | Phentermine, a sympathomimetic: (Schedule IV)
Appetite suppressant
Topiramate, an antiepileptic
Increases feelings of fullness, blunts taste, and increases calorie burning
BEST USE BY BARIATRIC MD
🗑
|
||||
| Appetite suppressants-most controversial and less used today due to rebound weight gain & CVD risk | Chemically related to amphetamines
Schedule IV
Short-term ( 3 month) use
Rare side effect of pulmonary hypertension
Phentermine HCL
Adipex, Fastin, Ionamin, others
Dosed differently
🗑
|
||||
| Both glucophage (Metformin) and Byetta (exenatide) have been shown to | reduce weight in diabetics.
🗑
|
||||
| MAINTENANCE OF WEIGHT LOSS Successful strategies | Consultation with health care provider or nutritionist or other support source
Adhering to stable diet
Monitoring weight
Eating breakfast
Regularly exercising
🗑
|
||||
| Consistent weight loss is limited by adherence | to a consistent regimen
🗑
|
||||
| MAINTENANCE OF WEIGHT LOSS Behavioral factors associated with success | Establish social support
avoid disinhibited eating
Avoid binge eating
Avoid eating in response to negative emotions/stress
Be accountable for one’s decisions
Foster sense of autonomy, internal motivation and self-efficacy toward wt loss maintenance
🗑
|
||||
| Risk factors associated with weight regain | Disinhibited eating
Binge eating
Periods of excessive hunger
Eating in response to negtive emotions/stress
Passive reactions to problems
Less assumption of responsibility in life
🗑
|
||||
| SURGICAL TREATMENT | According to National Institute of Diabetes and Digestive and Kidney Diseases GI surgery most effective treatment for severely obese persons who fail to lose weight through diet and exercise.
🗑
|
||||
| SURGICAL TREATMENT Option for weight reduction in limited number of patients with BMIs | >40 or >35 with comorbid conditions
Include: vertical-banded gastroplasty and gastric bypass
🗑
|
||||
| Malabsorptive operation | decreases the amount of food that can be ingested, as well as calories and nutrients.
🗑
|
||||
| Restrictive operations | reduce stomach size: adjustable gastric banding and vertical banded gastroplasty
🗑
|
||||
| Gastric bypass patients | require nutritional supplementation
at risk for vitamin B-12 deficiency
may experience dumping syndrome (weakness, sweating, diarrhea
🗑
|
||||
| Anorexia Nervosa Definitions | Refusal to maintain a reasonable body weight; divided into restricting and binge-eating/purging subtypes (Dambro, 2000).
Symptomatic disturbance of eating behavior unique to the developed world (Uphold & Graham, 2003).
🗑
|
||||
| Anorexia Nervosa Etiology | Exact etiology is unknown; however, is thought to be largely emotional
Co-morbid major depression and/or dysthymia in 50-75% of patients
Obsessive-compulsive disorder in 10-13% of patients
🗑
|
||||
| Anorexia Nervosa Predispositions | First degree female relatives
Usually adolescents or young adults
Female-to-male ratio: 10:1
Perfectionistic, rigid, inflexible, and conforming personalities
Low self-esteem
Acceptance of the culturally condoned ideal of slimness
🗑
|
||||
| Anorexia Nervosa Signs & Symptoms | Insidious onset, or
Stress-related onset
Deny problem
Claim to feel fat
Elaborate eating rituals
Preoccupation with body size/weight control
Extensive exercising
Stress fractures
Cracked, dry skin
Social isolation
Sexual disinterest
🗑
|
||||
| Fine, downy lanugo hair on extremities, face, and trunk Amenorrhea Hypotension and bradycardia Hypothermia Cognitive decline | Anorexia Nervosa Signs & Symptoms
🗑
|
||||
| Diagnostic Criteria for Anorexia Nervosa | Refusal to maintain weight at or above a minimally normal weight for age and height
Severe body-image disturbance in which wt has undue influence on feelings of self-worth; denial that current wt is problematic
Intense fear of weight gain
Amenorrhea
🗑
|
||||
| Types of Anorexia Nervosa | Restricting type: not regularly engaged in binging or purging behaviors
Binge-Eating/Purging type: regularly engaged in binging or purging behaviors
🗑
|
||||
| Anorexia Nervosa History | Obtain weight history
Establish absence of diagnostic criteria via appropriate questions
Medication use to induce weight loss
Inquire about other eating behaviors
Careful diet history
Exercise patterns
🗑
|
||||
| Anorexia Nervosa Initial lab should include | CBC, UA
Electrolytes
Calcium, magnesium, phosphorous
Liver function, BUN, Creatinine, TSH
Serum amylase
Elevated during active vomiting
Return to normal within 72 h after vomiting stops
May be useful in documenting presence of bulimia
EKG
🗑
|
||||
| Anorexia Nervosa Hospitalize | if weight <75% of normal for height and age
if marked orthostatic hypotension, bradycardia <40, tachycardia >100, or inability to sustain core body temperature of 98.6°
if patient is suicidal; or if there has been no response to outpatient therapy
🗑
|
||||
| Anorexia Nervosa Outpatient Treatment | Imperative to build trust and treatment alliance
Involve client in establishing target weight
Achieve gradual weight gain
Weigh weekly at first; monthly when progress is evident
🗑
|
||||
| Focus on overall indices of health, rather than wt gain alone Challenge fear of wt gain Family therapy for adolescents; couples therapy for older clients When conditioning is chronic, goal may be to achieve a safe wt rather than a healthy wt | Anorexia Nervosa Outpatient Treatment
🗑
|
||||
| Anorexia Nervosa Medication Treatment Medications should not be used as sole or primary treatment of this disorder; however: | SSRIs relieves symptoms, are considered safest antidepressants
Helpful for patients with depression, anxiety, and obsessive-compulsive tendencies
🗑
|
||||
| Bulimia: Diagnosis | Episodic binge eating
At least 2x weekly for 3 months
Sense of lack of control
followed by recurrent inappropriate compensatory behavior to prevent weight gain
Self-induced vomiting
Diuretic or laxative use
dieting or fasting
excessive exercise
🗑
|
||||
| Types of Bulimia Nervosa | Purging type: engaged in self-induced vomiting, laxative, diuretic or enema use on regular basis
Nonpurging type: engages in fasting or excessive exercise, but not regularly engaged in above purging behaviors
🗑
|
||||
| bulimia affects predominantly | Young, white, middle and upper class women
More difficult to detect than anorexia due to the typically normal weight for age and height
Some individuals may have above normal weight range however
As high as 19% of college-age women
🗑
|
||||
| Binge eating | Premeditated, secretive episodes of binging
Consume large quantities of easily ingested high-calorie foods
Fast eating with inability to slow down or stop
Eat until painfully full
Typically occurs separately from regular meals
🗑
|
||||
| Purging | Self-induced vomiting
Relieves pain and facilitated further binging
Fingers, spoon, toothbrush used to trigger gag reflex
Some can elicit vomiting reflex at will
Cathartics, diuretics
Syrup of ipecace, enema use
🗑
|
||||
| Bulemia Non purging type Binging, then use of compensatory mechanism to make up for calories consumed | Fasting
Excessive exercise
Defined as taking precedence over other important activities
Ritualistic
Less secretive than other compensatory behaviors, so can serve as red flag to clinicians
Strict dieting
🗑
|
||||
| Bulimia Nervosa Clinical findings | History of premorbid obesity
Greater incidence of cathartics and diuretics
More impulsive or anti-social behavior
Menstruation is usually preserved
Symptoms usually related to mechanism of purging
Abdominal pain
🗑
|
||||
| Bulimia Nervosa pt complain of Abdominal pain due to | Gastroesophageal reflux due to loss of lower esophageal sphincter control due to repetitive vomiting
Gastritis due to irritated mucosa from increased acid exposure
Early satiety
Involuntary vomiting
Hematemesis or esophageal rupture
🗑
|
||||
| Physical exam of Bulimia | Dehydration
Orthostatic hypotension
Enlargement of parotid glands
Oral cavity
Abdominal tenderness
Abrasion of finger joints (PIPs) due to scraping of fingers against teeth to induce vomiting
Tachycardia and hypertension
🗑
|
||||
| Bulimia Laboratory findings Vomiting | Metabolic alkalosis
Hypokalemia
Hypochloremia
🗑
|
||||
| Bulimia Laboratory findings laxative overuse | Metabolic acidosis
Hypokalemia
Hypochloremia
🗑
|
||||
| Bulimia Laboratory findings | Elevated amylase due to chronic parotid stimulation
🗑
|
||||
| Complications of Bulimia | Gastric dilatation
Pancreatitis (check amylase)
Poor dentition
Pharyngitis
Esophagitis and esophageal rupture
Aspiration pneumonia
Electrolyte imbalance and dehydration
Severe constipation with withdrawal of laxatives
Hemorrhoids
🗑
|
||||
| Diet pill side effects | Insomnia
Hypertension
Tachycardia
Seizure
Sudden death
🗑
|
||||
| Bulimia Hospitalization If failure in outpatient management If medically unstable | If K+ < 3.0 mEq/L inpatient admission
Oral K+ supplementation
IV K+ if <2.5
🗑
|
||||
| Chronic dehydration in bulimia | Renin-angiotensin-aldosterone axis and antidiuretic hormone level elevate to compensate for chronic dehydration
Fluid retention possible when dehydration corrected as levels take 7-10 days to normalize
Patient at risk for CHF
🗑
|
||||
| Psychotherapy and nutrition counseling in Bulimia | Cognitive-behavioral therapy (CBT)
Understand disease
Suggestions for stopping binge/purge cycle
Interpersonal therapy (IPT)
Understand the sources and reason for poor coping skills
Family therapy
Nutrition therapy
Normalize eating patterns
🗑
|
||||
| Drug therapy For Bulimia | SSRIs recommended (FDA approved in higher doses than for depression)
Fluoxetine (Prozac) 60 mg/day
Blackbox warning: risk of suicide in children and adolescents
🗑
|
||||
| Medical Therapy in Bulimia | Electrolyte monitoring periodically
Drug therapy
Treatment for reflux and gastritis
Parotid gland swelling and pain
Sucking on tart candy
Application of heat
🗑
|
||||
| Long-term psychiatric prognosis in severe bulimia is worse than that in anorexia nervosa | Prognosis is better if younger age of onset and shorter duration of illness
Prognosis worse if coexisting psychiatric conditions
🗑
|
||||
| Associated problems of eating disorders | Depression and anxiety
Obsessive-compulsive disorders
Suicidal ideation and attempt
🗑
|
||||
| NP role is in recognizing, diagnosing, and appropriately referring cases of bulimia nervosa. | Listen for physical complaints that may provide clues that patient is in denial; d
Establishing a therapeutic alliance is essential
Proceed in nonjudgmental manner
assessment of healthy behaviors and nutritional habits to diffuse denial
🗑
|
||||
| Depression Definition: illnesses that affect mood and results in a range of feelings and symptoms. | Diagnosis based on criteria in the Diagnosis and Statistical Manual of mental Disorders, 4th Edition (DSM-IV).
🗑
|
||||
| DSM-IV Criteria | 1. Depressed mood/Sadness
2. loss of pleasure
3. Sleep changes
4. Appetite changes
5. Feelings of worthlessness
6. Fatigue or loss of energy
7. Trouble concentrating/making decisions
8. Low self-esteem
9. Recurrent thoughts of suicide (ideation)
🗑
|
||||
| Depression ETIOLOGY: Organic: can be a part of or presenting symptom of medical illness: | Alzheimer’s
End-stage renal failure
Parkinson’s disease
CVA
Cancer
Chronic fatigue, chronic pain+
🗑
|
||||
| Depression often occurs in individuals with family history | of depression or related illnesses
🗑
|
||||
| Brain-based illness: | changes
in brain neurochemistry and function demonstrated by research,
including sleep electroencephalographic studies, positron-emission
tomography, single-photon-emission CT, or CSF catecholamine metabolite
levels.
🗑
|
||||
| Medications that Cause Depression | Antihypertensives
Hormones
Anticonvulsants
Steroids
Digitalis
Antiparkinsonian agents
Antineoplasstic agents
Antibiotics
🗑
|
||||
| Mixtures of environmental/biologic factors underlying severe mood disorders. | Elevated cortisol
Blunted response to TSH
Abnormal response of growth hormone to prolactin
Neurotransmitter levels (norepinephrine/ serotonin 5-HT) may be altered.
🗑
|
||||
| Major Depressive Disorder: | Est. that 1 out of every 10 people treated in primary care. > in females.
Episodes can be single or recurrent.
Can last up to 2 years. High co-morbidity with substance abuse disorders.
🗑
|
||||
| Dysthymic Disorder (Chronic Depression):Onset less discreet, symptoms less acute. Duration of symptoms must be in excess of 2 yrs. (1 year in children). | Usually
do not require hospitalization due to less acute symptoms. Talk
psychotherapy needed along with pharmacotherapy. Pts. at risk for
suicide and substance abuse.
🗑
|
||||
| Substance-Induced Depressive Disorder: Consider DX when symptoms emerge as result of use of illegal drugs, medications, or toxins. | Symptoms
exceed what is usually seen with intoxication and withdrawal syndromes
or when symptoms are severe enough to warrant independent evaluation and
treatment.
🗑
|
||||
| Adjustment Disorder (Situational depression): | Symptoms associated with an identifiable stressor within the last 6 months.
Symptoms > 6 months would indicate a major depression.
🗑
|
||||
| Seasonal Affective Disorder: Episodes of MDD emerge in fall and last through winter and cannot be attributed to other biologic or psychosocial stressors. | Higher the latitude, more prevalent the incidence.
Treatment with traditional therapy and medications along with exposure to intense light is effective.
🗑
|
||||
| Postpartum Depression: Onset occurs within 4 weeks after birth of infant. Symptoms similar to MDD, but in addition mother often has psychotic symptoms that involve delusional thoughts about the infant. | Occurs in up to 1 in 500 births. Can result in infanticide. Mother needs emotional support and often separation from infant.
🗑
|
||||
| Premenstrual Dysphoric Disorder | (PMDD): Depressive symptoms during the late luteal phase of the menstrual cycles may occur throughout the year.
🗑
|
||||
| Psychotic Depression: | Exhibits all S&S of MDD as well as psychotic symptoms. May include delusions and/or hallucinations.
Associated with high incidence of suicide and commonly warrants inpatient care.
Meds include antidepressants and antipsychotics.
🗑
|
||||
| Bipolar Disorder: 1% of the general population Strong biological and genetic influence 10% of children with one parent who is bipolar will develop the illness | Episodes of mania and depression, or extreme highs and lows.
4 or more episodes/yr are “rapid cyclers”
Psychotic features may or may not be present during manic episodes.
Generally manic phase is shorter than depression phase
🗑
|
||||
| Bipolar characterized by excesses: | hyperactivity
increased irritability/flight of ideas
over indulges in activities that later regrets
overspending/gambling
sexually acting out
hasty marriage, quitting a job
🗑
|
||||
| Treatment of Bipolar Disorder | Mood stabilizers are the main foundation for maintenance therapy.
Antidepressants are not used as first line and should be used only with a mood stabilizer.
Electroconvulsive therapy may be used for nonresponsive to psychopharmacology
🗑
|
||||
| Depression - Any type | First-must evaluate patient’s potential risk for self-harm and ensure patient safety.
🗑
|
||||
| Depression - Management | Adjunctive psychotherapy should be considered .
Treatment is usually effective> 90%
Treatment 6-9 months for MDD
Adults who exercise regularly report lower levels of depressive and anxiety disorders.
🗑
|
||||
| Antidepressants should be continued indefinitely at full dosage in persons with more than 2 episodes | after age 40 or one episode after age 50.
🗑
|
||||
| Treatment for Depressive Disorders | Takes 4-6 weeks to yield significant reduction or remission of symptoms.
Small percentage are unresponsive to existing treatments.
🗑
|
||||
| Depression Nonsedating medication: | Tricyclic antidepressants and SSRIs are appropriate antidepressants prescribed by primary providers
Both equally efficacious, but SE of SSRIs are less problematic and more frequently used.
🗑
|
||||
| Tricyclics For Depression | Available since the 1950’s
All have similar effects, dosing, & efficacy
Major advantage over newer agents is sedation potential and cost
Start at low doses and increase gradually
🗑
|
||||
| Side Effects of Tricyclic medications | Anticholinergic effects: dry mouth, constipation, urinary retention, increased ocular pressure, confusion.
Anti-adrenergic effects: postural hypotension, less with Nortriptyline
Have quinidine-like effects increasing QT interval on the ECG.
🗑
|
||||
| Serotonin Reuptake Inhibitors | Few side-effects
Major reason for stopping is libido/ejaculatory problems
Tolerated by elderly, but start at low doses
Monitor for worsening of Parkinson’s symptoms
SSRI’s inhibit various isoenzymes of the cytochrome P-450 system of the liver
🗑
|
||||
| SSRI and combinations have now been given a warning in pregnancy due to risk of congenital problems. | SSRI and combinations have now been given a warning in pregnancy due to risk of congenital problems.
🗑
|
||||
| Fluoxetine (Prozac) 10-20 mg | Long half-life
Well tolerated
Main reason for stopping: decreased libido/ejaculatory problems (true for all SSRIs)
Stigma associated with Prozac
Now available in generic-may be less cost
🗑
|
||||
| Zoloft (Sertraline) 50-100mg x 1 | Similar to Prozac in action and side effect.
SSRI for Depression
🗑
|
||||
| Celexa (Citalopram) 20 mg x 1 | SSRI for Depression
Less effect on libido
🗑
|
||||
| Paxil (Paroxetine) 10-20mg x 1 | FDA approval for anxiety, panic, OCD
🗑
|
||||
| SSRI/norepinephrine, dopamine blocker Bupropion (Wellbutrin, Zyban) | Wellbutrin, should use SR
Less weight gain-warning with eating disorders.
Low toxicity
Lower risk of sexual dysfunction
Useful with bipolar and ADHD
Disadvantage-raises threshold for seizures
🗑
|
||||
| Norepinephrine/serotonin Reuptake Inhibitors | work well with both depression and anxiety symptoms
Different structure than any other antidepressant
Can elevate B/P
Need to titrate dose when starting and weaning off Effexor and Cymbalta,
Headache, dizziness, body aches, with abrupt withdrawal.
🗑
|
||||
| St John’s Wart: more effective than placebo in mild to moderate depression. | Warning: MAO derivative-drug interactions
Interacts with oral contraceptives
🗑
|
||||
| Exercise combined or alone | improves mild to moderate depression.
🗑
|
||||
| All antidepressants effective in acute treatment of all grades of depressive disorder in | young adults
🗑
|
||||
| No clinical significance in effectiveness between different kinds of antidepressants. | Did vary on tolerance of side effects.
🗑
|
||||
| ECT involves passing electrical current through brain to induce series of generalized seizures. | Hypothesized that these seizures render changes in neurotransmitter receptors which are similar to those seen in pts who have been on long-term pharmacotherapy with antidepressants.
🗑
|
||||
| Current research suggests ECT is one of safest treatments for MDD and psychotic depression. | Works quickly and proven useful for pts who are unresponsive to lengthy trials of medications. Causes short-term, temporary confusion and memory loss.
🗑
|
||||
| Consideration for Referral/Hospitalization | At risk for suicide
Inability to care for oneself
Diagnosis of Bipolar Disorder
Initiation of ECT
Evaluation and treatment with psychotherapy and/or cognitive therapy
Education and support for family members
🗑
|
||||
| Depression Treatment of children, adolescents, and elders. | Children/adolescents do have depression, Counseling is an important component. SSRI’s frequently used.
Children with severe symptoms should be referred.
🗑
|
||||
| Diagnosis of depression should be considered in all older persons who report somatic symptoms, particularly those having chronic symptoms that appear to have no definite organic basis. | Elderly:
Side effects more of an issue
Start with 1/4 to 1/2 average dose
At higher risk for suicide
🗑
|
||||
| Depression Follow-up | initial follow-up visit within 1 week to evaluate medication SE and encouragement
Weekly or biweekly visits for 6 weeks while medications are being adjusted and evaluated Then Monthly or bimonthly
PT should be seen quarterly as long as on medication
🗑
|
||||
| ECT should be primary treatment for patients with | psychotic or delusional depression or for patients who are actively suicidal or who will not eat or drink, but societal and legal prejudice limits its use.
🗑
|
||||
| A signed “contract” may be an option to utilize in a clinic setting for a patient that is waiting for appointment at a psychiatrist, especially if they have suicidal ideation. | Should see these patients daily until stable or seen by specialist.
🗑
|
||||
| DEFINITION of ANXIETY: | Common natural emotion: temporary sense of panic, fear, nervousness, or being overwhelmed-everyone experiences
May be part of disorder in which symptoms are prominent, persistent and disruptive to daily living or to sense of well being
🗑
|
||||
| Anxiety - Second most common group of mental disorders in general population Women 2X than men | Persons seek medical attention because attribute symptoms to serious physical problems
Anxiety disorders frequently unrecognized
🗑
|
||||
| Types of Anxiety Disorders | Panic disorder
Generalized anxiety disorder (GAD)
Adjustment disorder with anxious mood
Post traumatic stress disorder (PTSD)
Simple phobia
Social phobia
Obsessive-compulsive disorder (OCD)
🗑
|
||||
| Anxiety Associated with specific biological abnormalities in CNS; associated with receptor of neurotransmitter (GABA) and area in pons called locus ceruleus. | Stimulation of locus ceruleus increases anxiety.
Benzodiazepines stimulates GABA receptors and reduces anxiety symptoms. GABA receptors in cerebral cortex are inhibitory.
May have a genetic component
🗑
|
||||
| Panic Disorder EPIDEMIOLOGY: | Most commonly presents in young adulthood (24-26 years- mean)
Increase in onset of panic attacks observed at ages 15-19.
Onset of panic disorder after age of 40 is rare
🗑
|
||||
| Panic Disorders SYMPTOMS: | Dyspnea, choking sensation, syncope, palpitations, tachycardia, chest pain, diaphoresis, nausea, trembling, paresthesias, hot flashes, and chills
Fear that they are going crazy or doing something uncontrolled
🗑
|
||||
| Panic Disorders CLINICAL FINDINGS | Initial attack-spontaneous, unexpected
Attacks occasionally follow excitement, emotional trauma, or exertion and do not necessarily represent panic disorder
Ingestion of caffeine, alcohol, or nicotine or drugs may precede attack
🗑
|
||||
| Panic disorders Typical attack: begins with 10-15 minute period of accelerating symptoms Entire attack lasts about 30 minutes | Not unusual for patient to develop phobic avoidance of certain situations coincidental with panic attack
Common feature-anticipatory anxiety
Young, healthy adults frequently present to ER with cardiac and respiratory complaints
🗑
|
||||
| Panic Disorders DSM-IV diagnostic criteria: Recurrent unexpected panic attacks At least one of attacks has been followed by at least 1 month of one or more of following: | Concern about additional attacks
Worry about implications or consequences of an attack
Significant change in behavior related to attacks
not due to direct effects of a substance
not better accounted for by another mental disorder
🗑
|
||||
| Panic Disorders LABORATORY TESTS: | Basic tests and studies needed to rule out associated disease: thyroid studies, serum electrolytes, blood glucose, ECG, CXR.
Other tests based on clinical judgment
🗑
|
||||
| Panic disorders TREATMENT: Psychological | Relaxation training
Exposure therapy in PD with agoraphobia
Cognitive therapy
🗑
|
||||
| Panic disorders TREATMENT-PHARMACOLOGICAL | Antidepressants-effective. Imipramine-improvement in symptoms in 70-90% of pts after 6 weeks of therapy. Tricyclics, SSRIs used in full therapeutic antidepressant doses
🗑
|
||||
| Benzodiazepines effective in reducing anticipatory anxiety. Xanax results in marked improvement in 50% of pts. | Should be for short term use only.
🗑
|
||||
| Panic Disorders treatment | Most effective form is combination of pharmacologic agent and cognitive behavioral therapy
🗑
|
||||
| Panic disorders Lifestyle Changes: | DIET: Avoid caffeine, nicotine, and ETOH.
Stress management !!!!!!
Relaxation Techniques: Yoga!
Exercise: 30 minutes aerobic exercise per day
Desensitization to triggers
🗑
|
||||
| GENERALIZED ANXIETY DISORDER SYMPTOMS: Worry and anxiousness over multiple real or projected problems. Worry out of proportion to situation and out of control At least three of following | Restlessness
Fatigue
Trouble concentrating
Irritability
Sleep disturbance
Muscle tension
🗑
|
||||
| GENERALIZED ANXIETY DISORDER Frequently episodes of severe autonomic symptoms: | Cardiac: chest pain, palpitations, tachycardia, tachypnea
Pulmonary: hyperventilation, smothering sensations, dyspnea
Gastrointestinal: indigestion, abdominal pains, flatulence, diarrhea, constipation
🗑
|
||||
| Obsessive Compulsive Disorder | Recurring thoughts such as fear of exposure to germs.
Anxiety may be alleviated by ritualistic performance-frequent hand washing, hair pulling, in severe forms may perform self mutilation-cutting
May present with an eating disorder
🗑
|
||||
| SYMPTOMS COMMON TO ANXIETY AND DEPRESSION: | Fatigue
Tearfulness
Eating disturbances
Irritability
Excessive worry
Difficulty concentrating
🗑
|
||||
| SYMPTOMS ESPECIALLY CHARACTERISTIC OF ANXIETY | Difficulty falling asleep or staying asleep
Pain syndrome-tends to be acute, sharp
Complaints of nervousness-want help
Mood may be elevated
Autonomic symptoms prominent
🗑
|
||||
| SYMPTOMS ESPECIALLY CHARACTERISTIC OF DEPRESSION: | Early morning awakening
Pain syndromes-chronic, dull
Pts unaware of their illness, want to be left alone
Mood may be depressed
Anhedonia
Suicidal thoughts
🗑
|
||||
| Depression combined with Anxiety TREATMENT: Psychotherapy | Stressors should be sought and patient’s coping mechanisms explored
Supportive counseling, cognitive therapy, psychodynamic psychotherapy, family therapy, or various behavior therapies most frequently used
Other: exercise, medication, etc
🗑
|
||||
| Depression/Anxiety TREATMENT- Pharmacotherapy(agents) | SSRI frequently used in Primary Care
Azipirones: 1 approved-Buspirone (BuSpar). Benzodiazepines: grouped according to duration of action:
Tricyclic antidepressants: Often used with antianxiety agents. Occasionally effective alone for GAD
🗑
|
||||
| Approaches to Pharmacologic Treatment/Insomnia | Hypnotics:
Scheduled drugs CIV
CYP 34A inhibitors
🗑
|
||||
| Ambien-warnings for abnormal sleep activity-sleep walking/driving behavior | Zolpidem (Ambien) CR version is delayed release
Eszopiclone (Lunesta)
🗑
|
||||
| Sedating antidepressant for sleep disorders: | Elavil 10-50 mg at hs
Trazedone 50-100 mg at hs
Pamelar (Nortriptyline 50-100mg
🗑
|
||||
| 5.2 Million with CHF in the United States | 400,000 cases CHF diagnosed per year
🗑
|
||||
| 200,000 patients die from CHF per year | 870,000 hospitalizations (estimates in 2013 approach 1 Million)
1. Re-hospitalization rate within 30 days approaches 20%
🗑
|
||||
| 5. CHF costs | 1. Accounts for 5-10% of all hospital admissions
2. Annual U.S. Cost: $38.1 billion ($44.6 billion by 2015)
🗑
|
||||
| 1. Heart Failure is a syndrome, not a disease | 1. Heart Failure is a final common pathway
2. Maximize treatment of the underlying causes
3. Control the causes and prevent end organ damage
🗑
|
||||
| Heart failure (cardiac insufficiency, ventricular failure) | is the inability of the heart to pump adequate amounts of blood into the systemic circulation to meet tissue metabolic demands.
🗑
|
||||
| Left-sided failure (congestive heart failure [CHF]) Results from failure of the left ventricle to maintain adequate output. | Blood backs up into the left atrium and into the pulmonary veins.
Increasing pressure in the pulmonary capillary bed causes congestion, result in respiratory distress.
Increasing pulmonary pressure results in increased pressure on right side of heart.
🗑
|
||||
| Right-sided failure (cor pulmonale). Results from failure of the right ventricle to maintain adequate output. | Blood backs up into the systemic circulation and causes peripheral edema.
3. Most common cause is secondary to left-sided failure and chronic pulmonary disease
🗑
|
||||
| Each side of the heart is dependent on the other for adequate function. 1. Left-sided failure results in pulmonary congestion; precipitates right-sided failure. the majority of clinical situations involve failure on both sides. | However, right-sided failure may occur alone for an extended period of time. Frequently associated with chronic lung problems.
🗑
|
||||
| The heart will attempt to maintain the body requirements for cardiac output (increasing cardiac rate, vasoconstriction) | when these mechanisms become in- effective, cardiac decompensation or failure will occur.
🗑
|
||||
| In children, HF occurs most often as the result of | a congenital defect of the heart.
🗑
|
||||
| Edema development in heart failure. | Decreased cardiac output leads to decrease in renal perfusion, the kidneys respond by increasing the retention of sodium and water. Resulting in pitting dependent edma
🗑
|
||||
| Pulmonary congestion (left-sided failure). | Dyspnea and cough on exertion
Orthopnea, tachypnea
Paroxysmal nocturnal dyspnea
respiratory distress and hypoxia
Hemoptysis.
Congested breath sounds.
Feeding difficulties in infants due to dyspnea and decreased tolerance of activity.
🗑
|
||||
| Systemic congestion (right-sided failure). | Hepatomegaly early sign in children.
Peripheral edema and weight gain.
Dependent edema or generalized edema in infants; evaluate by weight gain.
Ascites.
Increase in (CVP).
Jugular vein distention (JVD) with head elevated 30 degrees
🗑
|
||||
| 1. Systolic Dysfunction (60-70% of Heart Failure cases) | 1. Decreased contractility
2. Decreased Left Ventricular Ejection Fraction
🗑
|
||||
| 2. Diastolic Dysfunction (30-40% of Heart Failure cases) | 1. Decreased compliance
2. Decreased filling
3. Variable Left Ventricular Ejection Fraction
🗑
|
||||
| All CHF patients should undergo | Echocardiogram
🗑
|
||||
| NYHA Classification Class I | Symptoms with more than ordinary activity
🗑
|
||||
| NYHA Classification Class III | Symptoms with minimal activity
1. Class IIIa: No Dyspnea at rest
2. Class IIIb: Recent Dyspnea at rest
🗑
|
||||
| NYHA Classification Class II | Symptoms with ordinary activity
🗑
|
||||
| NYHA Classification Class IV | Symptoms at rest
🗑
|
||||
| Stroke or brain attack is the disruption of the blood supply to an area of the brain, | resulting in tissue necrosis and sudden loss of brain function. It is the leading cause of adult disability in the United States.
🗑
|
||||
| Atherosclerosis, resulting in cerebro- vascular disease, | frequently precedes the development of a stroke
🗑
|
||||
| Ischemic stroke | Thrombotic stroke: formation of a clot that results in the narrowing of a vessel lumen and eventual occlusion; most common stroke.
Embolic stroke: occlusion of a cerebral artery by an embolus.
🗑
|
||||
| Thrombotic stroke: formation of a clot that results in the narrowing of a vessel lumen and eventual occlusion; most common stroke. | Associated with hypertension and diabetes.
(2) Produces ischemia of the cerebral tissue.
🗑
|
||||
| Embolic stroke: occlusion of a cerebral artery by an embolus. | ) Common site of origin is the endocardium.
(2) May affect any age group
🗑
|
||||
| Hemorrhagic stroke. | Rupture of a cerebral artery caused by hyperten- sion, trauma, or aneurysm.
b. Bleeding compresses the brain and causes inflammation.
C. The area of edema resulting from tissue damage may precipitate more damage than the vascular damage itself.
🗑
|
||||
| Transient ischemic attack (TIA, silent stroke). a. Brief episode, less than 24 hours, of neurologic dysfunction; usually resolves within 30-60 minutes. | Should be considered a warning sign of an impending stroke.
c. Neurologic dysfunction is present for minutes to hours, but no permanent neurologic deficit remains.
🗑
|
||||
| Reversible ischemic neurologic deficit (RIND). | Symptoms similar to TIA.
b. Neurologic symptoms last longer than 24 hours, but less than a week.
🗑
|
||||
| Stroke: | client has neurologic deficits related to mobility, sensation, and cognition.
🗑
|
||||
| PVD • Symptoms 1. Presentations | 1. Classic Claudication: 10% of cases
2. Atypical Leg Pain: 50% of cases
3. Asymptomatic: 40% of cases
🗑
|
||||
| 2. Classic Claudication1. Cramp-like leg muscle pain with Exercise, better with rest 1. Calf pain typical (pain may occur in thigh, buttock) | 2. Pain worse with exertion
3. Pain relieved within 10 minutes rest
4. Pain relieved with rest and dependent position
🗑
|
||||
| 3. Critical Limb Ischemia (1% of presentations) | 1. Tissue loss or gangrene
2. Chronic rest pain
🗑
|
||||
| PVD 1. Timing of symptoms related to degree of stenosis | 1. Exertional pain: 70% arterial pain
2. Nocturnal pain: 70 to 90% arterial stenosis
3. Ischemic rest pain: 90% arterial stenosis
🗑
|
||||
| PVD 1. Vascular Exam (Arterial Bruits or diminished pulses) | 1. Abdominal aorta bruit
2. Femoral artery pulse
3. Dorsalis pedis pulse (absent in up to 3% of normal patients)
4. Posterior tibial pulse
5. Carotid Artery pulse and bruit (for comorbid Carotid Stenosis)
🗑
|
||||
| PVD 2. Neurologic Exam | 1. Critical in determining Acute Limb Ischemia degree (see Rutherford Classification)
2. Extremity Motor Exam
3. Extremity Sensory Exam
🗑
|
||||
| 1. Most reliable signs of Peripheral Vascular Disease | 1. Posterior tibial artery doppler Ultrasound
2. Dorsalis pedis AND posterior tibial pulse absent
3. Femoral artery bruit
4. Atypical Skin Color (pale, red, blue) of extremity
🗑
|
||||
| 1. Posterior tibial artery doppler Ultrasound | 1. All 3 components present rules-out Peripheral Arterial Disease
2. Only 1 of 3 components present is strongly suggestive of PAD (Positive Likelihood Ratio = 7.0)
🗑
|
||||
| 2. Dorsalis pedis AND posterior tibial pulse absent test for PAD | 1. Test Sensitivity: 63%
2. Test Specificity: 99%
🗑
|
||||
| 3. Femoral artery bruit test for PAD | 1. Test Sensitivity: 29%
2. Test Specificity: 95%
🗑
|
||||
| 4. Atypical Skin Color (pale, red, blue) of extremity test for Pad | 1. Test Sensitivity: 35%
2. Test Specificity: 87%
🗑
|
||||
| 2. Local Signs of Peripheral Vascular Disease | Dry, scaly, shiny atrophic skin
Skin hairless over lower extremity
Dystrophic, brittle Toenails
Non-healing ulcers or other wounds on legs or feet Decreased skin Temperature
Decreased Capillary Refill Time
Distal extremity color change with position
🗑
|
||||
| PVD Sign 7. Distal extremity color change with position | 1. Skin rubor when leg dependent
2. Skin pallor when leg elevated >1 minute
1. Color returns within 15 seconds in mild cases
2. Delay >40 seconds suggests severe ischemia
🗑
|
||||
| Signs: Acute Limb Ischemia (5 P's) | 1. Early finding
1. Pain
2. Late findings
1. Pulselessness
2. Pallor
3. Paresthesias
4. Paralysis
🗑
|
||||
| FOUR HEART LAYERS | Pericardium
Epicardium
Myocardium
Endocardium
🗑
|
||||
| PERICARDIUM | Outermost layer
Known as parietal pericardium
Holds the heart in a fixed position
Provides a physical barrier against infection.
🗑
|
||||
| EPICARDIUM | Covers the surface of the heart.
Known as visceral pericardium
Together with the pericardium form a sac around the heart
Space between the pericardium and epicardium contains 10-30 cc serous fluid.
🗑
|
||||
| MYOCARDIUM | Middle layer
Thick and muscular
Contains all of atrial and ventricular muscle fibers
Responsible for the movement of blood in and out of the heart.
🗑
|
||||
| ENDOCARDIUM | Innermost layer
Thin layer of endothelium is continuous with blood vessels
Lines inner chambers of heart and valves.
Disruption can lead to infection
🗑
|
||||
| RIGHT ATRIUM (RA) | Thin walled receiving chamber, 2mm thick.
Receives blood from SVC, IVC and coronary sinus.
Atrial contraction (atrial kick) contributes 30 % to ventricular filling.
O2 Sat about 75%
🗑
|
||||
| RIGHT VENTRICLE (RV) | Most anterior chamber
Lies directly below the sternum
3-5mm thick
Blood enters via tricuspid valve during diastole, (resting phase).
Ejected into the pulmonary circulation through pulmonic valve
🗑
|
||||
| LEFT ATRIUM (LA) | Most posterior chamber
Receives oxygenated blood from the lungs via R/L pulmonary veins.
3mm thick
O2 Sat about 98%
🗑
|
||||
| LEFT VENTRICLE (LV) | 2-3 times thicker than the RV, 13-15 mm in size, necessary to generate enough pressure to move blood into the circulation.
Apex is the tip of the LV
PMI – is the movement of the apex during ventricular contraction.
🗑
|
||||
| CARDIAC VALVES | Prevent regurgitation from one chamber to another – blood flows in ONE direction.
Flexible, fibrous tissue, covered with endocardium
Open/Close in response to pressure gradients
4 valves- tricuspid, pulmonic, mitral, aortic.
🗑
|
||||
| ATRIOVENTRICULAR VALVES | Mitral – 2 cusps
Tricuspid – 3 cusps
Separates atriums from ventricles.
Cusps are attached by the chordae tendinae and papillary muscles.
These are at risk for damage with an anterior MI.
🗑
|
||||
| SEMILUNAR VALVES | Aortic and pulmonic
Separates the ventricles from their outflow arteries.
Smaller than the AV valves
Aortic cusps are thicker than the pulmonic
Composed of fibrous supporting ring – ANNULUS.
🗑
|
||||
| CORONARY ARTERIES RCA | RCA – supplies posterior septum, left papillary muscle, sinus and AV nodes.
🗑
|
||||
| CORONARY ARTERIES LCA | LCA – divides into LAD and LCX. Supplies anterior ventricular wall, anterior septum, papillary muscle and apex.
🗑
|
||||
| CORONARY ARTERIES CX | CX – supplies inferior and posterior portions of LV in some people (left coronary dominance)
🗑
|
||||
| stroke volume. | Systole – ventricles depolarized, blood ejected from the ventricles
Amount of blood ejected with each heart beat.
Comprised of;
Preload
Afterload
Contractility
🗑
|
||||
| Ejection Fraction- | ratio of blood ejected to blood present in ventricle (N = 50-100%)
🗑
|
||||
| FRANK-STARLING LAW | “The more the heart muscle is stretched, the greater the force of contraction”.
🗑
|
||||
| CARDIAC OUTPUT (CO) | Amount of blood expressed in liters or per minute.
Determined by heart rate and stroke volume.
“Heart rate X Stroke volume = CO
Normal 4-8 liters /minute.
🗑
|
||||
| DETERMINANTS OF CARDIAC OUTPUT | Heart Rate
Stroke Volume
Preload
Afterload
Contractility
🗑
|
||||
| HEART RATE Chronotropic | SA node – N=60-100
Influenced by neural, (PNS –SNS) hormonal, (catacholamines) chemical (acid-base disturbances) and pharmacological means (medications).
🗑
|
||||
| PRELOAD | Pressure (load) generated in cardiac chambers prior (pre) to ejection. (pressure in the ventricles at the end of diastole).
Determined by the end diastolic volume, (the amount of blood left in the ventricles during rest)
🗑
|
||||
| AFTERLOAD | Resistance (load) to ejection (after) of blood from the ventricles (the amount of pressure the ventricles must push against).
Clinical indicators; systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR)
🗑
|
||||
| CONTRACTILITY Inotropic | The force of ejection .
Can be positive or negative.
Clinical indicators; cardiac output, and cardiac index.
🗑
|
||||
| CARDIAC INDEX | Relationship between cardiac output and body surface area.
Decrease indicates heart failure.
Increase indicates decreased SVR, (common in sepsis).
Calculate by dividing CO into body surface area.
Normal; 2.5 – 4.0 liters/min.
🗑
|
||||
| CHF | Most common cause of in-hospital mortality.
1/3 rd of patients with AMI die of CHF.
2nd most common complication after an MI
Men are affected more than women.
5 yr mortality rate for men is 60 %, women 45%.
🗑
|
||||
| CHF DEFINITION | Inability of the heart to pump enough blood to meet the body’s metabolic requirements leading to discrepancies between myocardial oxygen supply and demand.
🗑
|
||||
| CHF PATHOPHYSIOLOGY | Malfunction of the contractile properties of the heart leading to decrease CO.
Heart rate
Stroke volume
🗑
|
||||
| Damaged heart is unable to pump extra volume = decreased CO, | (decreased CO=^ HR = short diastolic filling time and ^myocardial O2 demand.
🗑
|
||||
| STROKE VOLUME Preload Volume of blood in ventricles at end of systole. Volume causes maximal stretch. | Greater the stretch = greater SV up to a certain point. Past this point = overstretch of muscle = a non-compliant ventricle, needs extra volume = heart failure.
🗑
|
||||
| CHF Causes | Primary: cardiomyopathies, CAD or valvular disorders.
Aortic stenosis; narrow valve = hypertrophy, non-compliant ventricle.
Aortic regurgitation: back flow of blood = hypertrophy.
Mitral regurgitation; pulmonary congestion = RV failure.
🗑
|
||||
| PRECIPITATING FACTORS FOR CHF | Cessation of cardiac drugs.
Dysrythmias – tachycardia, atrial dysrythmias.
Viral and/or bacterial infections
Environmental, emotional or physical stress
🗑
|
||||
| Right-sided failure: CHF | ineffective (R) ventricular contraction or total (R) sided failure, ie; PE, right-sided MI, or blood backing up into the left ventricle.
🗑
|
||||
| Left-sided failure: | inability of the (L) ventricle to produce adequate SV = decreased CO. ie; (L) ventricular MI, HTN and/or valvular disease.
🗑
|
||||
| Systolic vs. diastolic failure | Systolic ; inability of ventricles to eject adequate volume.
Diastolic failure; inability of ventricles to relax and fill.
🗑
|
||||
| High vs. low output failure; | High-conditions that increase CO i.e.; fever, thyrotoxicosis
Low: insufficient ejection that results in inadequate CO.
🗑
|
||||
| Forward Failure: | inability of the ventricles to pump blood into the systemic and pulmonary circulation. (afterload)
🗑
|
||||
| Backward Failure: | Inadequacy of the ventricles to empty the blood into the arterial circulation.
🗑
|
||||
| Acute CHF | ; heart overwhelmed by abrupt alteration in cardiac function; unable to bring compensatory mechanisms into play.
🗑
|
||||
| Chronic CHF | compensatory mechanisms have time to partially/completely restore cardiac function.
🗑
|
||||
| IMPROVE CONTRACTILITY Positive inotropic agents. | Dopamine
Dobutamine
Primacor
Digoxin
Natrecor
🗑
|
||||
| DECREASE Cardiac PRELOAD AND AFTERLOAD | Loop/potassium sparing diuretics - prevents reabsorption of NA.
Nitrates- increases CO and reduces ventricular filling pressures. (not effective in chronic therapy)
ACE inhibitors- vasodilatation by blocking the renin-angiotensin-aldosterone system.
🗑
|
||||
| Carvedilol (Coreg) | Beta-1 and alpha-1 blocker
Reduce afterload
HF classes II, III and IV
Symptomatic hypotension, start low and increase to 25 mg BID.
Use caution in asthmatics
🗑
|
||||
| Amiodarone | Reduces the possibility of sudden death in patients with LV dysfunction from AMI.
Effective in atrial fibrillatio
Anti-ischemic effects
Does not increase mortality
Half life – 40-50 days.
🗑
|
||||
| Some of the causes of heart failure include: | coronary artery disease (CAD), damage after a heart attack (which stems from coronary artery disease), high blood pressure, diabetes, obesity, heart valve disease, viruses, chemotherapy agents, chronic alcohol use and abuse, & drug abuse.
🗑
|
||||
| There are two major underlying causes of the symptoms in heart failure: | excess fluid accumulation that may occur in the lungs and symptoms associated with reduced cardiac output that worsens with exertion.
🗑
|
||||
| Shortness of breath (dyspnea). In CHF | This is one of the earliest symptoms of heart failure. The patient gets winded and fatigued more quickly than before, just by doing regular daily activities or even lying in bed.
🗑
|
||||
| LEFT-SIDED HEART FAILURE | DYSPNEA ON EXERTION, TACHYPNEA
SHORTNESS OF BREATH, ORTHOPNEA, PND
WHEEZING, RALES/CRACKLES
DRY HACKING COUGH OR WET FROTHY SPUTUM, DROWNING FEELING
SKIN IS CLAMMY AND PALE AND MAY TURN BLUE
🗑
|
||||
| RIGHT-SIDED HEART FAILURE | SWELLING IN FEET, ANKLES, LEGS, AND STOMACH
BLOATING, ASCITES
DEPRESSED APPETITE, ANOREXIA, NAUSEA, CONSTIPATION
WEIGHT GAIN OF > 2 POUNDS IN ONE NIGHT
LOSS OF MUSCLE MASS
🗑
|
||||
| CHF NONSPECIFIC FINDINGS | EXERCISE INTOLERANCE, FATIGUE, WEAKNESS, NOCTURIA, CNS SYMPTOMS, TACHYCARDIA, PALLOR
🗑
|
||||
| The normal pumping ability of our left ventricle is | 50-75%
🗑
|
||||
| BNP is very helpful in diagnosing CHF. | A normal BNP level is about 98% accurate in ruling out the diagnosis.
🗑
|
||||
| BNP is very helpful in guiding the treatment of CHF. | Effective therapy reduces the backup of blood in the heart. The heart chambers get smaller, and as the muscle cells recover from being stretched, they produce less BNP
🗑
|
||||
| Right Heart Catheterization (RHC). | A catheter is passed through the jugular vein in your right neck into the right side of your heart. This catheter is used to measure right and left pressures, as well as, pulmonary wedge pressures.
🗑
|
||||
| Left Heart Catheterization (angiogram) | is performed to determine if you have coronary artery disease. A catheter is inserted in your right groin and guided to your heart. blockages in the coronary arteries are shown on x-ray.
🗑
|
||||
| Heart failure is usually a chronic condition that has taken years to develop and worsen. Treatment for heart failure is generally designed for three purposes: | 1. to improve any symptoms
2. to slow progression of the heart failure, and
3. to prolong survival.
🗑
|
||||
| CHF lifestyle changes | include limiting salt intake and reduced fat diet to achieve or maintain a healthy weight. Other lifestyle modifications include stress management, limiting caffeine and alcohol, stop smoking, and getting regular exercise
🗑
|
||||
| What would be a key education point to make with patients about low salt diets and salt substitutes? | Salt substitutes vary in their composition, but their main ingredient is always potassium chloride.
🗑
|
||||
| Patient education specific to CHF that should be included: | Keep a daily weight diary and call for an increase in >3lbs in a single week
Staying as active as possible once cleared for activity
Take frequent breaks and rest periods throughout the day
Limit salt intake
Avoid excess fluid intake
🗑
|
||||
| Agonist | drugs that bind to a receptor site to CAUSE a response
🗑
|
||||
| Antagonist | drugs that block a receptor site from a response or to keep other drugs from binding
🗑
|
||||
| Inotropic Action- | myocardial contraction (positive increases contraction, negative decreases contraction)
🗑
|
||||
| Chronotropic Action- | heart rate (positive increases HR, negative decreases HR)
🗑
|
||||
| Alpha Receptors- | Alpha 1- generalized vasoconstriction and mediates positive inotropic and negative chronotropic effects
Alpha 2- mediates arteriolar and venous vasoconstriction
🗑
|
||||
| Beta Receptors- | Beta 1- increases heart rate, cardiac contractility, conduction and irritability
Beta 2- vasodilation in skeletal and smooth cardiac muscle and bronchodilation
🗑
|
||||
| Dopaminergic Receptors | vasodilation of renal and mesenteric arteris
🗑
|
||||
| The diuretics most commonly used for heart failure are loop diuretics. These diuretics are usually taken by mouth on a long-term basis | Loop diuretics are preferred for moderate to severe heart failure.
🗑
|
||||
| Thiazide diuretics, which have milder effects and can lower blood pressure, may be prescribed particularly for people who also have high blood pressure | For people with severe heart failure due to systolic dysfunction, Spironolactone is the preferred potassium-sparing diuretic
🗑
|
||||
| The mainstay of heart failure treatment is a group of drugs called ACE inhibitors. | These drugs not only reduce symptoms and the need for hospitalization but also prolong life.
🗑
|
||||
| Beta-blockers are often used with ACE inhibitors to treat heart failure. By blocking the action of the hormone norepinephrine | (which causes the heart to pump faster and more forcefully), these drugs produce long-term improvement in heart function and survival.
🗑
|
||||
| Beta-blockers may significantly reduce the force of the heart's contractions initially, so they are usually introduced after heart failure has first been stabilized with other drugs. | In people with heart failure due to diastolic dysfunction, beta-blockers are used to slow the heart rate and relax the stiff or thickened muscle allowing for complete filling.
🗑
|
||||
| Digoxin is the only oral inotrope available. It has been used to treat heart failure since the 1700's. However, modern science recommends the treatment of heart failure should now begin with the prescribing of | ACE inhibitors or carvedilol before digoxin.
🗑
|
||||
| Digoxin does NOT reduce mortality rates, but it improves | symptoms and seems to decrease hospitalizations.
🗑
|
||||
| Lacunar Infarction | Seen more in the elderly and diabetic patients
Small lesions usually < 5 mm in diameter that occur in the basal ganglia, pons, cerebellum,
usually associated with poorly controlled HTN.
The neurologic symptoms progress over 24-36 hrs before stabilizing
🗑
|
||||
| Klippel-Trenaunay syndrome | Triad of of varicose veins, limb hypertrophy, and a cutaneous birthmark (port wine stain or venous malformation)-Tierney pg 451
🗑
|
||||
| “Tracheal tug” is palpable pull from midline with breathing | pull with inspiration (Adam’s apple (trachea) moves up and down) is a diagnostic sign for emphysema
(also pull with pulsation is diagnostic sign for aneurysm of the arch of the aorta)
🗑
|
||||
| Digital clubbing | does not normally accompany asthma or COPD-IF PRESENT SUSPECT CONCOMITANT LUNG CANCER
🗑
|
||||
| CIGARETTE SMOKING IS THE MOST IMPORTANT RISK FACTOR FOR THE DEVELOPMENT OF | COPD
🗑
|
||||
| Chronic bronchitis | Blue Bloater due to obstruction-term not used today
🗑
|
||||
| Emphysema | Pink Puffers (term not used today)-
No obstruction with adequate oxygen intake, puff to blow off extra co2
Differentiated from acute asthma (asthma remits between episodes
🗑
|
||||
| Pulmonary Function Tests will determine severity of both obstructive and restrictive pulmonary dysfunction | Defines severity
Helps in determining prognosis
Measures response to therapy
Measures disease progression
🗑
|
||||
| COPD Treatment | Smoking cessation most important intervention- must be documented
🗑
|
||||
| Supplemental oxygen COPD | only other drug therapy that is documented to alter natural history of COPD in pts with resting hypoxemia
Prolongs life and improves quality
🗑
|
||||
| Ipratropium bromide (Atrovent) | Superior in achieving bronchodilation in pts with mod to severe COPD
Slower onset but longer duration
Advantage
Low incidence of SE’s; no tachyphylaxis
🗑
|
||||
| Tiotropium (Spiriva) | capsule activated inhaler
once a day dosing-a significant improvement for compliance issues
some studies show greater efficacy over ipratropium over 1 year but may be a compliance issue
used with short acting bronchodilator
🗑
|
||||
| Narcotics are contraindicated | in COPD
🗑
|
||||
| Oxygen Criteria | Prescribe O2 at 0.5-4 L/min to produce Pao2 >65 mm or SaO2>90% at rest and with activity
Specify in L/min and hours per day used
Reevaluate in 1-3 months as 30-45% will not need long-term
therapy
🗑
|
||||
| Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. Spirometry is required to establish a diagnosis of COPD | Dyspnea that is Progressive
Characteristically worse with exercise.
Persistent.
Chronic cough:
Chronic sputum production:
Any pattern of chronic sputum production
History of exposure to risk factors:
Tobacco smoke
Family History
🗑
|
||||
| Spirometry is required to make a clinical diagnosis of COPD; | the presence of a postbronchodilator FEV 1
/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.
🗑
|
||||
| Classification of Severity of Airflow Limitation in COPD (Based on Post-Bronchodilator FEV1) Gold 1 | Mild
FEV1≥ 80% predicted
🗑
|
||||
| Classification of Severity of Airflow Limitation in COPD (Based on Post-Bronchodilator FEV1) Gold 2 | Moderate
50%≤FEV1< 80% predicted
🗑
|
||||
| Classification of Severity of Airflow Limitation in COPD (Based on Post-Bronchodilator FEV 1)Gold 3 | severe
30% ≤ FEV1< 50% predicted
🗑
|
||||
| Classification of Severity of Airflow Limitation in COPD (Based on Post-Bronchodilator FEV 1)Gold 4 | Very Severe
FEV1< 30% predicted
🗑
|
||||
| FVC (Forced Vital Capacity): | maximum volume of air that can be
exhaled during a forced maneuver
🗑
|
||||
| FEV1 | (Forced Expired Volume in one second): volume expired in the
first second of maximal expiration after a maximal inspiration. This is a measure of how quickly the lungs can be emptied.
🗑
|
||||
| FEV1/FVC: | expressed as a proportion of the FVC, gives a clinically useful index of airflow limitation.
The ratio FEV
1
/FVC is between 0.70 and 0.80 in normal adults; avalue less than 0.70 indicates airflow limitation and thus of COPD.
🗑
|
||||
| Screening for Lung Cancer | Screening for lung cancer has not been recommended by any major advisory groups
🗑
|
||||
| Low dose helical (spiral) computed tomography (LDCT) evaluated in randomized clinical trial by NLST* | First validated screening test that reduces mortality from lung cancer
20% lower mortality from lung cancer vs. serial chest radiography
🗑
|
||||
| Bronchogenic carcinoma 4 types account for more than 90% of lung cancers | Squamous cell carcinoma (25-35%)
Adenocarcinoma (35-40%)
Large cell carcinoma (5-10%)
Small cell carcinoma (15-20%)
🗑
|
||||
| Small cell lung cancer (SCLC) | Early hematogenous spread
Agressive course
Untreated survival of 6-18 weeks
Not amenable to surgical resection
🗑
|
||||
| Non-small cell lung cancer (NSCLC) | Includes other 3 types
Spread more slowly
Cure in early stages following resection
Respond similarly to chemotherapy
🗑
|
||||
| Squamous Cell Carcinoma | Originates from the respiratory epithelium.
Typically x-rays show atelectasis or pneumonitis.
🗑
|
||||
| Adenocarcinoma | Probably arise from the goblet cells in the major bronchi.
Most often found in nonsmokers.
Bronchoalveolar cell carcinoma:
subset of adenocarcinoma
can mimic an infectious or inflammatory pneumonia.
🗑
|
||||
| Large-Cell Carcinoma | Tend to appear as large peripheral mass lesions.
50% develop brain metastases.
Giant-cell carcinoma
subset of large-cell carcinoma
aggressive, highly malignant tumor
🗑
|
||||
| Horner’s Syndrome | Ipsilateral symptoms (same side)
Ptosis (drooping of eyelid)
Miosis (pupilary constriction)
Anhidrosis (absent sweating)
🗑
|
||||
| Horner’s Syndrome Cause: | paralysis of paravertebral sympathetic nerve trunk due to compression by a tumor
Most frequently caused by Pancoast tumor of either upper lung
🗑
|
||||
| TNM international staging | Physical description of neoplasm
T --size and location of primary tumor
N --presence and location of nodal metastases
M --presence or absence of distant metastases
🗑
|
||||
| Solitary Pulmonary Nodule (SPN) | Unexpected finding, usually incidental on chest radiograph
Referred to as a “coin lesion”
Isolated , round opacity,< 3 cm
No mediastinal adenopathy
No associated infiltrate or atelectasis
Important because carries significant chance of malignancy
🗑
|
||||
| Hodgkin’s Disease | Peak incidence 3rd decade
Fatigue, fever, weight loss, anemia
Peripheral lymphadenopathy
May involve the thorax
Radiation and chemotherapy
🗑
|
||||
| Non-Hodgkin’s | Peak incidence over 50
Involves mediastinum and lungs
Fever, anorexia, weight loss
Treatment with chemotherapy and radiation
Response to treatment/prognosis less favorable than for Hodgkin’s
🗑
|
||||
| Sarcoidosis is a type of interstitial lung disease (diffuse parenchymal lung disease) Large group of disorders Share common response of lung to injury | alveolitis or inflammation
fibrosis of interalveolar septum
🗑
|
||||
| Sarcoidosis Epidemiology | 1 per 10,000 per year
Age 20-40
North American blacks
Women > men
Blacks have 3-4 times incidence of whites
Northern European whites
🗑
|
||||
| Sarcoidosis Etiology | Unknown
Granulomatous inflammation of lungs
Resolves in 2/3
15-20% lung damage
5% will die
🗑
|
||||
| Sarcoidosis Pathophysiology | Hyperimmune response to unknown agent
Lesions in any organ
Lungs and intrathoracic lymph nodes affected in 90%
Alveolitis
Interstitial pneumonitis
Granuloma formation
🗑
|
||||
| Children with chronic illnesses in general are affected by a ________ number of common diseases. | large
🗑
|
||||
| In differentiating delirium from dementia, which of the following questions posed to a family member is most important? | How long have the symptoms been present?
🗑
|
||||
| The most common cause of progressive dementia is: | Alzheimer's disease
🗑
|
||||
| The most common type of Parkinson's Disease is: | Idiopathic
🗑
|
||||
| Carbidopa is added to levodopa for which of the following reasons: | Carbidopa inhibits breakdown of levodopa, increases CNS concentrations, and increases half-life of levodopa.
🗑
|
||||
| Serum amylase is often checked in patients with anorexia nervosa or bulimia. Elevated results would indicate: | active vomiting and associated pancreatitis.
🗑
|
||||
| What should be the practitioner's initial goal in the treatment of anorexic clients? | Establishing trust and a treatment alliance
🗑
|
||||
| Which of the two conditions anorexia nervosa and bulimia nervosa carry the poorest long-term psychiatric prognosis? | bulimia nervosa
🗑
|
||||
| The regional distribution of body fat is helpful in determining risk for complications of obesity. Which of the following body shapes is associated with the highest risk: | Apple-shaped.
🗑
|
||||
| A female patient presents with severe depressive symptoms that occur nearly monthly around her menstrual cycle. You suspect: | Premenstrual Dysphoric Disorder
🗑
|
||||
| A person with chronic depressive symptoms of sadness, loss of interest, and withdrawal from activities over a period of 2 or more years with a relatively persistent course is MOST likely diagnosed with: | Dysthymia
🗑
|
||||
| Which of the following would not routinely be ordered in the initial work-up to rule out medical causes of depression? | CT brain scan.
🗑
|
||||
| In the management of depressive disorders the plan always includes: | Evaluation of the patient's potential risk for self harm.
🗑
|
||||
| Symptoms especially characteristic of depression do not include |
Acute-sharp pain syndromes.
🗑
|
||||
| Symptoms of mania and depression that may show psychotic features is most consistant with the diagnosis of: | Bipolar Disorder
🗑
|
||||
| Symptoms of palpitations, tachycardia, chest pain, hot flashes, & chills in an otherwise healthy 21 year old is most consistent with the diagnosis of: | Panic Attack.
🗑
|
||||
| Which of the following statements concerning Panic Disorders is true? | Onset of Panic Disorder is rare after age of 40.
🗑
|
||||
| DSM-IV criterion for major depressive episode? | Persistence of symptoms for a period of at least 2 weeks
🗑
|
||||
| Calcium channel blockers should be used with extreme caution to treat angina or hypertension in a patient with congestive heart failure for the following reason: | Calcium channel blockers can accelerate progression of congestive heart failure.
🗑
|
||||
| Clinical trials dealing with beta-blocker use in congestive heart failure have led to a strong recommendation that: | Stable patients with congestive heart failure should be treated with beta blockers unless there is a noncardiac contraindication.
🗑
|
||||
| Inhibition of what system is important in preventing progression of congestive heart failure? | renin-angiotensin-aldosterone system
🗑
|
||||
| A patient with peripheral arterial occlusive disease is also at risk for: | Coronary artery disease.
🗑
|
||||
| Bruits heard with decreased pulse distally indicate: | Significant obstruction.
🗑
|
||||
| The decline in stroke incidence over the last four decades has been MAINLY attributed to the management of which of the following risk factors for stroke. | Hypertension
🗑
|
||||
| Immediate treatment for stroke due to ischemic infarction is: | Thrombolytic therapy.
🗑
|
||||
| Chronic bronchitis is: | Defined as excessive secretion of bronchial mucous and productive cough 3 month or more in at least 2 consecutive years.
🗑
|
||||
| A client with a long history of chronic airflow limitation has noticed an increased cough and a change in sputum over the past few days (increased amount of thick, yellow-green mucus, congestion). Appropriate therapy is: | Augmentin 500 mg PO tid X 10 days.
🗑
|
||||
| In prescribing medications for your patient with COPD, you understand which of the following to be true: | Bronchodilators are not as effective in emphysema as in asthma.
🗑
|
||||
| One of the most common complications of an acute exacerbation of chronic bronchitis is: | Left sided heart failure
🗑
|
||||
| When assessing the pulmonary function studies of a client, which assessment finding is seen in chronic obstructive pulmonary disease? | FEV1/FVC ratio is < 70%.
🗑
|
||||
| Your 76 year old male patient is complaining of increased dyspnea at rest. You note his SaO2 is 86% while sitting in your office. You know that the only drug therapy that is documented to alter this patient's hypoxemia is: | Oxygen
🗑
|
||||
| Screening for lung cancer: | has not been recommended by any major advisory groups.
🗑
|
||||
| The most aggressive type of lung cancer is: | Small cell carcinoma
🗑
|
||||
| Upon consultation with the radiologist and pulmonologist, a Single Pulmonary Nodule is gauged as having a low probability of malignancy. The nurse practitioner's management plan will most likely consist of: | Watchful waiting with serial radiographs every 3 months for a year then every 6 months for a second year.
🗑
|
||||
| A benign neoplasm that is thought to be congenital and comprises about 5% of all lung neoplasms is: | Hamartoma
🗑
|
||||
| A patient states that he has noted his left pupil is smaller than his right and complains of a slight droop to the same eyelid. The practitioner upon noting this sign should check for Horner's syndrome by checking for absence of: | sweating of the ipsilateral (same side) of the forehead
🗑
|
||||
| Hodgkin's disease typically: | presents in the 3rd decade of life (20's)
🗑
|
||||
| Which of the following TNM stages represents the worst prognosis? | Stage IV
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
kcorkinsnctc
Popular Nursing sets