NR-601 Final Exam Study Guide
I I I I
How Ito Iconduct IMini-Cog-
• The IMini-Cog Ihas Ibeen Idemonstrated Ito Ihave Icomparable Ipsychometric Iproperties Ito Ithe IMMSE
• The Iprimary Iadvantage Iof Ithe IMini-Cog Iis Ithat Iit Iis Ishorter Ithan Ithe IMMSE Iand Imeasures Iexecutive Ifunction.
• It Iis Icomposed Iof Ia Ithree-item Irecall Iand Ithe IClock IDrawing ITest I(CDT) Iand Itakes Iabout I3 Iminutes Ito Iadminister
• The IMini-Cog Iis Ia Ishort Idementia Iassessment Ithat Icombines Ithree-word Irecall Iwith Iclock-drawing Icapability.
• Patients Iare Igiven Ia Itotal Iscore Ireflecting Iaccuracy Iin Iclock Idrawing Iand Irecollection Iof Ithe Igiven Ithree Iwords.
• A Iscore Iof I0 Ito I2 Iis Ia Ipositive Iscreen Ifor Idementia
ICauses Iof Idelirium Iin Ielderly-
• Causes Iof Idelirium Iare Inumerous Iand Iin Ielderly Ihospitalized Ipatients Ithere Iare Ioften Imultiple Ietiologies, Iincluding
metabolic, Iinfection, Icardiac, Ineurological, Ipulmonary, Isensory Iimpairments, Imedications, Iand Itoxins.
• Regardless Iof Icause, Ia Iconsistent Ifinding Iis Isignificant Ireduction Iin Iregional Icerebral Iperfusion Iduring Iperiods Iof
Idelirium Iin Icomparison Iwith Iblood Iflow Ipatterns Iafter Irecovery.
• A Ipossible Ineurological Icommon Ipathway Imay Iinvolve Iacetylcholine Iand Idopamine, Iand Ithe Idisruption Iin Ithe
sleep-wake Icycle Iin Idelirium Iindicates Imelatonin Ias Ia Ipossible Ifactor. I(Kennedy-Malone I59)
IAgnosia
• Loss Iof Iability Ito Iidentify Iobjects
IADA Icriteria Ifor Idiagnosing IDM-
• FPG I≥126 Img/dL I(7.0 Immol/L). IFasting Iis Idefined Ias Ino Icaloric Iintake Ifor Iat Ileast I8 Ih.*
• 2-h IPG I≥200 Img/dL I(11.1 Immol/L) Iduring IOGTT. IThe Itest Ishould Ibe Iperformed Ias Idescribed Iby Ithe IWHO, Iusing
Ia Iglucose Iload Icontaining Ithe Iequivalent Iof I75-g Ianhydrous Iglucose Idissolved Iin Iwater.*
• A1C I≥6.5% I(48 Immol/mol). IThe Itest Ishould Ibe Iperformed Iin Ia Ilaboratory Iusing Ia Imethod Ithat Iis INGSP Icertified
and Istandardized Ito Ithe IDCCT Iassay.*
• In Ia Ipatient Iwith Iclassic Isymptoms Iof Ihyperglycemia Ior Ihyperglycemic Icrisis, Ia Irandom Iplasma Iglucose I≥200
Img/dL I(11.1 Immol/L).
• Urinary Iincontinence-
• Involuntary Iloss Iof Iurine Ifrom Ithe Ibladder
▪ So Icommon Iin Iwomen Imany Iconsider Iit Inormal
▪ Common Iin Iolder Imen Iw/ Ienlarged Iprostate
Io ICan Iaffect Iquality Iof Ilife
o Significance-One Iof Ithe Imost Icommon Icomplains Iw/ Iolder Iadults, IDistress I& Iembarrassment, ICost Iburden Ito Ipt I&
Isociety Ias Ia Iwhole, INot Ilife-threatening, Imay Ieffect IQOL, IPCP Iessential Ito Ieducating Iindividuals
o Epidemiology- IIncreased Iprevalence Iw/ Iage Iin Imen I& Iwomen, INursing Ihome Ipopulation I– I40-70%, IOften Ia Ifactor Iin
Iplacement
▪ URGENCY IUI Iis Igreater Iin Imen
▪ STRESS IUI Iis Igreater Iin Iwomen
o Terminology
▪ UI- IUnintentional Ivoiding, Iloss Ior Ileakage Iof Iurine
▪ Continuous Iincontinence-Continuous Iloss Ior Ileak Iof Iurine
▪ Increased Idaytime Ifrequency-More Ifrequent Iduring Iday Ithan Iconsidered Inormal
▪ Nocturia-Interruption Iof Isleep Ione Ior Imore Itimes Idue Ito Ithe Ineed Ito Iurinate I– Iincreases Iin Ifrequency Iafter Iage I50
▪ Urgency-Sudden, Icompelling Idesire Ito Ipass Iurine Ithat’s Idifficult Ito Iprevent
▪ Overactive Ibladder Isyndrome- IUrgency, Ifrequency, Inocturia Iw/ Ior Iw/o Iincontinence
o Risk IFactors-Aging,Obesity,Smoking, ICaffeine,Uncontrolled IDM, IConstipation,Use Iof Idiuretics
o Risk IFactors Iby Igender-Women:Aging, Iobesity, Ismoking, Icaffeine Iintake, IDM, Ipregnancy, Imultiparity, Iestrogen
Ideficiency, Ihx Iof Ipelvic Isurgery, Idiuretics
Men:Aging, Iobesity, Ismoking, Icaffeine, IDM, Iprostate Idx, Ihx Iof Iprostate Isurgery, Ihx Iof IUTIs, Idiuretics
o Physical Ichanges Iw/ Iaging Ithat Icontribute Ito IUI
▪ Lower Iurinary Itract-Detrusor Imuscle Iover Iactivity,Decrease Iin Idetrusor Icontractility, IIncrease Iin Ipost Ivoid
Iresidual,Decrease Iin Iurethral Iblood Iflow
▪ Women I– Idecrease Iin Iurethral Iclosure Ipressure,Low Iestrogen Ifollowing Imenopause I- Ileads Ito Iatrophy Iof Iureteral Imucosal
Iepithelium I& Iincrease Iin Iurethral Isensation
▪ Men Ican Iexperience Iconstriction Iof Iurethra Idue Ito IBPH Iwhich Imay Iresult Iin Ibladder Ioutlet Iobstructing Isymptoms
, - Initial Iclinical Iworkup Ifor IUI Iin IMen
o PMH, IPE, IUA, IDRE: IEval Iof Iprostate,PSA Iw/ Inew Ionset Iin Imen
- UI Iworkup Iin Iwomen:Exclude Iunderlying Icauses,PMH, IPE, IUA, IPelvic Iexam, Ivaginal Iexam, Iperineal, IIdentify Iestrogen
Istatus Iof Ipt, IPelvic Iprolapse, Ifistula,
-Cough Itest, IIntegrity Iof Ipelvic Imusculature, Ileaking Iof Iurine
▪ Full Ibladder
▪ Standing Iposition
▪ Asked Ito Icough
▪ If Iurine Ileak Iis Iobserved, Istress Iincontinence Iis Iconfirmed
- Red Iflags Iin Imales
o Higher Ilevel Iof Isuspicion Ifor Iserious Idiseases, IRefer Ito Iurology Iif IPrevious Ipelvic Isurgery, IPelvic Iradiation, IPelvic Ipain,
Severe Iincontinence, ISevere IUTI Isymptoms, IRecurrent Iurologic Iinfection,Abnl IProstate Iexam,Elevated IPSA
o Be Ialert Ito Ithese Iwith INEW IONSET IUI- IHematuria,Pelvic Ipain,Abdominal Imass, IDysuria, IProteinuria, IGlucosuria, ICVA
Itenderness,Nodular Iprostate,Any Inew Ineuro Isymptoms
- Goals Iof Itreatment: IReduce Isymptoms, IImprove IQOL, IIncrease Isocial Iactivity, IReduce Ileakage Ivolumes, Iincrease
Idryness, Iuse Iless Iprotection; IIncrease Iindependence Iin Iincontinence Imanagement; IDecrease Icaregiver Iburden
- 1st Iline Imanagement Iguidelines
o AHRQ Iguidelines Ifor Imanagement Iof IUI Iin Iwomen
▪ Behavioral Itherapy
▪ Lifestyle Imodification
▪ Try Ifor I3 Imonths Ibefore Ipharm Imanagement
o Weight Iloss, ISmoking Icessation(Tobacco Iis Ia Ibladder Iirritant),Less Icoughing
o Dietary Ichanges-Alcohol, Isoda, Icoffee Iwith Ior Iwithout Icaffeine, Iacidic Ifoods Iand Ispicy Ifoods
o Maintain Iadequate Ifluid Ibalance Ito Ireduce Iconstipation, Iprovide Iadequate Iflow Ito Ikidneys
- Behavioral Istrategies:Bladder Itraining, IBladder Icontrol Istrategies,Timed Ivoiding,Kegels, IPelvic Ifloor Itraining
- 2nd Iline Imanagement I- IMedication
o Antimuscarinic Imedication: I1st Iline Ifor Iwomen
▪ Block Ithe Iparasympathetic Imuscarinic Ireceptors
▪ Inhibit Iinvoluntary Idetrusor Icontractions
▪ Side Ieffects Idue Ito Ithe Ieffects Ion Iother Imuscarinic Ireceptors
o Outcomes Iunpredictable Iand Iside Ieffects Icommon
o Common Is/e: IDry Imouth**, IBlurred Ivision, IConstipation,Nausea,Dizziness, IHeadache
o AntimuscarinicsMechanism Iof Iaction
● Blocks Iacetylcholine Iat Imuscarinic Ireceptors, Irelaxes Ibladder Ismooth Imuscle, Iinhibits Iinvoluntary Idetrusor Icontractions
I(anticholinergic)
● CYP3A4 Isubstrates
▪ Indications: IUI Iand IOAB
▪ Contraindications: IUntreated/uncontrolled Inarrow Iangle Iglaucoma,Gastric Iretention, IUrinary Iretention
▪ Precautions:CNS Idepression,Caution Iin Ielderly
● Renal Idosing
o CrCl I<30
o Beta I3 IAdrenergic IAgonist I– IMirabegron I(Myrbetriq)
▪ Also Iapproved Ifor IUI Iand IOAB
▪ Clinical Itrials I– Isignificant Ireduction Iin Iincontinence Iand Imicturations
● No Ianticholinergic Is/e
▪ Mech Iof Iaction
● Selectively Istimulates Ibeta-3 Iadrenergic Ireceptors
● Relaxes Ismooth Imuscle I– Ibladder
▪ Contraindications/caution: IHTN- IDo Inot Iuse Iif ISBP I>180, IDBP I>100
▪ Avoid Isevere Irenal/liver Idisease
▪ Dose I– I25-50mg IPO IQD
▪ CrCl I<30 I– Imax I25mg
- 2nd Iline Iof IUI Iin IMales I– IAlpha I1 Iblockers
o Men, Inot Iwomen!
I I I I
How Ito Iconduct IMini-Cog-
• The IMini-Cog Ihas Ibeen Idemonstrated Ito Ihave Icomparable Ipsychometric Iproperties Ito Ithe IMMSE
• The Iprimary Iadvantage Iof Ithe IMini-Cog Iis Ithat Iit Iis Ishorter Ithan Ithe IMMSE Iand Imeasures Iexecutive Ifunction.
• It Iis Icomposed Iof Ia Ithree-item Irecall Iand Ithe IClock IDrawing ITest I(CDT) Iand Itakes Iabout I3 Iminutes Ito Iadminister
• The IMini-Cog Iis Ia Ishort Idementia Iassessment Ithat Icombines Ithree-word Irecall Iwith Iclock-drawing Icapability.
• Patients Iare Igiven Ia Itotal Iscore Ireflecting Iaccuracy Iin Iclock Idrawing Iand Irecollection Iof Ithe Igiven Ithree Iwords.
• A Iscore Iof I0 Ito I2 Iis Ia Ipositive Iscreen Ifor Idementia
ICauses Iof Idelirium Iin Ielderly-
• Causes Iof Idelirium Iare Inumerous Iand Iin Ielderly Ihospitalized Ipatients Ithere Iare Ioften Imultiple Ietiologies, Iincluding
metabolic, Iinfection, Icardiac, Ineurological, Ipulmonary, Isensory Iimpairments, Imedications, Iand Itoxins.
• Regardless Iof Icause, Ia Iconsistent Ifinding Iis Isignificant Ireduction Iin Iregional Icerebral Iperfusion Iduring Iperiods Iof
Idelirium Iin Icomparison Iwith Iblood Iflow Ipatterns Iafter Irecovery.
• A Ipossible Ineurological Icommon Ipathway Imay Iinvolve Iacetylcholine Iand Idopamine, Iand Ithe Idisruption Iin Ithe
sleep-wake Icycle Iin Idelirium Iindicates Imelatonin Ias Ia Ipossible Ifactor. I(Kennedy-Malone I59)
IAgnosia
• Loss Iof Iability Ito Iidentify Iobjects
IADA Icriteria Ifor Idiagnosing IDM-
• FPG I≥126 Img/dL I(7.0 Immol/L). IFasting Iis Idefined Ias Ino Icaloric Iintake Ifor Iat Ileast I8 Ih.*
• 2-h IPG I≥200 Img/dL I(11.1 Immol/L) Iduring IOGTT. IThe Itest Ishould Ibe Iperformed Ias Idescribed Iby Ithe IWHO, Iusing
Ia Iglucose Iload Icontaining Ithe Iequivalent Iof I75-g Ianhydrous Iglucose Idissolved Iin Iwater.*
• A1C I≥6.5% I(48 Immol/mol). IThe Itest Ishould Ibe Iperformed Iin Ia Ilaboratory Iusing Ia Imethod Ithat Iis INGSP Icertified
and Istandardized Ito Ithe IDCCT Iassay.*
• In Ia Ipatient Iwith Iclassic Isymptoms Iof Ihyperglycemia Ior Ihyperglycemic Icrisis, Ia Irandom Iplasma Iglucose I≥200
Img/dL I(11.1 Immol/L).
• Urinary Iincontinence-
• Involuntary Iloss Iof Iurine Ifrom Ithe Ibladder
▪ So Icommon Iin Iwomen Imany Iconsider Iit Inormal
▪ Common Iin Iolder Imen Iw/ Ienlarged Iprostate
Io ICan Iaffect Iquality Iof Ilife
o Significance-One Iof Ithe Imost Icommon Icomplains Iw/ Iolder Iadults, IDistress I& Iembarrassment, ICost Iburden Ito Ipt I&
Isociety Ias Ia Iwhole, INot Ilife-threatening, Imay Ieffect IQOL, IPCP Iessential Ito Ieducating Iindividuals
o Epidemiology- IIncreased Iprevalence Iw/ Iage Iin Imen I& Iwomen, INursing Ihome Ipopulation I– I40-70%, IOften Ia Ifactor Iin
Iplacement
▪ URGENCY IUI Iis Igreater Iin Imen
▪ STRESS IUI Iis Igreater Iin Iwomen
o Terminology
▪ UI- IUnintentional Ivoiding, Iloss Ior Ileakage Iof Iurine
▪ Continuous Iincontinence-Continuous Iloss Ior Ileak Iof Iurine
▪ Increased Idaytime Ifrequency-More Ifrequent Iduring Iday Ithan Iconsidered Inormal
▪ Nocturia-Interruption Iof Isleep Ione Ior Imore Itimes Idue Ito Ithe Ineed Ito Iurinate I– Iincreases Iin Ifrequency Iafter Iage I50
▪ Urgency-Sudden, Icompelling Idesire Ito Ipass Iurine Ithat’s Idifficult Ito Iprevent
▪ Overactive Ibladder Isyndrome- IUrgency, Ifrequency, Inocturia Iw/ Ior Iw/o Iincontinence
o Risk IFactors-Aging,Obesity,Smoking, ICaffeine,Uncontrolled IDM, IConstipation,Use Iof Idiuretics
o Risk IFactors Iby Igender-Women:Aging, Iobesity, Ismoking, Icaffeine Iintake, IDM, Ipregnancy, Imultiparity, Iestrogen
Ideficiency, Ihx Iof Ipelvic Isurgery, Idiuretics
Men:Aging, Iobesity, Ismoking, Icaffeine, IDM, Iprostate Idx, Ihx Iof Iprostate Isurgery, Ihx Iof IUTIs, Idiuretics
o Physical Ichanges Iw/ Iaging Ithat Icontribute Ito IUI
▪ Lower Iurinary Itract-Detrusor Imuscle Iover Iactivity,Decrease Iin Idetrusor Icontractility, IIncrease Iin Ipost Ivoid
Iresidual,Decrease Iin Iurethral Iblood Iflow
▪ Women I– Idecrease Iin Iurethral Iclosure Ipressure,Low Iestrogen Ifollowing Imenopause I- Ileads Ito Iatrophy Iof Iureteral Imucosal
Iepithelium I& Iincrease Iin Iurethral Isensation
▪ Men Ican Iexperience Iconstriction Iof Iurethra Idue Ito IBPH Iwhich Imay Iresult Iin Ibladder Ioutlet Iobstructing Isymptoms
, - Initial Iclinical Iworkup Ifor IUI Iin IMen
o PMH, IPE, IUA, IDRE: IEval Iof Iprostate,PSA Iw/ Inew Ionset Iin Imen
- UI Iworkup Iin Iwomen:Exclude Iunderlying Icauses,PMH, IPE, IUA, IPelvic Iexam, Ivaginal Iexam, Iperineal, IIdentify Iestrogen
Istatus Iof Ipt, IPelvic Iprolapse, Ifistula,
-Cough Itest, IIntegrity Iof Ipelvic Imusculature, Ileaking Iof Iurine
▪ Full Ibladder
▪ Standing Iposition
▪ Asked Ito Icough
▪ If Iurine Ileak Iis Iobserved, Istress Iincontinence Iis Iconfirmed
- Red Iflags Iin Imales
o Higher Ilevel Iof Isuspicion Ifor Iserious Idiseases, IRefer Ito Iurology Iif IPrevious Ipelvic Isurgery, IPelvic Iradiation, IPelvic Ipain,
Severe Iincontinence, ISevere IUTI Isymptoms, IRecurrent Iurologic Iinfection,Abnl IProstate Iexam,Elevated IPSA
o Be Ialert Ito Ithese Iwith INEW IONSET IUI- IHematuria,Pelvic Ipain,Abdominal Imass, IDysuria, IProteinuria, IGlucosuria, ICVA
Itenderness,Nodular Iprostate,Any Inew Ineuro Isymptoms
- Goals Iof Itreatment: IReduce Isymptoms, IImprove IQOL, IIncrease Isocial Iactivity, IReduce Ileakage Ivolumes, Iincrease
Idryness, Iuse Iless Iprotection; IIncrease Iindependence Iin Iincontinence Imanagement; IDecrease Icaregiver Iburden
- 1st Iline Imanagement Iguidelines
o AHRQ Iguidelines Ifor Imanagement Iof IUI Iin Iwomen
▪ Behavioral Itherapy
▪ Lifestyle Imodification
▪ Try Ifor I3 Imonths Ibefore Ipharm Imanagement
o Weight Iloss, ISmoking Icessation(Tobacco Iis Ia Ibladder Iirritant),Less Icoughing
o Dietary Ichanges-Alcohol, Isoda, Icoffee Iwith Ior Iwithout Icaffeine, Iacidic Ifoods Iand Ispicy Ifoods
o Maintain Iadequate Ifluid Ibalance Ito Ireduce Iconstipation, Iprovide Iadequate Iflow Ito Ikidneys
- Behavioral Istrategies:Bladder Itraining, IBladder Icontrol Istrategies,Timed Ivoiding,Kegels, IPelvic Ifloor Itraining
- 2nd Iline Imanagement I- IMedication
o Antimuscarinic Imedication: I1st Iline Ifor Iwomen
▪ Block Ithe Iparasympathetic Imuscarinic Ireceptors
▪ Inhibit Iinvoluntary Idetrusor Icontractions
▪ Side Ieffects Idue Ito Ithe Ieffects Ion Iother Imuscarinic Ireceptors
o Outcomes Iunpredictable Iand Iside Ieffects Icommon
o Common Is/e: IDry Imouth**, IBlurred Ivision, IConstipation,Nausea,Dizziness, IHeadache
o AntimuscarinicsMechanism Iof Iaction
● Blocks Iacetylcholine Iat Imuscarinic Ireceptors, Irelaxes Ibladder Ismooth Imuscle, Iinhibits Iinvoluntary Idetrusor Icontractions
I(anticholinergic)
● CYP3A4 Isubstrates
▪ Indications: IUI Iand IOAB
▪ Contraindications: IUntreated/uncontrolled Inarrow Iangle Iglaucoma,Gastric Iretention, IUrinary Iretention
▪ Precautions:CNS Idepression,Caution Iin Ielderly
● Renal Idosing
o CrCl I<30
o Beta I3 IAdrenergic IAgonist I– IMirabegron I(Myrbetriq)
▪ Also Iapproved Ifor IUI Iand IOAB
▪ Clinical Itrials I– Isignificant Ireduction Iin Iincontinence Iand Imicturations
● No Ianticholinergic Is/e
▪ Mech Iof Iaction
● Selectively Istimulates Ibeta-3 Iadrenergic Ireceptors
● Relaxes Ismooth Imuscle I– Ibladder
▪ Contraindications/caution: IHTN- IDo Inot Iuse Iif ISBP I>180, IDBP I>100
▪ Avoid Isevere Irenal/liver Idisease
▪ Dose I– I25-50mg IPO IQD
▪ CrCl I<30 I– Imax I25mg
- 2nd Iline Iof IUI Iin IMales I– IAlpha I1 Iblockers
o Men, Inot Iwomen!
