FNP 3 NURO 714 MIDTERM EXAM |380 QUESTIONS WITH COMPLETE SOLUTIONS 2024.

Name and briefly describe the 6 elements of the Chronic Care Model (CCM): 1. Organizational Support: leadership must create a culture where EBP , care coordination is accepted. 2. Clinical Information Systems: Organize data, data systems, tracks trends, EMAR, prompt immunizations, etc. 3. Delivery System Design: roles/tasks of the members of the team, mgmt of f/u care, working within scope by to highest level of training. Telephone f/u, suppt groups, nurses, MAs, MDs, and NP f/u visits in between. 4. Decision Support: Integration of EBP (Via UpToDate, etc) 5. Self-Management Support: Empower patients to be involved in own care. Need education, that emphazie empowerment, create SMART goals for self. 6. Community Resources: Community-based programs-- State, neighborhood, support groups, church groups, visiting nurses, SW, etc. Why is the CCM important? Chronic Dz makes up 60-70% of premature deaths and disability in the United States. Over half of those over 65 y/o have a chronic dz. We need ways to prevent chronic disease! CCM goal was to change from a reactive to proactive stance. CCM has been shown to improve care and outcomes. What are some issues in regards to current chronic dz management? Increases in chronic dz Delivery system is ineffective Shortage of PCPs Increase cost Lack of time and f/u care What is the goal of the CCM? Improved patient outcomes, patient and provider satisfaction and cost savings What is population focused care/population mangement? Care that focuses on a specific population of patients; ie. asthmatics, COPD patients, etc. Uses clinical info systems for patient registeries and tracks outcomes data with respect to clinical guidelines..ex: tracks HGBa1C for diabetics (goal of 7% or less), LDL (goal of less than 100 for diabetics) and BP levels (130/80 or less). What does planned care refer to in the CCM? Planned visits for chronic care patients. Proactive, well-organized. Integrate EP guidelines. Know timing of labs, meds, diagnostics, etc. Briefly describe the 5A's Ask, Advise, Assess, Assist, Arrange According to the 2012 BEERs criteria, what are some drug classes to avoid/use caution with in the elderly? First-generation antihistamines, antiparkinson agents, nitrofurantoin, Alpha1blockers (doxazosin), Anti-arrythmics, Nifedipine immediate release, TCAS such as amitriptylline, barbituates, benzos, oral estrogen, testosterone (unless SEVERE low T), Ketorlac, avoid chronic NSAID use unless taking a PPI ( 325 of ASA) muscle relaxants. Interventions according to guidelines to prevent falls in elderly: -fall risk assessment and migtation of fall risk factors - reduce number of meds if 4 - assess for postural hypotension -cardiac pacemaker if hx of unexplained falls/with carotid sinus hypersensitivity -Vit D 800Units/daily -No specifics on assistive devices, alarms, hip protectors What are three screening questions for falls: 1. Two or more falls in the last year? 2. Presents with acute fall? 3. Difficulty with walking or balance? What to assess regarding fall risk: History of falls, medications, gait/balance/mobility, visual acuity, neurological impairments, muscle strength, heart rate and rhythm, postural hypotension, feet/footware, environmental hazards. What are risk factors for a fracture according to the FRAX tool? Smoking, glucocorticoid use, RA, previous fx, parent fracutred hip, low BMD, high alcohol use, osteoporosis Define Delirium? Acute confusional state is a syndrome characterized by disturbance of 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 a day. ACUTE AND FLUCTUATING nature differentiate this from depression, dementia or other conditions. Risk factors for delirium: prior hx of delirum, hx of dementia, depression/alcohol use, hearing or vision loss, anticholinergic use, assistance needed for ADLs, dehydration BUN:creat 21:1, sodium abnormal 130 or 150, HTN, CHF, DM, CVA, AFIB 4 diagnostic features of delirium: (Confusion Assessment Method CAM) is diagnostic for delirium 1. Acute onset and flucutating course 2. Inattention 3. Disorganized thinking 4. Altered LOC Interventions for delirium: 1. Maintain 4-6 hours of sleep at night (decrease environmental noise, drink hot milk, back rub, may need hypnotic drug if all ineffective) 2. Orient patient to place, date, time, clock present. Keep light on 7a-7p. 3. Bring personal items, hearing aid/glasses 4. ID and manage pain/constipation 5. DC IV lines, Foley, tethers if risk outweighs harm 6. DC sedating and anticholinergics when possible/ 7. Professional sitter is good, check skin frequently. 8. Early mobilization 9. short acting benzo IF AT HIGH RISK for ETOH WD Timed up ad Go Test: Describe briefly (gait assessment) Measures time taken to stand up from a chair with armrests, walk 3 meters, turn, walk back to the chair and sit down. asynch says 29 seconds is predictive of mobility dysfunction What are the three components of failure to thrive in the elderly? 1. Physical Frailty 2. Disability 3. Impaired neuropsychiatric function It is NOT normal part of the aging process. Describe criteria for frailty: 3/5 present 1. weight loss (%5 in 6-12 mos, BMI 24-29 is optimal, sm amount is normal 0.1-0.2kg/year) 2. exhaustion 3. weakness 4. slow walking speed (7 sec to walk 15 feet) 5. decrease in physical activity Causes of FTT? 1. Medication side effects 2. Medical comorbidities 3. Psychosocial factors/SE issues (can't afford food, cognitive decline--depression, delirium, dementia) Drugs that may affect weight loss: 1. Anorexia inducing: anticonvulsants, dig, NSAIDs, PPI, SSRI, H2 blockers 2. Dysphagia: ACE, antibiotics, KCI, biphosphonates 3. GI rxns: chemo, amiodrarone, laxatives, NSAIDs 4. Alter taste: ACE, allopurinol, anithist, coumadin, lasix, lithium How does neuromuscular function play into frailty? Decrease in skeletal mass/strength (sarcopenia), decrease in aerobic capacity, FEV1 Define disability and a way to assess for this? -Difficulty or dependency in completing tasks essential for self-care and independent living. Disability is often reversible and many adults can compensate THIS IS DIFFERENT FROM F.T.T ADLS and Instrumental ADLS--KATZ ADL scale assesses bathe, toilet, dress, transfer, feeding, continence (6 pts patient independent and 0 points is very dependent) Describe Lawton IADLS? telephone, shopping, transportation, meal prep, housework, finances, medication mgmt History points in those with FTT: timing of symptoms, medical hx, meds, alcohol/drug use, vision or hearing loss, poor mobility?, difficult with feeding (dentures, tremors, dysphagia)?, infxn signs (UTI, fever, pain, weithgt loss), neuromuscular issues? Red flags for elder abuse: Substance abuse among caregivers, limited social support, behavior change in presence of caregivers, unexplained injuries, fail to fill prescriptions PE and Labs for FTT patient Exam: physical/cognition, VS, HEENT, neck, breast, retal, gait get-up-and-go, hearing/vision, neuro Labs: CBC with Diff, CMP, UA, TSH, B12, Folate, lipids, vitamin D, CXR, EKG, albumin/lipids (decrease) What is polypharmacy? Peak age? Prevalance and which gender is more at risk? Concomittant use of more drugs than are clinical necessary. FIVE OR MORE drugs per day in elderly patients. Inappropriate drug use, risk of med errors. 7 or more drugs is a common amount in which issues occur. Peak age: 70-84 Prevalence: 1/5 americans Gender: WOMEN MEN Cause of polypharmacy? Inadequate communication between providers, OTC meds, no med rec during hospitalizations, prescribing cascade--we are prescribing drugs for SE of other meds! What are the three most common drugs that cause AE? What is a class that commonly causes issues in elderly? 1. Insulin 2. Digoxin 3. Warfarin Anticholinergics cause issues in the eldery Pharmacokinetic changes in older adults -Decreased hepatic blood flow/changes in enzyme activity and renal function -Low body weight or BMI -Increased sensitivity to adverse effects of drug therapy -Increased receptor response to benzos, antipsych, antidepressants -Lipophillic (fat) drugs have increased volumes of tissue distribution with aging (elderly have more fat) -Polar/water soluble drugs have lower volumes of distribution 3 drugs to avoidable according to the BEERS criteria: 1. Amitriptylline 2. Muscle relaxants (Flexeril) 3. Benadryl Clinical presentation of ADE in the elderly: Restlessness, falls, depression, confusion, constipation, loss of memory, incontinence, EPS, syncope, loss of function Why is the elderly at risk for dehydration? -Medication side effects such as diruetics in CHF patients. -43-50% of body is water rather than 80% in kids -Concentration of kidneys decreases, urine flow not decreased with dehydration until late in the process. --Sensation of thirst is diminished or absent -Alteration in mental state Changes in renal function in aging: -Decrease in kidney mass and RBF -Decrease in GFR after age 40 -Renal sodium retention leads to water overload, with a decrease in GFR, it favors enhanced sodium conservation. -Vasopressin increased or decreased. ANP hormone increased and may lead to sodium loss. Decreased plasma renin activity can lead to high K especially with ACEI's on board. Drugs that cause sodium retention, sodium loss, impaired concentration, drugs that cause SIADH Retention: NSAIDS Loss: Thiazide and loop diruetics Impaired concentrating capacity: lithium, diurectics SIADH: TCI, SSRI, SNRI, ACEI, narc Mild, mod, severe dehydration signs Mild: decrease in skin turgor best assessed on forehead or sternum, dry mucous membranes, ortho hypo, swollen tongue, sunken eyeballs, high temp, decrease in output, ARF, lyte imbalance, tachycardia Moderate: Oliguria, anuria, resting hypotension, confusion Severe: Shock Labs for dehydrated patient: UA, lytes, Hematocrit, BUN/creat Hyponatremia: definition, causes, types, treatment Decrease in sodium plasma concentration 135meq/L Excess of water in relation to sodium. Dilutional is assoc with high mortality. Causes: caused by nutritional supplements such as ensure, isocal, osmolite, tube feedings (low in NA). N/V/D/ diruetics. CHF, cirrhosis, ascites: (hypervolemic hyponatremia) Urinary loss, sweat, gastric suctioning: (Hypovolemic hyponatremia) Tx: acute---0.9% NSS IVF in ICU, chronic---fluid restriction 800-1000ml per 24 hours Hypernatremia: definition, causes, treatment Definition: Elevated plasma sodium 145meq/L Causes: decrease in water intake, increase in NA intake, increase of water loss from GI tract and loop diretics. Lethargy, weakness, seizures, stupor may occur. Tx: Start with 0.9% NS..then IVF 0.45% NaCl or 5% dextrose in water-correct slowly over 24-72 hours to decrease brain edema. Maintain normal BP/HR. Diagnostic Criteria for depression: 2 core symptoms and at least 4 of the other symptoms 2 core symptoms: (need 1 or both) FOR AT LEAST 2 WEEKS 1. Depressed mood 2. lack of interest/pleasure At least 4 of these s/s: worthlessness, guilty, inability to concentrate, fatigue, psychomotor agitation, insomnia/hypersomnia, increase/decrease in weight/appetitie, thoughts of death/suicide (note :minor depression" is 1-3 of the other s/s and one core symptom) Define dysthymic Disorder Chronic depressive syndrome. AT LEAST FOR 2 YEAR PERIOD, present for most of the day and more days than not. Early vs late onset of depression differences? Early: before age 60 indicates a psych disorder Late: after age 60 can be vascular lesions, loss of planning functions History taking points for depression family hx, med hx, life-changing events, social/SE status, physical problems. -Geriatric depression scale, Mini Mental status exam (score below 20 indicates impairment)