NR 601NR 601 week 8 exam study guide .

NR 601 Week 8 exam Study guide Week Topics Concept: endocrine 5 Glucose metabolism disorders Types of diabetes (prediabetes, type 1 and type 2) risk factors: most common ethnicity- caucasian, native american, Alaska ...

NR 601 Week 8 exam Study guide Week Topics Concept: endocrine 5 Glucose metabolism disorders Types of diabetes (prediabetes, type 1 and type 2) risk factors: most common ethnicity- caucasian, native american, Alaskan native men and women. Diagnostic criteria- FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*  2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*  A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*  In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L). Initial treatment recommendations- first line treatment for each type Type 1- insulin Type 2- 1st line-lifestyle change, metformin o common medication side effects- n/v/d/abd pain/anorexia/taste disturbancv Treatment goals for older adults (Kennedy table 14-2) see picture Hbg A1C goals based on complications (Dunphy p.925)- greater than/equal 6.5 Weight loss recommendations (Kennedy) to decrease risks related to diabetes Risk factors- obesity, sedentary lifestyle, fam hx, HLD, sed life, HTN Complications- diabetes is the leading cause of which complication? obesity Treatments for complication referrals- nutritionist, endocrinology hga1c >13, ophthalmologist,Obesity Comorbidities related to obesity- CAD, HTN, HLD, DM, CVA, central obesity (abd), metabolic syndrome,osa, osteo, breast/colon/endometrial ca, kidney, liver, esophagus, gastric, pancreatic, gallbladder, leukemia, dementia, ckd o BMI classifications (Kennedy) see picture 6 Urology and aging (Kennedy) Urinary incontinenceInvoluntary loss of urine from the bladder ▪ So common in women many consider it normal ▪ Common in older men w/ enlarged prostate o Can affect quality of life o Significance-One of the most common complains w/ older adults, Distress & embarrassment, Cost burden to pt & society as a whole, Not life-threatening, may effect QOL, PCP essential to educating individuals o Epidemiology- Increased prevalence w/ age in men & women, Nursing home population – 40-70%, Often a factor in placement ▪ URGENCY UI is greater in men ▪ STRESS UI is greater in women o Terminology ▪ UI- Unintentional voiding, loss or leakage of urine ▪ Continuous incontinence-Continuous loss or leak of urine ▪ Increased daytime frequency-More frequent during day than considered normal ▪ Nocturia-Interruption of sleep one or more times due to the need to urinate – increases in frequency after age 50 ▪ Urgency-Sudden, compelling desire to pass urine that’s difficult to prevent ▪ Overactive bladder syndrome- Urgency, frequency, nocturia w/ or w/o incontinence o Risk Factors-Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diuretics o Risk Factors by gender-Women:Aging, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen deficiency, hx of pelvic surgery, diuretics Men:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diureticso Physical changes w/ aging that contribute to UI ▪ Lower urinary tract-Detrusor muscle over activity,Decrease in detrusor contractility, Increase in post void residual,Decrease in urethral blood flow ▪ Women – decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral mucosal epithelium & increase in urethral sensation ▪ Men can experience constriction of urethra due to BPH which may result in bladder outlet obstructing symptoms - Initial clinical workup for UI in Men o PMH, PE, UA, DRE: Eval of prostate, PSA w/ new onset in men - UI workup in women: Exclude underlying causes, PMH, PE, UA, Pelvic exam, vaginal exam, perineal, Identify estrogen status of pt, Pelvic prolapse, fistula, -Cough test, Integrity of pelvic musculature, leaking of urine ▪ Full bladder ▪ Standing position ▪ Asked to cough ▪ If urine leak is observed, stress incontinence is confirmed - Red flags in males o Higher level of suspicion for serious diseases, Refer to urology if Previous pelvic surgery, Pelvic radiation, Pelvic pain, Severe incontinence, Severe UTI symptoms, Recurrent urologic infection,Abnl Prostate exam,Elevated PSA o Be alert to these with NEW ONSET UI- Hematuria,Pelvic pain,Abdominal mass, Dysuria, Proteinuria, Glucosuria, CVA tenderness,Nodular prostate,Any new neuro symptoms - Goals of treatment: Reduce symptoms, Improve QOL, Increase social activity, Reduce leakage volumes, increase dryness, use less protection; Increase independence in incontinence management; Decrease caregiver burden  lower urinary tract symptomso frequency, pain on urination or pain increasing with uriuiation.  Acute bacterial prostatitiso presence of more than 10 WBC per high power field on mid stream urine collection.  If acutely ill, hospitalization. o Treat with Cipro 500mg BID x 10 days or Levaquin 500mg daily x 10 days. o Choose a fluoquinolone - it penetrates prostate tissue well.  Education o May need a stool softener. Repeat UA is recommended. Avoid anal intercourse. Use condom to prevent reintroduction of bacteria intourethra. - 1st line management guidelines o AHRQ guidelines for management of UI in women ▪ Behavioral therapy ▪ Lifestyle modification ▪ Try for 3 months before pharm management o Weight loss, Smoking cessation(Tobacco is a bladder irritant),Less coughing o Dietary changes-Alcohol, soda, coffee with or without caffeine, acidic foods and spicy foods o Maintain adequate fluid balance to reduce constipation, provide adequate flow to kidneys - Behavioral strategies:Bladder training, Bladder control strategies,Timed voiding,Kegels, Pelvic floor training - 2nd line management - Medication o Antimuscarinic medication: 1st line for women ▪ Block the parasympathetic muscarinic receptors ▪ Inhibit involuntary detrusor contractions ▪ Side effects due to the effects on other muscarinic receptors o Outcomes unpredictable and side effects common o Common s/e: Dry mouth**, Blurred vision, Constipation,Nausea,Dizziness, Headache o AntimuscarinicsMechanism of action ● Blocks acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detrusor contractions (anticholinergic) ● CYP3A4 substrates ▪ Indications: UI and OAB ▪ Contraindications: Untreated/uncontrolled narrow angle glaucoma,Gastric retention, Urinary retention ▪ Precautions:CNS depression,Caution in elderly ● Renal dosing o CrCl <30 o Beta 3 Adrenergic Agonist – Mirabegron (Myrbetriq) ▪ Also approved for UI and OAB▪ Clinical trials – significant reduction in incontinence and micturations ● No anticholinergic s/e ▪ Mech of action ● Selectively stimulates beta-3 adrenergic receptors ● Relaxes smooth muscle – bladder ▪ Contraindications/caution: HTN- Do not use if SBP >180, DBP >100 ▪ Avoid severe renal/liver disease ▪ Dose – 25-50mg PO QD ▪ CrCl <30 – max 25mg - 2nd line of UI in Males – Alpha 1 blockers o Men, not women! o Alpha 1 blockers antagonize peripheral alpha 1 adrenergic receptors o Used in men d/t high incidence of BPH in aging men o Alpha antagonists ▪ Alpha 1A – prostatic smooth muscle relaxation ▪ 1B – vascular smooth muscle contraction ▪ 1D – bladder muscle contraction and sacral spinal cord innervation o Meds ▪ Doxazosin SE: Dizziness, dyspnea, edema, fatigue, somnolence ▪ Terazosin SE: Asthenia, dizziness, postural hypotension ▪ Tamsulosin SE:Abnormal ejaculation, asthenia, back pain, dizziness, increased cough ▪ Alfuzosin- CrCl <30 use with caution, SE: Dizziness, URI ▪ Silodosin SE- Retrograde ejaculationUTI risk factors, differences based on gender - Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diuretics female- bacteria in urethra, bladder, chronic inflammation (interstitial cystitis), age, sex, suppressed immune system, pregnancy, urinary obstruction, neurogenic bladder, DM, f/c, urethral obstruct, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen deficiency, hx of pelvic surgery, diuretics, decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral mucosal epithelium & increase in urethral sensation Men- prostate issues, prostatitis, f/c, uti, unprotected anal sex, Men:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diuretics, obesity,UTI pathophysiology- common bacterial causes – women- 1st cause gram neg rod (e-coli), 2nd cause- gram pos coccus-staph saprophyticus, proteus mirabilis, klebsiella, Enterobacter, serratia, pseuomonas, staph aureus, fungi (candida) o UTI diagnostic criteria and when to treat (review week 6 discussion and know criteria for treatment based on symptomatic and asymptomatic bacteriuria o medications o complications of untreated urinary tract infection o Incontinence – involuntary loss of urine from bladder, common in women, older men with enlarged prostate  risk factors- infection, delirium, meds, DM, fecal impaction, restricted mobility  types of incontinence -stress, urge, overflow (not empty bladder), functional (delirium, fecal impact, dec mobility, meds) o Causes of hematuria and proteinuriahematuria- food, caffeine, spices, tomatoes, chocolate, alcohol, citrus, soy sauce, herbal med, beta-lacam abx, sulfonamides, nsaids, warfarin, heparin, aspirin, Dilantin, cipro, allopurinol, Tagamet, urolithiasis, menses. For men >50 needs workup Proteinuria- illness, stress, exercise, fever, chf, acute pulm eema, cva, head injury, mult myeloma, lymphosarcoma, leukemia, hodgkins, albumin transfusion, o urologic changes in the male and female