NURS: 610 EXAM 1 STUDY GUIDE
1. Focus on patient presentation, management (pharmacologic and nonpharmacologic), any side
effects, adverse reactions or contraindications to medications, diagnosis and differential
diagnosis, follow-up needed
a. TB – know induration with regards to specific co-morbidities
i. ≥5 is + if HIV, exposed to active TB, old TB fibrosis on CXR, transplants and
immunosuppressed
ii. ≥ 10 is + if immigrant <5yrs, foreign born, IV drug user, congregate residents,
lab workers, comorbid pts-DM, Renal, Heme
iii. ≥ 15 is + for anyone else
b. Asthma – medications (step-up, step-down)
i. Step 1: mild intermittent: <2x/week, no sx, normal peak flow
1. SABA-rescue inhaler-albuterol; provides rapid relief, 10-15min onset,
can use up to 4x/day
a. Anyone with asthma must have this!
b. SE: HTN, increased HR, nervousness
c. EX: Albuterol, Combivent, ProAir, Ventolin
ii. Step 2: mild persistent: <1x/week, exacerbations may affect activity
1. ICS-maintenance-reduces inflammation, 2-4 puffs/day
a. Anyone with persistent asthma
b. Budesonide is only inhalation approved for <4yo
c. SE: thrush-prevent with spacer and rinse
d. EX: Pulmicort, Flovent, Qvar
iii. Step 3: moderate persistent: >2x/week exacerbation do affect activity
1. ICS + LABA-maintenance, slow onset, NEVER monotherapy
a. Preferred therapy for >12yo or exercise induced
b. EX: Advair, Symbicort, Breo Elipta, Dulera (Ds and Bs are
combos)
c. Consider referral to asthma specialist
iv. Step 4: moderate to severe persistent: cont. sx with limited activity, frequent
nighttime sx
1. Medium to high dose ICS+LABA OR ICS + Singulair
v. Step 5: severe persistent:
1. High dose ICS+LABA + omalizumab if allergies involved
vi. Step 6: severe persistent
1. High dose ICS+LABA + oral corticosteroid + omalizumab for allergy
vii. Leukotriene modifier may be suggested to start with Step 1 or 2, especially if
considering an allergy/seasonal component
viii. Omalizumab: Anti IgE monoclonal antibody
ix. Pregnant patients cannot have LABAs or NSAIDs, decongestants, live vaccines,
immunotherapy, some anbx: tetracycline, sulfonamides, ciprofloxacin
x. Inhaled flu vaccine not for asthma pt
1. Must have SABAs, cromolyn sodium, anti-cholinergics
2. If must have LABA give budesonide
xi. HTN and asthma best to treat with CCB and/or diuretic
xii. Spirometry is the gold standard of diagnosis; forced vial capacity and forced
expiratory volume then get SABA then repeat
1. 15% increase in PEF after 15-20min of SABA
xiii. Follow up in 1-2hr or next day for acute episodes
xiv. Follow up in 6mo if mild under control for >3mo
c. COPD: irreversible lung damage
i. Stage 1: mild obstructive FEV >80%, chronic cough, sputum
1. SABA + flu vaccine
ii. Stage 2: moderate obstruction FEV 50-80%, SOB with exertion, chronic sx
1. SABA + LABA + flu vaccine + cardiopulm rehab
iii. Stage 3: severe obstruction: FEV 30-50%, dyspnea, reduced activity tolerance,
exacerbation affect QofL
1. SABA + LABA + ICS + flu vaccine + cardiopulm rehab
iv. Stage 4: very severe obstruction: FEV <30%, dyspnea at rest, chronic respiratory
failure
1. SABA + LABA + ICS + flu vaccine + Oxygen
a. Resting O2 sat must be <88%
v. Chronic bronchitis: narrowed airways and increased airway resistance
1. Blue Bloaters
vi. Emphysema: loss of elastic recoil and alveoli destruction causes air limitation
1. Pink Puffers
vii. Pneumovax-23 and Prevnar-13 for >65yo
viii. Annual Quadrivalent flu vaccine for all COPD patients
ix. Follow up q1-2mo depending on client needs
d. Cough – acute vs chronic, what are main causes (p.195)
i. Acute: <3 weeks: viral URIs, bronchitis, bacterial pna, viral bronchitis, allergies,
mycoplasmic pna, ACE
ii. Chronic: >8 weeks: postnasal drip, asthma, GERD, COPD, chronic bronchitis,
psychogenic, CHF, carcinoma
e. Pneumonia
i. Causative agents
1. Strep pneumoniae: typical
2. Hemophilus influenzae: typical: ETOH abuse, viral URI
3. Staph aureus: typical: chronic disease, IV drug use, viral influenza
4. Mycoplasma pneumoniae: atypical “walking pneumonia
ii. Treatment
1. Macrolide for 7-14 days
a. Azithromycin, Clarithromycin
2. If allergic to macrolides
a. Doxycycline
3. Recent anbx use in <3mo use Fluroquinolones
a. Moxifloxacin, Levaquin OR
b. Macrolide and Augmentin or Amoxicillin
4. Recent anbx use in
iii. CURB-65: tells us mortality risk for pt with CAP
1. Confusion, BUN >19, RR >30, SBP <90 or DBP <60, Age >65
2. 0-1: low risk: outpatient
3. 2: moderate risk: hospital
4. 3: severe risk: ICU
5. 4-5: highest risk: ICU
f. Acute Bronchitis
g. Dyspnea
2. Vaccines
a. Herpes Zoster(Shingrix): >50yo
i. 2 shots 2-6mo apart, min 4wk apart
b. HPV: 1, inactivated 11-12yo; up to 21yo if not prev. vaccinated
i. Syncope post immunization so watch for 15min after
ii. Can give up to 26yo if immunocompromised or gay
iii. Prevents cervical, vaginal, vulvular, anal cancers and gential wars
c. Pneumonia
i. Pneumovax-23: 65yo, 1 dose
1. If <65yo when receive give 2nd dose in 5 yrs after 1st dose then last dose
at 65yo
a. Only given for risk: asthma, comorbidities,
immunocompromised, spleen issues, smoker, LTAC
ii. Prevnar-13: 65yo, 1 dose
1. If <65 when receive give 2nd dose at 65yo no matter age of first shot
i. Immunocompromised, organ transplant, asplenia,
leukemia, malignancy
iii. Prevnar-13 is given first then Pneumovax-23 can be given later
1. 8 weeks after if immunocompetent, liver dx, lung dx, DM, smoker
2. 1 year after if immunocompromised
iv. If Pneumovax-23 given first then must wait 1 year before Prevnar-13
d. Flu: Annual vaccine during October-March
i. >6mo old
ii. Flumist, nasal spray, activated given to healthy, nonpregnant <50yo
3. Health Promotion
a. States of Wellness: POISESEF
i. Physical, occupational, intellectual, spiritual, environmental, social, emotional,
financial
b. Primary Prevention: taking measures to prevent disease
i. Immunizations, vitamins
c. Secondary: screening measures to check for disease and catch early
i. Mammograms, pap smear, BP readings
d. Tertiary Prevention: modifying tx to prevent further disease progression/death
i. Increasing med doses for HF or COPD
e. Screening Men
i. Prostate: 40yo if increased risk OR 55yo for no risk
1. Monitoring for rise in level rather than increased level
ii. Testicular: routine screening is not recommended for everyone
1. Based off of self exam, family history
iii. AAA: 65-75yo if ever smoked >100 cigarettes
1. One time only screening
f. Screening Women
i. Bone Density: 60yo if increased risk OR 65yo no risk
1. Increased risk: steroids, smoker, drinker, RA, biologics may get DEXA
scan before 60yo
ii. Mammogram: 40yo annually (ACOG) or 45yo annually (ACS)
1. After menopause (55yo) q2yr minimum
2. Continue as women are expected to live 10yrs or older
iii. Pap Smear: 21yo q3yr until 65yo
1. Even if sexually active do not need til 21yo
2. Pelvic exam annually needs to begin once sexually active
3. If abnormal or HIV will get pap smears more frequently
g. Screening Adults
i. BP: annually >18yo
ii. DM: 35yo even without sx
1. Fasting BS and then if elevated do 2hr glucose test or HA1C
iii. Lung Cancer: 50yo if 20pack smoke history, current smoker, or quit <15yr ago
1. CT chest low dose annually til 80yo
2. Can D/C after not smoking for 15yrs or to the point of wouldn’t want
surgical intervention or life expectancy is not long
iv. Colon Cancer: 45yo colonoscopy q10yr
1. Cologuard 92% effective for DNA markers and blood
2. If + refer for colonoscopy (gold standard)
v. CVD: 50yo start low dose aspirin
1. Continue for life expectancy of >10 yrs
vi. Smoking: >18yo asking about smoking
1. Vaping, cigarettes, cigars, chewing
4. Smoking Cessation
a. Nicotine gum 2-4mg dose max 20mg/day
b. Patches: higher dose 4 weeks then lower dose 2 weeks later; most effective for 8 weeks
c. Nasal spray: 1-2 sprays/hr; max 40/day 8 weeks, taper at 4-6 weeks
d. Nicotine inhalers: 6-16 cartridges/day, 3mo tx and max 6mo
e. Buproprion/Zyban: antidepressant start 1-2 weeks before quitting
i. No seizures, eating disorders, or if taking Wellbutrin
f. Varenicline/Chantix: start 1 week before quitting
i. No ETOHseizures, mood/suicide MUST follow up for mood changes
5. Weight Management
a. Drugs used if BMI >30 or >27 and comorbidities
b. Nondrug interventions for 6mo before drug therapy
c.
d.
e.
f.
If 5% weight loss in 3mo continue, if not reassess
Sympathomimetic Drugs >16yo and BMI as above
Bariatric surgery BMI >40 with comorbidities
Meds to Avoid:
i. NSAIDs, salicylates, corticosteroids, bisphosphonates, XR form meds, CCBs, BBs,
nitrates, anticholinergics, antihistamines, tobacco
6. Lung Cancer
a. Small Cell: (SCLC): 15% all lung cancers: aggressive, quickly grows, early mets
b. Nonsmall Cell (NSCLC): 85% all lung cancers:
i. Squamous cell: slow growing, men, smokers
ii. Adenocarcinoma: most common, slow-moderate, men, nonsmokers, better
prognosis
c. Stages 1&2: surgery
d. Stage 3: chemo/radiation
e. Stage 4: chemo only0
f. Large Cel: most rare, rapid growing, mets to small intestine
7. Cognitive Issues: Dementia vs Delirium – how to tell apart, any diagnostics used to diagnose.
8. Mental Status Exam – Purpose of using it.