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NRNP 6560 Midterm exam with verified
correct answers 2024-
Surgery risk classes - CORRECT ANSWER-Class 1: benefits outweigh risk, should be done Class 2a: reasonable to perform Class 2b: should be considered Class 3: rarely appropriate General rules for surgery: testing - CORRECT ANSWER-ECG before surgery only if coronary disease, except when low risk surgery Stress test not indicated before surgery Do not do prophylactic coronary revascularization Meds before surgery - CORRECT ANSWER-- Diabetic agents: Use insulin therapy to maintain glycemic goals(iii) Discontinue biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas, and GLP-1 agonists
- Do not start aspirin before surgery
- Stop Warfarin 5 days before surgery. May be bridged with Lovenox.
- Do not stop statin before surgery
- Do not start beta-blocker on day of surgery, but may continue Assessment of surgical risk - CORRECT ANSWER-- Unstable cardiac condition (recent MI, active angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF. arrhythmia, CVD
- patient stable or unstable?
- urgency of the procedure (oncology will be time sensitive)
- risk of procedure
- nutritional status
- immune competence
- determine functional capacity (need to be more than 4 METS, more than 10 METs makes low risk) Low risk surgeries - CORRECT ANSWER-catarcts breast biopsy cystoscopy, vasectomy laporascopic procedures Plastic surgery intermediate risk surgeries - CORRECT ANSWER-Head/ neck surgery thyroidectomy Intraperitoneal Prostate Laminectomy Hip/ knee Hysterectomy cholecystectomy nephrectomy non majot intrathoracic High risk surgeries - CORRECT ANSWER-aortic/ cabg
- maintain euglycemia
- urinary catheters are to be removed within the first two postoperative days Osteoarthritis: what, incidence - CORRECT ANSWER-Slow destruction of bones/ joint followed by production of replacement collagen which causes inflammatory changes
- older than 60
- more female after 55
- more black than white women
- men and women equal risk between 45 - 55
- abnormal height or weight (obesity)
- repetitive movement
- prior trauma (sprains/ dislocations)
- diabetic neuropathy
- genetic Osteoarthritis findings and diagnostics - CORRECT ANSWER-- Pain in weight bearing joints
- stiffness after sitting, gets better when arising
- feeling of instability on stairs
- fine motor skills deficit
- larger affected joints
- Heberden nodules (bony bumps on the finger joint closest to the fingernail)
- Bouchard's nodules (bony bumps on the middle joint of the finger)
- limited ROM with crepitus
- xr shows narrowing of joint space (need anteroposterior and lateral knee films bilaterally)
- synovial fluid is clear and without WBC Osteoarthritis treatment - CORRECT ANSWER-Goal is to relieve symptoms, maintain/ improve function, and avoid drug toxicity Hand OA:
- rest/ joint protection, with splinting
- heat/ cold therapy
- topical capsaicin
- topical NSAID (trolamine salicylate) (especially for older than 75)
- Oral NSAIDS, incl COX2 inhibitors such as celecoxib (Celebrex) (may cause cardiac problems)
- tramadol
- no opioids Hip/ knee OA:
- weight reduction, cardiovascular exercises
- transcutanous external nerve stimulator
- acetaminophen
- Topical NSAIDS (knee)
- intraarticular corticosteroid injections
- XR: joint swelling, later cortical and space thinning
- synovial fluid: yellow, thick with elevated WBC up to 100. Felty's syndrome - CORRECT ANSWER-rheumatoid arthritis, splenomegaly, neutropenia Rheumatoid arthritis treatment - CORRECT ANSWER-- early treatment better than stepwise
- early referral rheumatologist
- disease-modifying anti-rheumatic drugs (DMARDs):
- methotrexate ( no alcohol, monitor renal and liver, give with folic acid)
- cyclosporine
- Gold preparations (can cause thrombocytopenia)
- Hydroxychloroquine: antimalarial drug (may cause visual changes, monitor)
- sulfasalazine, moderate RA
- Leflunomide, moderate to severe RA
- Etanercept
- monitor liver function with DMARDs
- screen for TB (skin test) and Hep B
- surgery: joint debridement, joint replacement Gout: what, who - CORRECT ANSWER-Inflammatory disorder in response to high uric acid production/ levels in blood and synovial fluid causing crystallization which causes inflammation (Type A and Mediterranean)
- impaired renal function which causes excess uric acid
- foods high in purine, such as dairy, red meat, shellfish, beer Gout findings, diagnostics - CORRECT ANSWER-- acute painful joint, often great toe (warm, swollen)
- pain at night
- flank pain because of renal calculi
- fever
- leukocytosis
- elevated erythrocyte sedimentation rate
- tophi (bump under skin) on ear
- limited joint motion
- elevated serum uric acid (greater than 7mg/dl)
- urate crystals seen with joint aspiration
- xr: joint erosion and renal stones Gout treatment - CORRECT ANSWER-- NSAIDS: naproxen, ondomethacin, sulindac
- Colchicine for those who do not tolerate NSAIDS (caution with renal impairment). Also for prophylaxis
- Corticosteroids, if NSAIDS and colchicine not tolerated
- 24hr urine for uric acid
- Allopurinol after flare is over (100mg PO daily)
- Biological modifiers of disease (BMD): Pegloticase. Not for asymptomatic. Treat with prophylaxis first. Monitor serum uric acid
Increased with infection and inflammation, RA. Decreased with succesfull RA treatment RF. Tests in rheumatic disease: what, normal level, abnormal with. - CORRECT ANSWER-Rheumatoid factor. antibody against IgG. Positive RF in most people with RA Corticosteroids and arthritis: what does it do and adverse effects - CORRECT ANSWER-Not for maintenance Use lowest dose Suppresses flares nausea, hyperglycemia, weight gain, adrenal insufficiency, mask infections NSAIDS and arthritis: what and adverse effects - CORRECT ANSWER-analgesic and anti-inflammatory give PPI concurrently to prevent GI complication Headache, htn, fluid retention, n/v, ulcers/ bleeding, abnormal liver function tests, rash, renal insufficiency Celebrex and Arthritis - CORRECT ANSWER-Analgesic and anti-inflammatory Fewer ulcers than with other NSAIDS Not recommended in renal or liver failure Screen for sulfa allergy May cause cardiovascular thrombotic event
May cause GI adverse event subluxation: what, cause - CORRECT ANSWER-partial dislocation of a joint. Common sites: shoulder, elbow, wrist, hip, knee, patella, ankle, spine trauma, blunt force neuromuscular disease inflammatory joint disease, RA Loose ligaments Ehlers-Dantos syndrome (loose ligaments and overflexible joints- congenital) Findings and diagnostics subluxation - CORRECT ANSWER-Pain over affected area previous subluxation swelling around joints loss of ROM XR, CT, MRI show subluxation Increased WBC (stress response) Management of subluxation - CORRECT ANSWER-Early reduction, many spontaneously immobilization (splint, sling) PT NSAIDS for pain/ swelling
xr: dislocation (should get anteroposterior) CT scan for pelvic trauma to rule out hip/ pelvic fracture Order ultrasound for posterior knee dislocation: high incidence of popliteal artery injury McMurray test, Lachman Test, straight leg test - CORRECT ANSWER-McMurray: turn foot and bend knee. Positive with Meniscus injury Lachman test: Hold upper and lower leg, around knee, stretch. Hyperstretch: ACL injury Straight leg test: Pain when raising leg, while supine. Positive for herniated disk. Dislocation management - CORRECT ANSWER-Early reduction is essential: closed/ manual if no fracture. If fracture then may need surgery. Postreduction immobilization (splint, cast, sling) surgical repair of ligaments PT/ OT NSAIDS Muscle relaxant for muscle spasms Narcotics for short term use Soft tissue injury: definition, classifications, incidence - CORRECT ANSWER-Injury to non-bony tissue, such as muscle, ligament, tendon, bursa, cartilage, skin Classification:
- Closed injury: contusion, hematoma, crush, strain (muscle), sprain (ligament, first to third degree), rupture (muscle and ligaments: instability, inability to move)
- Open injury: laceration, abrasion, penetrating/ puncture, amputations trauma exercise/ overuse autoimmune (RA, SLE) obesity age (skin tear elderly) Findings and diagnostics soft tissue injury - CORRECT ANSWER-pain swelling feeling of instability of joint Ruptures/ muscle tear: decreased ROM, immediate swelling and hematoma, abnormal contour muscle, instability of joint, pain/ guarding, watch neurovascular integrity Ligaments/ sprain: pain on palpation and ROM, decreased ROM with moderate swelling, Lachman's test (hypermobile joint is positive sign) Strain/ muscle or tendon: swelling, decreased/ absent ROM, pain/ guarding Cartilage: swelling, click during McMurray's test (would indicate meniscus tear), pain/ guarding
Type 2: wound larger than 1cm, moderate contamination Type 3: high degree of contamination, severe fracture instability, soft tissue damage. T3A: soft tissue coverage adequate, T3B: extensive injury soft tissue, exposed bone, T3C: open fracture with arterial injury
- Incomplete or complete
- stress
- traumatic/ pathologic
- displaced/ non-displaced Type of fracture lines - CORRECT ANSWER-Transverse Spiral Oblique Comminuted Logtitudinal butterfly segmental impacted Salter-Harris Fracture Classification - CORRECT ANSWER-Concerns growth plate S: straight across growth plate A: Above growth plate L: BeLow growth plate T: Through growth plate R: ERaser of growth plate (Rammed)
Cause of fractures - CORRECT ANSWER-Trauma, tumor, osteoporosis, drugs (prednisone), nutritional deficiency (Vit D), neuromuscular disorders Findings and diagnostics of fractures - CORRECT ANSWER-Pain History of traumatic event Neuromuscular dystrophy: headache (autonomic dysreflexia) Deformity of limp Diminished/ absent pulses ecchymosis and swelling xr, always order anteroposterior and lateral CT scan for pelvic and spinal fractures MRI for suspected spinal cord injury Mortise view (leg inward) for ankle to check talus bone oblique films for humerus, femur, ankle DEXA scan to determine degree of osteoporosis Acute Fractures Management - CORRECT ANSWER-- ABC care (Airway, breathing, circulation), musculoskeletal second survey
- fluid resuscitation
- early reduction of fracture
- cover open wounds
- surgical irrigation and debridement for open fracture
- Ab's: Cefazolin for gram pos. Clindamycin for tetani infection
hx of trauma paresthesia heaviness in affected extremity Six P's: Pain on passive stretch Paresthesia Paralysis of affected limb (late finding) Pulses, bounding first then pulseless later Pallor of affected limb Polar/ poikilothermia (ice cold limb) Elevated WBC Hyperkalemia (tissue necrosis) CPK and LDH elevated Myoglobin in urine Elevated compartment pressure (normal 0-8) Clinical diagnosis, MRI may confirm Acute renal failure (due to myoglobinuria) Compartment syndrome management - CORRECT ANSWER-Non surgical:
- limb at heart level (do not elevate)
- remove bandages/ immobilizers
- diuretic
- neurovascular checks
- CRRT/ dialysis to treat ARF
- intracompartmental pressure monitoring Surgical:
- fasciotomy, with delayed closure of wounds (negative pressure wound vac)
- skin grafting
- amputation if septic from necrotic tissue Restorative:
- functional splinting
- ROM
- early prostethic fitting post amputation Low back pain - four major syndromes - CORRECT ANSWER-1. Back strain
- Disk herniation
- Osteoarthritis/ disk degenration; osteophyte (bone spur)
- Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment Specific findings for back pain - CORRECT ANSWER-- numbness
- saddle anesthesia (CA, mass)
- bowel, bladder dysfunction (emergency surgery)
- pain worse at rest (CA, tumor, infection)
- Discitis, epidural abcess (IV drug use)
