State of Michigan Nursing Home Administrator Exam

PATIENT TRUST FUNDS

1) Policy:
Must have a policy.
May state that the facility will not handle monies in excess of $5,000.00.
The facility may charge a reasonable fee not to exceed the ACTUAL COST of providing service.

2) Required Printed Information:
This must be given resident upon admission.
A statement that the facility will handle personnal funds if no other person is available.
Periodic statement of accounts (Minimum: Quarterly)

3) Procedure: American Institute of CPA
Quarterly statements including all activity, (A-H) in easily readable form.

Written account of all personal funds held in trust must be sent to the executor, administrator, rep payee or next of kin within 10 DAYS OF THE DEATH OF A PATIENT.

Account must be closed and balance sent to resident within 3 DAYS OF DISCHARGE.

Access to Funds

4) Financial records:
not less than two (2) hours during normal business hours.

5) Petty Cash:
during all normal business hours.

Accounts

6) Funds:
Cannot be CO-MINGLED with any other facility funds (Can with Residents’)

7) Interest Bearing Accounts:
May keep up to $200.00 in a non-interest bearing account of petty cash fund.

Money in excess of $200.00 shall be deposited in an interest bearing account within 15 days of the date the $200.00 minimum is exceeded.

8) Designation For Patient Unable To Handle Own Funds:
Facility notifies the Family Independence Agency, Adult Protective Services in writing when a mentally incompetent patient has no one to act on his behalf.

9) Sale Or Transfer of Ownership
Written receipt from new owner acknowledge receipt of the funds for safeguarding.

10) Surety Bond:
Not LESS than $2,000.00 or 125% of the previous year’s patient trust funds average balance held, whichever is greater.

Michigan State Plan For Long Term Care

11) Department of Community Health (MDCH or DCH)
DCH is responsible for the Medicaid Program under contract to the federal agency named Centers for Medicare and Medicaid Services (CMS).

MDCH also contracts with other departments and agencies to provide specific services.

12) Medical Services Administration (MSA)
This agency, under authority of MDCH writes policy, acts as fiscal intermediary, designs categorical reimbursement programs, audits and authorizes facility-specific reimbursement rates.

13) Bureau of Health Systems: DCH
has this bureau under its department for oversight of the quality of care within nursing homes through the certification process.

The actual certifying agency is CMS. This is accomplished through the surveys and inspections.

14) Department of Community Health, Bureau of Construction Codes, Office of Fire Safety.
DCH contracts with Office of Fire Safety to conduct the Life Safety Code portion of the survey.

15) Michigan Department of Human Services (DHS):
DCH contacts with DHS who determine an individuals Medicaid eligibility and “co-payment” responsibility. DHS utilized the local offices for direct contract with applicants.

16) Bureau of Health Professions: DCH
Has this bureau under its department for oversight and licensing of Nursing Home Administrator (NHA)

17) Michigan Department Community Health
This Department contracts directly with the federal agency CMS and as such is designated responsibility for Title XIX of the Social Security Act.

Currently this program is 56% federally funded and 44% state funded.

18) Medical Service Administration (MSA)
itself handles two primary aspects of the program POLICY AND REIMBURSEMENT.

Medicaid Policy

19) Providers must adhere to
ALL POLICIES TO PARTICIPATE

20) Facility must be licensed
MANDATORY

21) Certification of Facility
VOLUNTARY

22) MDCH uses the
Bureau of Health Systems to perform surveys for this certification.

23) Delivery of Services (Fairness/Non-Discrimination Doctrine)
Services Reimbursed by MSA are listed in the Medicaid manual.

Facilities MUST render covered services to ALL ELIGIBLE recipients in the same scope, quality, and manner as provided to the general public.

24) Compliance:
Facility must render services in accordance with all federal and state statutory and regulatory requirements.

25) Medicaid is Payor of :
LAST RESORT

26) Medicaid Payment is:
PAYMENT IN FULL (critical issue)

For covered services the facility must except the Medicaide reimbursement rate as payment in full for each and every Medicaid recipient.

The facility may not seek additional payment from residents or families for covered services.

27) For NON-COVERED SERVICES
The facility may seek payment from the recipient IF the resident chooses the service AND is informed of the charge PRIOR to receiving the service.

Record Keeping

28) Retention:
Facility services – 6 years
Orders of Contracted Services (Not records) – 6 years

Attending Physician

29) Attending Physicians’ responsibility
Federal and State regulations require the attending physician (MD or DO licensed in Michigan) to provide specific services to recipients.

30) Physician Compliance
It is the facilities responsibility

31) Physician Visits
Every 30 days for first 90 days, then every 60 days thereafter (more frequently if medically necessary)

32) Physicians’ must have
Written Plan of Care, signed

Annual Requirements for Inspection of Care

33) Under State Plan, DCH utilizes its
Bureau of Health Services to complete this during the annual survey.

Process assures that residents are receiving the appropriate care at the APPROPRIATE level of care.

Grounds for Termination of Enrollment or Refusal to Renew

34) Facility actions that:
Threaten the health, safety, or welfare of Medicaid recipients (determined through the survey process)

35) Facility actions that:
Threaten the fiscal integrity of the Medicaid program.

Abuse of Resident Trust Fund

36) Enforcement actions:
Failure to meet the federal conditions of enrollment or participation

Failure to meet the Certification Standards

Termination or suspension of Medicare automatically does the same to Medicaid

37) Patient Pay Amount
recipient must pay to the nursing home each month the amount of income determined to be in excess.

Facility is responsible for collecting

May NOT bill Medicaid for uncollected portion.

38) Co-insurance:
Must be applied to the FIRST DAYS OF STAY.

Remember facility MAY NEVER CHARGE A MEDICAID RECIPIENT MORE than the MEDICAID RATE.

39) Medicaid resident is discharged on the 11th of the month. How much do you charge whom if:

Private Pay Rate: $100.00 per day
Medicaide Rate: $80.00 per day
Patient Payed: $1000.00 per day

Amount due = Medicaid Rate X Days of Stay (80.00 X 10 = 800.)

Facility may charge for day of Admission, but not day of Discharge.
So stay = 10 days.

You must notify the local DSS office of all discharges.

Amount due from (to) resident = Amount Due – Patient Pay Amount for month
(800 – 1000 = -200)
You owe resident $200.00
Bill Medicaid 0.00

39). Under NO circumstances may a facility change the payment status of the resident to private pay and charge the full $100.00.
The DHS determines whether or not the recipient is Medicaid eligible. If the resident had stayed more days, you would have billed Medicaid.

40) Prior authorization for Services is Mandatory for
all recipients BEFORE receiving care.

41) Prior authorization for Routine Services is accomplished
Through the PreAdmissions Screening of PASAAR. Conducted by MDCH by contract to local Community Mental Health (CMH).

Pre-payment review for nursing need.

42) Prior Authorization for Ancillary Services
is Mandatory for all ancillary services (Therapies and Durable medical equipment).

43) Invoice (DSS-1073) is submitted to DCH AFTER
SERVICES RENDERED. You may bill both ROUTINE and ANCILLARY services on the same bill.

44) Therapeutic Leave Days:
Each recipient is entitled to 10 hospital leave days providing:

Hospitalization is unexpected
Return Anticipated within 10 days
Resident returns before day 10

REIMBURSEMENT

45) DCH
is the fiscal intermediary for Medicaid program.

46) Reimbursement Structure:
limits are established by legislature.

47) Cost Reporting:
to determine the facility-specific rates, DCH utilizes the MICHIGAN STATISTICAL and OPERATING COST REORT which must be filed within 90 days of the facility’s fiscal year end.

Relationship Between Medicare and Medicaid

48) Many recipients are eligible for both types of benefits.
If so, then facility MUST first bill Medicare, receive initial payment and then bill Medicaid

49) Medicare Part A:
Routine Services plus Ancillaries

Medicare pays in full for days 1 – 20

On Day 21, you begin to bill co-insurance (Medicaid) for day 21 – 100.

50) A recipient must enroll in Medicare Part A to be eligible for Medicaid.
If a recipient refuses to enroll, he is automatically denied Medicaid.

51) Medicare Part B:
Ancillary Services provided

Outpatient or Medical Services

Therapies (Non Medicare A)

Billable Medical Supplies D.M.E.

Diagnostic Services

Payment: Bill deductible to Medicaid

Workers Compensation

52) Purpose:
Alternative to employer “tort” liability in the legal system.

53) Sole:
Workers Compensation is the sole remedy for workers injured or disabled in the corse of employment.

54) Employees accepting workers compensation
cannot sue the employer

55) Workers Compensation Benefits
are statutory

56) Workers Compensation Rates
are set by rating agency on behalf of insurers

57) Workers Compensation Claims
appeals process is handled by state bureau

58) “Rate Making”
Process used in determining rates to be charged by insurance companies. Rates are set by the bureau

59) “Loss Experience”
Actual Payments and reserves for anticipated payments added together.

60) “Manual (or Book) Rate”
Assume parity with the averages within a given employer group, such as clerical, nursing, maintenance.

61) “Reserves”
Estimates of medical cost and lost time payment (including fringe benefits) that are set aside by the carrier for each anticipated injury AT THE TIME THE CLAIM IS FILED.

62) Michigan is a Total Disability State:
any injury is considered total disability. Either you can work or you can not.

63) Compensable injuries:
any injury arising out of and in the course of employment.

death due to or rising out of the course of employment

any injury received going to or from the workplace on the premises
where work is to be performed and within a reasonable time before and after working hours.

Coverage Liabilities

64) Employers Mandatory Participation:
Every private employer who employs one or more employees 35 hours per week or more for 13 weeks or longer.

65) Compensation Payments:
No loss time compensation shall be paid unless the employee is incapacitated from earning wages for more than one week.

66) Benefits Level:
Maximum weekly benefit is 90% of State average weekly wages as set by the Department of Consumer and Industry Services

67) Statue of Limitations:
Two years from date of injury, or two years from the time that employee knows that injury is work related.

Employers’ Responsibility To Bureau

68) Form 100
“Employers’ Basic Report of Injury” Filed immediately with
The “Bureau of Workers’ Compensation” and copies distributed to
The insurance carrier
The employer and
The employee

69) Form 104
“Petition for Hearing” –

70) Form 107
“Notice of Dispute” aq

Union Process of Recognition and Certification

71) Petition NLRB (National Labor Relations Board
potential union members for interest with signature cards.

show interest must be equal to or greater than 30% of potential bargaining unit interested.

the election (NLRB Conducts; 50% plus 1 of potential bargaining unit members voting wins)

The Nursing Home shall provide a written copy of facility rules and regulations:
to the patient or the patient’s representative upon admission and when the rules and regulations are changed.

The Policy shall be developed by a:
Patient Care Policy Committee

The Patient Care Policy Committee must consist of:
At least 1 Physician, the Director of Nursing, and the Administrator, with such additional memebers as the committee dems appropriate.

Oxygen Administration:
Only personnel who have been trained to administer oxygen shall do so and that Oxygen shall only be administered on the Order of a Physician or as authorized in Emergency Situations.

Infection Control Committee
The Director of Nursing and Representative of Administration, dietary, housekeeping, and maintenace services.

Medical Examination of Patients
1) Except in the case of a Friday Admission, in which case the patient shall be exaimed by a licensed physician within 72 hours.

2) A patient admiitted to a home shall be examained by a licensed physician within 48hours after admission

Medical Examination of Patient currently in the facility:
Shall be seen and, to the extent appropriate, shall be examined by a licensed physician at least once every 60 days, unless justified otherwise and documented by the attending

Standing Orders Must be:
Reproduced in the patients Clinical record and shall be signed by attending physician within 48 hours.

Telephone or Verbal Orders Recorded by the licensed nurse in charge
Shall be countersigned by the physician withhin 48 hours.

The Director of Nursing
Shall be a Registered with specialized training or relevant experience in the area of gerontology and shall be employed FULL TIME BY ONLY 1 NURSING HOME

The Charge Nure
A licensed nurse shall be the charge nurse on each shift or tour of duty and shall be responsible for the immediate direction and supervision of nursing care provided to patients.

In Homes less than 30 beds the Director of Nursing
May serve as Charge Nurse on a shift when present for full shift.

Reporting and enforcement of nurse staff requirements:
A home Shall maintain for a priod of Not Less than 2 years , employee time records, including time cards or their equivalent and payroll record

An Ambulatory Resident/Patient shall have a complete Tub or Shower
under staff supervision at least once a week, unless the physician writes an order to the contrary.

A Bedfast Resident/Patient shall be assisted with bathing or bathed completelt
at least twice a week and shall be partially bath daily and as required due to secretions, excretions, or odoors.

A patient’s Clothing or Bedding shall be changed Promptly
when they become wet or soiled

A patient shall be Weighed and have his or her vital signs tanken and recorded
On Admission and at least Monthly thereaftter or more frequently if ordered by a physician.

Begining Patient Care Planning
An assessment of a patient shall be initiated by licensed nursing personnel within 24 hours of admission and the results of the assessment shall be documented in the patients clinical record.

A Patient Care Confrence
shall be held periodically, but not less than Once Every 90 Days to evaluate a patient’s needs and evaluate care plan

Equipment and Supplies Bed
An individual bed not less than 36 inches wide and 72 inches long, or longer when necessary, with springs in good condition, and a mattress not less than 5 inches thick in good condition, with a nonobsorbent cover.

The home Shall provide a written copy of facility rules and regulations
To the patient or the patients representative upon admission and when the rules and regulations are changed

Diversional Activities
A Home shall provide an on going diversional activities program that stimulates and promotes social interaction, communication, and constructuctive living.

Patient Counsel
shal permit the formation of a patient/resident counsel by interested patients, and at time of admission to home shall inform all of the counsel and the rules if any

When the Dietary or Food service supervisor is other than a registered dietitian
The supevisor shall receive routine consultation and tecnical assisstance from a registered dietitian (R.D) not less than 4 hours every 60 days.

Food and Nutritional Needs of a patient
Shall be met in accordance with the physicians orders in keeping with acceptable standards of practice of most recent recommended daily dietary allowences

Not less than 3 meals or their equivalent
shall be served daily, at regular times, with not more than a 14 – hour span between a substantial evening meal and breakfast.

Menus, postings, filing
as actually served to patients must be kept for preceding 3 montns on file in the home

Food acceptance record
shall be retained in the facility

Self Administration of Medication by a Patient
shall not be permitted, except when special circumstances exist and when supported by a physician’s written order and justification

Diagnostic Services
An arrangement shall be made by the administrator for obtaining promptly and conveniently a clinical laboratoy, x-ray, or other diagnostic services ordered by the physician

A written report of each diagnostic test and service
shall be included in the patients clinical record within 1 week

Clinical Records of DISCHARGED patients
shall be completed within 30 days following discharge.
Clinical records shall be under the supervision of a full time employee of the home

Clinical Records are Retained for a Minimum of
6 years from date of discharge or, in the case of a minor, 3 years after the individual comes of age under state law, which ever is longer.

Accident Records and Incident Reports
shall be prepared for each accident or incident involving a patient, personnel, or visitor and shall include all of the following information.

Employee Records and work Schedules
a daily work schedule shall be prepared in writting and be maintaned to show the number and type of personnel on duty in the home for the previous 3 months

A Time Record for each employee
shall be maintained for not less than 2 years

“Medical Audit”
means the retrospective examination, review, and evaluation of the clinical application of medical knowledge utilized in the diagnosis and treatment of poatients as revealed n the patient’s clinical record and carried out for purpose of education, accountability, and quality control.

“Quality Control”
means the planned and systematic medical management actions which assures the consistent acceptabe quality of health care and services rendered to patients including the use of variousmonitoring techniques.

“Utilization Review”
means retrospective, concurrent, and prospective review of the provision and utilzation of health care services by providers and recipients in terms of cost, effectiveness, efficiiency, and quality

Home Entrance for Physically Hanicapped
IN A NEW CONSTRUCTION, addition, major change, or conversion after AUGUST 22, 1969, at least 1 entrance Shall provide easy access for the Physically handicapped

A minimum od 20 square feet of floor space per patient bed
Shall be provided for dayroom, dining room, recreation, and activity purposes.

A new contruction after August 22, 1969 Shall provide
A sleep, day, dining room, recreation, or activity room with a minimum ceiling height of 8 feet

20 feet of unobstructed vision space outside of any
window in a room requiring windows. One additional foot shall be added to the minimum distance of 20 feet for each 2 foot rise above the first story up to a max of 40 feet of required unobstructed space

A multi bed patient room (not more than 4 beds)
shall have a 3 foot clearance btw beds and not less than 70 square feet of usable floor space per bed

The temerature of HOT WATER at plumbing fixtures used by patients
shall be regulated to provided tempered water NOT LESS than 120 degrees fahrenheit.

A room used for patients shall maintain a regular daytime temperature
of NOT LESS than 72 dehrees fahrenheit

Kitchen and Dietary
A Reliable Thermometer
shall be provided for each refrigerator and freezer

In new construction (August 22, 199) general storage space of
10 square feet shall be provided in the home

In a 100 bed Nursing Home Day Staff
8:1 ration RN?LPN/ CNA

In a 100 bed Nursing Home Evening Staff
12:1 ratio RN/LPN/CNA

In a 100 bed Nursing Home Night Saff
15:1 ration RN/LPN/CNA

Class Outlines and Lesson Plans
shall be retained in the facility for not less than 2 years

MIOSHA
General recording criteria
You must consider an injury or illness to meet the criteria, if it results in
a) DEATH
b) Days away from work
c) Restricted work or transfer to another job
d) Medical treatment beyond first aid
e) LOSS of consciousness

MIOSHA
Retention and Updating
Must save MIOSHA 300 Log during the 5 year storage period

MIOSHA
Hospitilization
Within 8 hours after death of any employee from a work-related incident or the inpatient hospitialization of 3 ormore employees as a result of a work-related incident

MIOSHA incident reporting
You must orally report the fatality/multiple hospitilization by telephone or in person to the Michigan Department of Consumer and Industrial Services, Bureau of Safety and Regulation, State Secondary complex

MIOSHA
If the Building Office is Closed, May I report the incident by leaving a message on MIOSHA’s answering machine, faxing the bureau office, or sending an e-mail?
NO! If you can’t talk to a person at the bureau office you must report the fatality or multiple hospitilization incident using the 800 number

800-858-0397

“Licensed bed capacity”
means the autorized and licensed bed complement of a nursing home

Rule #107 Type Documentation
When the statue or these rules required a document or parts of a document to be printed in 12 point type the distance btw the top

Rule # 111 Governing Body
The governing body of the nursing home shall assume full responsibility for the overall conduct and operation of the home

The Governing Body Shall Appoint a
Licensed Nursing Home Administrator and shall deligate to the administrator the responsibility of operating the facility according to the policy and perceedures they established

Rule #112 Posting Resident Rights
Shall develop, adopt, post in a public place, distribute, and implement a Policy on the rights and responsibilities of patients in accordance with the requirements

All patient complaints shall be investigated with in
15 days of the complaint and home within 30 days following the complaint the home shall provide complintee a written status report or results of investigation

Patient Trust
Policy that home will not handle funds freater than $5,000.00

Patient has the right to have a representative from_____________ to handle his/her funds
Social Security Administration

Disaster Plan
Shall have a written Plan or procedure to be followed in case of fire, explosion, or other emergency

A regular Simulated Drill
shall be held for each shift NOT LESS than 3 times per year

Building Construction
If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least two hour fire resistance rating

Interior Walls and Partitions in building of Type I or Type II
construction shall be noncombustible or limited-combustible material.

Interior Walls and Partitions in building of Type I or Type II
shall be noncombustible or limited-combustible materials

Interior Finish 2000 EXISTING
Interior finish for corridors and exitways, includeing exposed interior surface of building has flame spread rating of Class A or Class B

Interior Finish 2000 NEW
Must have Flame Spread Rating of Class A or Class B. LOWER PORTION OF CORRIDOR WALLS CAN BE CLASS C

Corridor Walls and Doors 2000 EXISTING
are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating.

Corridor Walls 2000 NEW
NO fire resistance rating is required for corridor walls.

Doors 2000 EXISTING
doors protecting corridor opening in other than required enclosures of verticle openings, exits, or hazardous areas shall be constructed of 1 3/4 inch sold-bond wood

Doors in Sprinkler buildings
are only required to resist smoke.

Exit Components 2000 Exists
such as stairways are enclosed with construction having a fire resistance rating of at least one hour,

Smoke Barriers New 2000
shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients

The smoke compartment
shall not exceed 22,500 square feet and smoke barrier shall not exceed 200 feet

Exit and Exit Access
Not less than Two exits, REMOTE from each other, are provided for each floor or fire section of the building

Exit and Exit access shall be arranged such that no
cooridor, aisle or passageway has a pocket or dead-end exceeding 30 feet

Width of Aisle or Corridors 2000 EXISTING
clear and unobstructed, serving as exits shall be at least 4 feet

Width of Aisles or Corridors 2000 NEW
clear and unobstructed serving as exit access in hospitals and nursing homes shall be at least 8 feet

Illumination of Means and Egress including exit discharge
is arranged so that failor of any single lighting fixture (bulb) will not leave the area in darkness

Emergency Lighting of at least
1 1/2 hour duraton is provided in accordance

Fire Alarm System 2000 Existing
There shall be ANNUNCIATION of the fire alarm system to an approved central station.

Fire Alarm System 2000 NEW
There shall be remote annunciation of the fire alarm system to an approved central station

Automatic Smoke Detection 2000 New
An automatic dectection system is installed in all cooridors with detector spacing not further apart than 30 ft on center, nor more than 15 ft from any wall.

Windor and Door 2000 Existing
Every patient sleeping room shall have an outside window or outside door.

The allowable height shall not exceed 36 inches (91 cm) above the floor.

Soiled linen or trash collection receptacles
shall not exceed 3 gal (121) in capacity

Oxygen storage locations of greater than
3,000 cu ft are enclosed by a one-hour separation.

Generators are inspected
weekly and exercised under LOAD for 30 minutes per month and shall be in accordance

National Fire Protection Association
Private, nonprofit organizaton – NOT A GOVERNMET AGENCY.

Author of Life Safety Code

Nursing Homes are required by OBRA to meet LSC

Proceedure in Event of Fire
1) Removing all residents involved
2) Transmitting alarm
3) Isolating the fire by closing doors
4) Evacuating by plan

Stairs: Clearance
44″; riser height – 7″ max

Smoke Towers
stair enclosure designed to limit penetration of heat and smoke. No more than 1% of the volume of air in stairwell will emanate from fire area

Handrails at bottom of stairs
Must extend parallel to floor for 12″

Windows must have
opening force requirement of no more 5lbs.

Preventive Maintenance
1) Save expense of requirs
2) Save labor
3) Assure safety

Facility Temperature
71F – 81F

Bed Space for each Patient
80 sq ft per resident in multi-bed rooms,
100 sq ft in private room

Obra Requirement for Housekeeping
Services necessary to maintain a sanitary, orderly, and clean interior.

Pharmacology – Ch. 3 – Pharmacokinetics

aka Biodisposition; The effects of biologic systems on drugs. It deals w/ the Absorption, Distribution, & Elimination of Drugs. Loading & Maintenance Doses can be calculated.
What is Pharmacokinetics? What processes are involved? What can be calculated in Pharmacokinetics?

The concentration of a drug AT THE RECEPTOR SITE (in contrast to drug concentrations that are more readily measured like in the blood)
What is Effective Drug Concentration?

Vd = (Amount of Drug in the Body) / (Plasma Drug Concentration) in Volume Units; The higher the Vd, the more the drug has been distributed to the tissues as opposed to free flowing in the plasma
What is the Volume of Distribution (Vd)?

CL = (Rate of Elimination of Drug) / (Plasma Drug Concentration) in Volume per Unit Time
What is Clearance (CL)?

CONSTANT (the ratio of elimination to plasma concentration is the same regardless of plasma concentration)
What is the Clearance of Drugs that are eliminated w/ 1st Order Kinetics?

1) Type of Drug; 2) Condition of Organs of Elimination (Liver, Kidney, etc); Clearance is often Flow-Limited because the clearance of a drug is sometimes very effectively extracted by an organ (the blood is completely cleared of the drug as it passes thru the organ); In these conditions, blood flow thru the eliminating organ is more important
What 2 things is Clearance dependent on? How is Clearance often Flow-Limited?

1) Ethanol; 2) Aspirin; 3) Phenytoin
Majority of Drugs follow 1st Order Kinetics. Which 3 important drugs do NOT follow this?

t1/2 = (.7 x Vd) / (CL); The time required for the amount of drug to fall to 50% of an earlier measurement; derived from Vd & Clearance; CONSTANT for 1st order kinetics
What is Half-Life? What is the Half-Life of drugs following 1st Order Kinetics?

The fraction (or %) of drug concentration/dose that reaches the Systemic Circulation; Unity or 100%
What is Bioavailability? Bioavailability of IV administered drugs?

Incomplete Absorption (expulsion of drug by intestinal transporters by intestine), 1st Pass Metabolism, & Any Distribution into Other Tissues that occurs before the drug enters the systemic circulation
What factors REDUCE Bioavailability of drugs administered other ways besides IV?

It is the Area Under the Plasma Concentration Curve (or AUC); (AUCroute) / (AUCiv); AUC is the graphic area under a plot of Drug Conc. versus Time after a single dose
How is Bioavailability measured on a graph curve? What is AUC?

The elimination of drug that occurs after administration but before it enters the systemic circulation; Ex: during passage thru Gut Wall, Portal Circulation, or Liver for an orally administered drug)
What is the 1st Pass Effect?

The fraction of the drug removed from the perfusing blood during its passage thru the organ; Drugs that have a high hepatic extraction ratio have a large 1st pass effect so the bioavailability of these drugs after oral administration will be low
What is Extraction Ratio?

Oral administration
What route of administration has a large 1st pass effect & therefore low bioavailability?

A plan for drug administration over a period of time. An appropriate regimen results in the achievement of therapeutic levels of the drug in the blood w/o exceeding the minimum toxic concentration;
What is a Dosage Regimen?

Maintenance: To maintain the plasma concentration w/in a specified range over long periods of therapy; Loading Dose: Necessary to achieve the target plasma level Rapidly and the volume of distribution is large; it is used to “Load” the volume of distribution w/ the drug
When are Maintenance Doses given? Loading Doses?

Dosing Rate = (Clearance x Desired Plasma Concentration) / (Bioavailability); Vd is not involved
What is Maintenance Dose? Which parameter is not involved?

Loading Dose = (Vd x Desired Plasma Concentration) / (Bioavailability); Clearance is not involved
What is Loading Dose? Which parameter is not involved?

The safe range b/t the minimum therapeutic concentration (Trough) & the minimum toxic concentration of the drug (Peak)
What is the Therapeutic Window? What are the Trough & Peak concentrations of a drug?

Renal Disease or Reduced Cardiac Output, sometimes Liver Disease; Corrected Dose = (Average Dose) x (Patient’s Creatinine Clearance / 100mL/min)
Which conditions normally reduces the clearance of drugs? What is the formula for the corrected dose needed for patient’s where the elimination of their drugs is altered by disease?

The condition in which the average total amount of drug in the body does NOT change over multiple dosing cycles (ex: The condition in which the rate of drug elimination = The rate of Administration)
What is Steady State?

Lippincott’s Pharmacology Chapter 1

Passive Diffusion
High conc. -> low
majority of drugs work this way
does not involve carrier, is not saturable, and shows a low structural specificity

Facilitated Diffusion
involves carrier proteins
High conc -> low
no energy required, an be saturated, may be inhibited by compounds that compete for the carrier

Active Transport
Shows saturation kinetics for the carrier
drugs closely resemble naturally occurring metabolites that are actively transported across cell membranes
may be competitively inhibited

exo/endocytosis
B12 is absorbed by endocytosis; some neurotransmitters (e.g., norepinephrine) are stored in vesicles and released by exocytosis

Distribution equilibrium
when the permeable form of a drug achieves an equal concentration in all body water space

P-glycoprotein
a multidrug transmembrane transporter protein responsible for transporting various molecules , including drugs, across cell membranes; in areas of high expression, it reduces drug absorption

bioavailability
the fraction of administered drug that reaches the systemic circulation

bioequivalence
when two related drugs show comparable bioavailability and similar times to achieve peak blood concentrations

therapeutic equivalence
when two similar drug products that are pharmaceutically equivalent with similar clinical safety profiles

Pharm – General Principles of Pharmacology

What are the four (4) types of names assigned to drugs?
1) Chemical name
2) Generic name
3) Official name
4) Trade name (brand name)

What are the three (3) key features of a drug’s chemical name?
1) Exact chemical makeup of the drug
2) Placement of the atoms or molecular structure
3) No capitalization

What are the four (4) key features of a drug’s generic name?
1) Non-proprietary
2) Name given to drug before it becomes official
3) May be used in all countries by all manufacturers
4) No capitalization

What are the two (2) key features of a drug’s official name?
1) Name listed in “The United States Pharmacopeia National Formulary”
2) May not be the same as the generic name

What are the four (4) key features of a drug’s trade name (brand name)?
1) Name is registered by the manufacturer and is followed by the trademark symbol
2) Can be used only by the manufacturer
3) Any given drug may have several trade names
4) First letter of the name is capitalized

What is the largest category of drugs?
Prescription

Prescription drugs require a prescription by a ________.
Licensed health care provider

Prescription drugs are also called ________ drugs.
Legend

Prescriptions must have 1) the ________ of the drug, 2) the ________ of the drug, 3) the ________ of administration, 4) the ________ of administration, and 5) the ________.
1) name
2) dose
3) number of times
4) route
5) amount to be dispensed

Non-prescription drugs may be obtained without a ________.
Prescription

What is another name for non-prescription drugs?
OTC (over the counter)

Name two general conditions under which risks may be associated with non-prescription drugs.
1) When directions are not followed
2) When adverse reactions occur

What is a controlled substance?
A controlled substance is a drug or chemical whose use, ownership, or manufacture is regulated by law — particularly the federal Controlled Substances Act.

Drugs, substances, and certain chemicals used to make drugs are classified into ________ distinct categories or schedules.
Five

Drugs, substances, and certain chemicals used to make drugs are classified into distinct categories or schedules depending upon 1) ________ and 2) ________.
1) the drug’s acceptable medical use
2) the drug’s abuse or dependency potential

The schedule numbering for controlled substances ranges from ________ to ________.
I to V

A schedule V drug has a [higher or lower] potential for abuse or dependency than a schedule I drug.
Lower

What are the two key features of a schedule I drug?
1) High abuse potential
2) No accepted medical use in the U.S.

What are the two examples of a schedule I substance listed in the PowerPoint presentation?
1) Heroin
2) LSD

Schedule II substances are characterized by potential for abuse with ________ physical or psychological ________.
Severe
Dependence

Schedule III substances have [more or less] abuse potential than schedule II substances.
Less

Schedule III substances are characterized by ________ physical or psychological dependence.
Moderate

Non-barbiturate sedatives, non-amphetamine stimulants, and limited amounts of certain narcotics are examples of schedule ________ drugs
III

Schedule III substances have [more or less] abuse potential than schedule IV substances.
More

Schedule IV substances are characterized by ________ dependence.
Limited

What are the two (2) general categories the PowerPoint presentation gives as examples of schedule IV substances?
1) Sedatives and anxiety agents
2) Non-narcotic analgesics

Schedule ________ substances are characterized by limited abuse potential.
V

Anti-________ and anti-________ medications are categorized as schedule V substances because they contain small amounts of ________.
(Anti)-tussives
(Anti)-diarrheals
Narcotics

Drugs taken by mouth (except liquids) go through how many phases?
Three

Drugs taken by ________ (except liquids) go through three (3) phases.
Mouth

The three (3) phases of drugs taken my mouth (except liquids) are:
1) Pharmaceutic phase
2) Pharmacokinetic phase
3) Pharmacodynamic phase

The ________ phase involves the dissolution of the drug.
Pharmaceutic

Drugs must be in ________ to be absorbed.
Solution

Liquid drugs and ________ drugs do not go through the pharmaceutic phase because they are already in solution.
Parenteral

________ administration involves the esophagus, stomach, and small and large intestines (i.e., the gastrointestinal tract).
Enteral

Oral, sublingual (dissolving the drug under the tongue), and rectal are ________ methods of administration.
Enteral

________ administration literally means to avoid the gut (gastrointestinal tract) and refers to any route of administration outside of or beside the alimentary tract.
Parenteral

________ tablets do not dissolve until reaching the small intestine.
Enteric-coated

Metabolic activities of the drug within the body after it is administered relate to the ________ phase.
Pharmacokinetic

The pharmacokinetic phase relates to how many different features or actions of the drug?
Six (6)

The six drug features or actions that figure into pharmacokinetics are:
1) Bioavailability
2) Absorption
3) Distribution
4) Metabolism
5) Excretion
6) Drug half-life

Mnemonic: BAD MED

Absorption is the process by which a drug ________.
Becomes available for use in the body

In ________ absorption, a carrier molecule moves the drug across a membrane.
Active

Passive absorption occurs when the drug moves from an area of ________ concentration to ________ concentration. This transport mechanism is known as ________.
Higher
Lower
Diffusion

________ is a method of absorption in which cells engulf the drug particle, causing movement across the cell.
Pinocytosis

________, ________, and ________ affect the rate of absorption.
Route of administration
Solubility of the drug
Certain body conditions

What are the two (2) PowerPoint examples of body conditions that affect the rate of absorption?
1) Lipodystrophy
2) Food in the stomach

Whether a drug is ________ soluble or ________ soluble can affect its rate of absorption.
Water
Lipid

IV, IM, SC, and PO are examples of ________, which affects the rate of absorption.
Route of administration

________ is the fraction of the drug that reaches systemic circulation chemically unchanged.
Bioavailability

Protein binding refers to the fact that drugs travel in the system circulation bound to ________ and are ________ when bound to protein.
Albumin
Inactive

Protein molecules release the drug, which diffuses through the tissue, interacts with receptors, and produces the desired ________.
Therapeutic effect

________ drug levels must be maintained in order for the drug to be effective.
Therapeutic

If the drug level [increases or decreases], the drug will not produce the desired effect.
Decreases

If the drug level increases, ________ symptoms may occur.
Toxic

________ is the chemical reaction that occurs in the liver and converts a drug to an inactive compound.
Biotransformation

The ________ effect applies to drugs that are absorbed in the small intestines and are transported to the liver via portal circulation. There they are metabolized by the liver before release into the circulatory system.
First-pass

The first-pass effect applies to drugs that are absorbed in the ________ and are transported to the liver via portal circulation. There they are metabolized by the liver before release into the circulatory system.
Small intestines

The first-pass effect applies to drugs that are absorbed in the small intestines and transported to the ________ via portal circulation. There they are metabolized by the ________ before release into the circulatory system.
Liver
Liver

The first-pass effect can ________ the bioavailability of a drug.
Decrease

The first-pass effect can decrease the ________ of a drug.
Bioavailability

Only ________ drugs undergo the first-pass effect.
PO

________ refers to elimination of a drug from the body.
Clearance

In the process of excretion, the ________ renders the drug inactive and the ________ excretes the inactive compounds.
Liver
Kidney

Some drugs are excreted by the kidney unchanged and without ________ involvement.
Liver

What are the six (6) PowerPoint examples of routes of excretion?
1) Kidney
2) Sweat
3) Breast milk
4) Respiratory
5) Feces
6) Bile

The ________ phase refers to drug actions and effects on the body.
Pharmacodynamic

As part of a drug’s pharmacodynamics, primary and secondary effects may alter the cellular ________ or the cellular ________.
Environment
Function

Alteration in ________ function can increase or decrease physiologic function.
Cellular

Physical changes in the cellular environment include what three (3) alterations listed in the PowerPoint?
1) Osmotic pressure
2) Lubrication
3) Absorption

________ refers to the intended effect of the drug on the body.
Therapeutic response

________ are drugs that bind with a receptor to produce results.
Agonists

Drugs that bind with a receptor and prevent another molecule from binding to the same receptor and producing some result are called ________
Antagonists

What are the six (6) main categories of drug reactions?
1) Toxic reactions
2) Drug tolerance
3) Drug idiosyncrasy
4) Allergic drug reactions
5) Adverse drug reactions
6) Cumulative drug effect

Mnemonic: Tall Talking Idiots Alert Comatose Advisors
Tolerance, Toxic, Idiosyncrasy, Allergic, Cumulative, Adverse

Adverse reactions are often called ________ when they are mild.
Side effects

________ reactions are often called side effects when they are mild.
Adverse

Allergic reactions can be called ________ reactions.
Hypersensitivity

________ can be called hypersensitivity reactions.
Allergic reactions

________ may prompt the body to produce antibodies against what it perceives as an antigen.
Allergic reactions

Allergic reactions may prompt the body to produce ________ against what it perceives as an ________.
Antibodies
Antigen

________ is an extremely serious allergic reaction and can be life-threatening if not recognized and treated immediately.
Anaphylactic shock

Anaphylactic shock is an extremely serious ________ and can be life-threatening if not recognized and treated immediately.
Allergic reaction

________ refers to any abnormal or unusual drug reaction of unknown cause and with no predictability.
Drug idiosyncrasy

________ refers to decreased response to a drug requiring increase in dosage.
Tolerance

[Increased or decreased] response to drug requiring [increase or decrease] in dosage is referred to as tolerance, which is a sign of ________.
Decreased
Increase
Drug dependence

________ refers to increased response to a drug because of decreased metabolism and excretion (usually secondary to ________ or ________ disease).
Cumulative effect
Liver
Kidney

Cumulative effect refers to [increased or decreased] response to a drug because of [increased or decreased] metabolism and excretion (usually secondary to liver or kidney disease).
Increased
Decreased

________ refers to poisoning of the system secondary to overdose of chemical resulting in elevated blood concentration.
Toxic reaction

Toxic reaction refers to poisoning of the system secondary to ________ of chemical resulting in ________ blood concentration.
Overdose
Elevated

________ refers to a genetically caused abnormal response to a drug.
Pharmacogenetic reaction

What are the two (2) main types of drug interactions from the PowerPoint?
1) Drug-drug
2) Drug-food

What are the three (3) basic types of drug-drug reactions?
1) Additive drug reaction
2) Synergistic drug reaction
3) Antagonistic drug reaction

________ is the term used when two or more drugs are taken at the same time and the action of one plus the action of the other results in an action as if just one drug had been given. This could be represented by 1+1= 2. An example would be a barbiturate and a tranquilizer given together before surgery to relax the patient.
Additive drug reaction

________ occurs when two drugs are taken together that are similar in action, such as barbiturates and alcohol, which are both depressants, resulting in an effect that is exaggerated out of proportion to that of each drug taken separately at the given dose. This could be expressed by 1+1= 5. An example might be a person taking a dose of alcohol and a dose of a barbiturate. Normally, taken alone, neither substance would cause serious harm in this example, but if taken together, the combination could cause coma or death.
Synergistic drug reaction

________ occurs when two drugs given together have an opposite effect on the body. This could be expressed by 1+1=0. An example might be the use of a tranquilizer to stop the action of LSD. Some stimulants will counteract the effects of depressants and thus are used to treat overdoses of barbiturates and narcotics.
Antagonistic drug reaction

What are the five (5) chief factors influencing drug response?
1) Age
2) Weight
3) Gender
4) Disease
5) Route of administration

________ refers to taking of multiple drugs and creates potential for ________
Polypharmacy
Interactions

Polypharmacy is often practiced by ________, who have more conditions for which to be medicated.
the elderly

Polypharmacy increases the possibility of ________ reactions.
Adverse

Oral Pathology – Exam 1

Lichen

Primitive plants composed of symbiotic algae and fungi

Grow on tree trunks or rocks

Pathology: any of various skin diseases characterized by patchy eruptions of small, firm papules

Lichen Planus
Chronic immunologically-mediated disease
Oral lesions; +/- lesions on skin, other mucosae
Oral lesions more persistant than skin lesions
Middle age onset
Slight greater predilection in females over males

Lichen Planus – Skin Lesions
Most on flexor surfaces
Plaques or papules
Purple, flat-topped with white (Wickham’s) striae
Pruritic
Wax and wane and often subside in 2 years
Oral Lichen Planus – Types
White adherent
Erosive (e.g. desquamative gingivitis)
Vesiculobullous
White Adherent Lesions
Reticular striae
Plaques
Papules
White Adherent Lesions – Reticular Type
Asymptomatic
Interlacing white lines
Bilateral and symmetrical
Buccal mucosa > tongue > gingivae, lips, etc.
White Adherent Lesions – Plaques

Tongue and buccal mucosa

*The most common site for plaque is the dorsum of the tongue

Erosive Lichen Planus
E.g. Desquamative gingivitis (slide 120)
Symptomatic
Atrophy, erythema around central ulceration
Peripheral radiating white striae
Rare malignant transformation
Thick fibrinous exudate gives an appearance suggesting a bulla
Erosive Lichen Planus – Clinical Differential Diagnosis
Hypersensitivity reactions:
Systemic (e.g. drugs)
Local or contact (e.g. amalgam, cinnamon)Lupus erythematosus

Chronic ulcerative stomatitis

Oral graft-versus-host disease

Lichen Planus – Management
******
In general, monitor for iatrogenic candidiasis
Reticular Type
No treatment needed after diagnosis
Clinical monitoring
Erosive
Topical corticosteroids
Systemic immunosuppressive, if necessary
Monitor for potential dysplasia, SCC
Oral Lichen Planus – Histology
Orthokeratosis or parakeratosis
Uneven acanthosis (diffuse epidermal hyperplasia)
Rete ridges prominent, sharp (“saw tooth”), or absent (due to lymphocyte “remodeling” rete ridges)
T-LYMPHOCYTE zone in UPPER LAMINA PROPRIA (immediately below the epithelium)
Loss of basal cells (lymphocytes attack basal cell layer; apoptotic bodies left behind)
Immunofluorescence non-specific: shaggy fibrinogen band along BMZ
Oral Lichen Planus – Histology, cont’d.
Colloid, cytoid or Civette bodies (apoptotic basal cells are eosinophilic degenerating keratinocytes)
Lichen mucositis may have similar features
“Lichen Mucositis”
Lesions with clinical and/or histological resemblance to classical lichen planus
May exhibit some variation from classical features*See slide 24 for picture

******
******
Pemphigus – Types
Vulgaris
Vegetans
Foliaceus
Erythematosus
Paraneoplastic
Drug induced*Foliaceus and erythematosus do not affect the oral cavity

Pemphigus Vulgaris – Clinical Features
Autoimmune vesiculobullous mucocutaneous disease
Appears first in mouth in some cases
Childhood to old age, but most occur between 30-50 years old
Pemphix (Greek) = bubble or blister
Skin lesions appear as flaccid blisters*Autoantibody against Desmoglein 3 triggers response and destroys epithelial cells

*See slides 26-28 for pictures

Pemphigus Vulgaris – Clinical Features
Oral mucosa:
Positive Nikolsky signOral lesions:
Painful
Vesicles rupture rapidly
Ulcers with irregular outlines
Spread peripherally and coalesce

Positive Nikolsky Sign
Pemphigus vulgaris
Paraneoplastic pemphigus
Pemphigoid (all types)
Bullous lichen planus
Erythema multiforme
Epidermolysis bullosa
Hypersensitivity reactions*May not be demonstrable in all cases

Pemphigus Vulgaris – Histology
Autoantibodies against desmoglein 3
Acantholysis (“acantho” = prickle)
Suprabasilar cleft with tombstone basal cells:
Cleft contains Tzanck cells (float off into space)*Basal cells lose attachment to the cells above them, but remain attached to the basement membrane

Pemphigus Vulgaris – Diagnosis

Exfoliative cytology: acantholytic round epithelial (Tzanck) cells

Histology: suprabasilar cledft with tombstone basal cells (cleft contains Tzanck cells)

DIF: Labelled Igs attached to autoantibodies against desmoglein 3 around epithelial cells in specimen (creates fishnet pattern)

IIF: Labelled CIRCULATING AUTOANTIBODIES to desmoglein 3 create same pattern on animal mucosa

Pemphigus Vulgaris – Management
Diagnosis ASAP
Prescriptions by experienced physician
Systemic corticosteroids
Other immunosuppressive agents
Monitor for iatrogenic candidiasis
Monitor disease by indirect immunofluorescence: circulating Igs correlate with disease activity
Serious drug side effects
10% fatal due to treatment
Systemic Corticosteroid Side Effects
Diabetes mellitus
Adrenal suppression
Weight gain
Osteoporosis
Peptic ulcers
Severe mood swings
Increased susceptibility to infections
******
******
Perilesional Biopsy – Chronic Blisters, Erosions and Ulcers

Perilesion = tissue around the lesion

Diagnosis of immunologically-mediated ulcerative conditions (e.g. PV, MMP, BP, LP, LE)

Biopsy specimen should include perilesional (clinically normal) tissue

One-half in 10% formalin for routine H & E stain
Other half in Michel’s (preservative) solution

Incubated with FLUORESCIN-LABELED KNOWN PREPARED ANTIBODY against tissue-bound autoantibody or tissue antigen (C3, fibrinogen)

Bound fluorescin emits bright yellow-green light when tissue is exposed to UV light

Direct Immunofluorescence

Identifies factors in fresh (or preserved) patient tissue

Patient tissue incubated with F-LABELED KNOWN, PREPARED ANTIBODY against:
Tissue bound autoantibody (in PV, MMP, BP, LE)
PV: autoantibody to desmoglein 3
Tissue antigen (C3, fibrinogen)
Foreign (e.g. viral) antigen

Bound fluorescein emits bright yellow-green light when tissue is exposed to UV light

Indirect Immunofluorescence

Identifies circulating autoantibody in patient’s serum

Monkey mucosa is incubated with patient’s serum

Autoantibody in serum attaches to corresponding structure in the mucosa

F-LABELED KNOWN PREPARED ANTIBODY against the antibody is incubated with tissue section

Bound fluorescein emits bright yellow-green light when tissue is exposed to UV light

Pemphigus Vegetans
Variant of pemphigus vulgaris (less serious form)
Oral involvement in a few cases
Acantholytic bullae followed by epithelial hyperplasia and intraepithelial abscess
Pustular vegetations may look verrucous
Many eosinophils present
Vegetans type may occur in lull in pemphigus vulgaris
Can spontaneously remit
Paraneoplastic Pemphigus
Mucocutaneous disease associated with lymphoma (or benign lymphoprolifierative disease)
May appear before lymphoma diagnosis
Sudden onset of multiple vesiculobullous lesions on skin and mucosae
Also seen in erythema multiforme
Paraneoplastic Pemphigus, cont’d.
Cicatricial conjunctivitis in some cases
Skin lesions papular and pruritic (like lichen planus)
Lips resemble erythema multiforme (crusting)
Corticosteroids controls this disease but make malignancy worse
Paraneoplastic Pemphigus – Pathogenesis
Tumor causes host lymphocytes to release IL-6
IL-6 stimulates Igs against basement membrane antigens
Cytotoxic T lymphocytes presentThis multifaceted immunologic attack produces a variety of clinical, histologic and immunologic changes

Paraneoplastic Pemphigus – Histology

Lichenoid mucositis with subepithelial cleft or intraepithelial cleft

Some cases are only lichenoid

DIF: Weak deposition of immunoreactions (IgG and C); between epithelial cells and/or linear deposits at the basement membrane zone

IIF (using patient serum and epithelium from rat bladder): Igs between epithelial cells against desmogleins 1 and 3; Igs in BMZ against desmoplakin I and II, BPAG-1, etc.

***REVIEW CASES***
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Mucous Membrane Pemphigoid – Clinical Features
Chronic vesiculobullous disease
Most often affects females greater than 40 years old
Vesicles rupture: painful ulcers may persist for months
Positive Nikolsky sign
Usually exclusive to the mucous membrane of the oral mucosa; much lesser extent in the skin
Causes desquamative gingivitis
Desquamative Gingivitis
Gingivae red, edematous and glazed
Superficial ulceration or desquamation/peeling
Occurs more on the buccal gingiva than the lingual
Vesiculobullous conditions: MMP, ELP, PV, CUS, EBA, SLE, drug reactions, LIgA, paraneoplastic pemphigus
Mucous Membrane Pemphigoid – Clinical Features, cont’d.

Conjunctival involvement may lead to scarring

Symblepharon
Ankyloblepharon
Entropion

Symblepharon
Adhesions between bulbar and palpebral conjunctivae
Ankyloblepharon
Adhesion of ciliary edges of eyelids to each other
Entropion
Scarring may cause eyelids to turn inward
Mucous Membrane Pemphigoid – Histology
Subepithelial cleft
Entire epithelium lifts off the surface; looks like “unzipping”
Separation of epithelium from connective tissue at the BMZ results in vesicle formation
Subepithelial Vesicles in Oral Vesiculo-Ulcers
Pemphigoid (all types)
Epidermolysis bullosa (some types)
Linear IgA disease
Angina bullosa hemorrhagica
Dermatitis herpetiformis
Mucous Membrane Pemphigoid – Immunofluorescence
Homogeneous linear fluorescence at BMZ on DIF (IgG, C3, etc.)
See a definite line along the basement membrane zoneCIRCULATING IGs IN ONLY 5-30% OF CASES (this is IIF)

Mucous Membrane Pemphigoid – Pathogenesis and Histology
AUTOANTIBODIES (IgG etc.) TO BMZ ANTIGENS:
Hemidesmosome: BPAG (230kd) in plaque (in BP and MMP); BPAG2 (180kd) TRANSMEMBRANE PROTEIN (in MMP); Integrin alpha-6, beta-4 (in MMP)
Lamina lucida: LAMININ (EPILIGRIN) IN ANCHORING FILAMENTS (in MMP)Binding of IgG triggers reaction involving C and PMNs

Weakens basement membrane

Homogenous linear fluorescence at BMZ in DIF

Circulating Igs in only 5-30% of cases

Mucous Membrane Pemphigoid – Management

Removal of drug-induced disease

Ophthalmic consult

Topical corticosteroids:
Increase potency as necessary

Systemic:
Corticosteroids
Steroid sparing immunosuppressives
Tetracycline or minocycline
Dapsone

Bullous Pemphigoid – Clinical Features
Most common autoimmune blistering disease
Occurs in older people (60-80)
Starts with pruritus
Multiple tense bullae on normal or erythematous skin
Bullous Pemphigoid – Clinical Features, cont’d.
Bullae rupture, producing crust
Heal without scars
Oral lesions uncommon
Clinical course shorter than MMP
Bullous Pemphigoid – Histology
Subepithelial cleavage
Antigens: BP180 and BP230
Eosinophils within bullae
DIF positive in 90-100% of cases
IIF positive in 50-90% of cases
Titers don’t correlate with disease activity
Bullous Pemphigoid – Management
Removal of drug-induced disease
Systemic immunosuppresive agents
Lower doses of prednisone than for pemphigus
Better prognosis
Spontaneous remission in 2 to 5 years in some
Mortality due to treatment in older patients
Systemic Lupus Erythematosus – Pathogenesis
Antibodies against host cell antigens:
Nuclear (seem to do the most damage)
Cytoplasmic
Cell surfaceGenetic, environmental and hormonal factors trigger:
Increased B cell function
Abnormal T cell activity

*Patients most often die from renal failure

Discoid Lupus Erythematosus
******
Organs Involved
Skin and oral only
Symptoms
NO
Serology
NO DETECTABLE ANTIBODIES
Histopathology
Basal cell loss
Lymphocytes at interface and perivascular
Keratosis
DIF
Granular/linear basement membrane deposits of IgG and C3
Systemic Lupus Erythematosus
******
Organs Involved
Skin, oral, heart, kidneys, joints
Symptoms
Fever, malaise, weight loss
Serology
Positive ANA
Anti-DNA antibodies
Histopathology
Similar to discoid
DIF
Similar to discoid
Systemic Lupus Erythematosus – Clinical Features
Young adult females
Erythematous cutaneous rash (“butterfly” pattern on face)
Fever, weight loss, malaise
Glomerulonephritis
Damage to: joints, heart, lungs
Oral Lesions – LE
White plaques +/- ulceration
Erythema
Erosions
Ulcers
Desquamative gingivitis*Classical lesion: central red area or ulcer with white spots and peripheral radiating white lines

*Oral lesions may occur in SLE and CCLE

Systemic Lupus Erythematosus – Laboratory Abnormalities
Hematologic changes:
Anemia
Leukopenia
ThrombocytopeniaReduced serum complement concentration

ANTINUCLEAR ANTIBODIES

SLE – Antinuclear Antibodies

IIF is the most common technique to detect ANAs

Pattern of nuclear fluorescence suggests type of antibody

Homogenous/diffuse: antibodies to chromatin, histones and ds-DNA

Rim: antibodies to ds-DNA

Speckled: antibodies to non-DNA antigens (histones and RNP):
Sm
RNP
SS-A (Ro)
SS-B (La)

Nucleolar: antibodies to nucleolar RNP

Lupus Erythematosus – Histology
Hyperkeratosis:
Follicle keratin plugging in skin in CCLE, but nor in SLEAlternating epithelial atrophy/acanthosis

Basal cell degeneration (apoptotic bodies)

Subepithelial edema (+/- vesicles)

Thick PAS + BMZ

Lupus Erythematosis – Histology, cont’d.

Subepithelial, perivascular and adnexal lymphocytes

Intense inflammation in superficial lamina propria; inflammatory cells in deeper connective tissue (perivascular tissue)

See bulging of rete ridges due to attacking lymphocytes

*See zone of lymphocytes attacking the basal cells
*Looks like lichen planus, until you see deeper perivascular inflammation

Lupus Erythematosus – Histology, cont’d.
IF shows shaggy, granular-linear deposits in BAND along mucocutaneous BMZ:
IgG (IgM and IgA), C3 and fibrinogen
Band along BMZ is LUPUS BAND TEST
Positive in clinically normal skin in SLE (not CCLE)*In patients with CCLE, will only see the bands in the lesions; in SLE patients, will see the bands even in normal skin

Systemic Sclerosis
Probable autoimmune pathogenesis
Occurs much more in females than males
Insidious onset
INCREASED COLLAGEN (produces a mask-like facies)
Microstomia
Sclerodactyly (fingers with tightly bound skin)
Systemic Sclerosis – Scleroderma
Fibrosis of lungs, heart, kidneys, GI tract
Fibrosis also causes atrophy of the ramus, coronoid process or condyle; PDL space around mandibular molar is widened (with intact lamina dura)
Interstitial pulmonary disease, which leads to pulmonary hypertension and heart failure
Localized Scleroderma

Morphea

The cutaneous alteration (from a limited form of scleroderma) called en coup de sabre because the lesion resembles a scar that might result from a cut with a sword

Raynaud’s Phenomenon

Arterial insufficiency of acral parts SECONDARY to another disorder that causes arterial narrowing (e.g. SLE, systemic sclerosis, etc.)

Claudication (limping), color and temperature changes

Chronic ulcerations and eventual gangrene

See breakdown and resorption of digits (fingers may be fixed in a claw-like position; shortening may occur from acro-osteolysis; ulcerated fingertips)

Raynaud’s Disease
Vasospasm and its consequences are primary (increased response to stimuli has no known cause
Systemic Sclerosis – Diagnosis

Histology

Rheumatoid factor (antibody against Fc fragment of human IgG)

ANAs (including Anto-Scl-70; Scl-70 is a centromere antigen)

Systemic Sclerosis – Management

D-penicillamine inhibits collagen formation

Surgery (esophageal dilation)

Calcium channel blockers (increase peripheral blood flow and reduce Raynaud’s)

ACE inhibitors (reduce hypertension if kidneys severely affected)

Oral hygiene instruction

Poor long-term prognosis

CREST

Mild form of systemic sclerosis

C: calcinosis cutis
R: Raynaud’s phenomenon
E: esophageal dysfunction
S: sclerodactyly
T: telangiectasia

Mostly affects 50-70 year old females

Erythema Multiforme
Vesiculo-ulcerative mucocutaneous disease
Mostly affects the lips
Occurs in young adults
Occurs in males more than females
Prodrome: fever, malaise, headache
Abrupt onset; usually resolves in four weeks
Recurrence linked to HSV
Erythema Multiforme – Pathogenesis
Self-limiting hypersensitivity reaction
Precise mechanism unknown
Possible involvement of both cell-mediated and humoral immune systems
Ag-Ab complexes target small mucocutaneous vessels
Some drugs may cause EM: Sulfas, Penicillin, Dilantin, Barbiturates, Iodines, Salicylates
Erythema Multiforme – Clinical
Usually acute, self-limited
Some cases chronic or recurring acute
Headache, fever, lymphadenopathy
Target skin lesions (concentric erythematous rings)
Skin macules, papules, vesicles, bullae, etc
Oral ulcers
Erythema Multiforme – Oral Lesions
Painful
Aphthous-type ulcers
Multiple superficial extensive ulcers
Bullae soon rupture*Destruction of epithelium that is superficial, but deeper than pemphigus vulgaris

Erythema Multiforme – Types
Minor
Major
Stevens Johnson syndrome (oral, eye and genital lesions)
*These three may overlapToxic epidermal necrolysis (usually caused by drugs; patients look like they have extensive burns)

Erythema Multiforme – Histology
Necrotic keratinocytes
Spongiosis
Vesicles in epithelium may extend to the subepithelium
Necrosis of vesicle roof
Interface infiltrate lymphohistiocytic
Perivascular inflammation
IF nonspecific*Histology is characteristic but not pathognomonic

Erythema Multiforme – Management
Eliminate triggers (antiviral agents in cases triggered by HSV)
Early corticosteroids (topical, systemic)
Rehydrate
TEN (toxic epidermal necrolysis): burn unit, avoid corticosteroids, pooled IgGs (blocks Fas ligand, which caused epithelial destruction)
Reactive Arthritis (Reiter’s Syndrome)
Abnormal immune reaction to microbial antigen (STD or dysentery)
See 1-4 weeks after exposure
Acute onset of triad: non-specific urethritis, conjunctivitis, arthritis
Skin lesions in some (histology is psoriasiform)
Reactive Arthritis (Reiter’s Syndrome), cont’d.
Oral in less than 20% of cases:
Ulcers (RAU)
Papules
Erythema migrans?Most affects young adult males

HLA-B27 phenotype

Lasts weeks to months with recurrences

NSAIDS for arthritis

Lange Q&A Surgery

Def high-output renal failure
BUN continues to rise with urine output >1000-1500

Mild-to-moderate renal insufficiency

Severe renal failure
Oliguric renal failure

How long can the kidneys tolerate ischemia?
30-90 minutes

Do vasopressors help with shock?
No, they aggravate the deleterious effects of shock

Hyperkalemia manifests with ____ or ____ signs
GI or cardiovascular

What are the GI signs and symptoms of hyperkalemia
Nausea, vomiting, intestinal colic, and diarrhea

T/F abdominal distension as a result of paralytic ileus is due to hypokalemia?
True.

What are the CV signs and symptoms of hyperkalemia
ECG is useful to monitor potassium levels.

Hyperkalemia = peaked T waves, ST segment depression, widened QRS complex, and heart block

When would you see Osborne (J) waves?
Seen in hypothermia

What is given to counteract the effect of potassium on the myocardium?
Calcium gluconate

How do you get metabolic acidosis with normal anion gap?
Loss of bicarbonate (e.g. small bowel fistula, pancreatic fistula, or diarrhea) and gain of chloride

What are some causes of SIADH?
Head injury
CNS disorders
Neoplastic diseases
Idiopathic

What are some signs of SIADH?
Impaired water excretion, oliguria, hyponatremia, significantly decreased serum osmolality, and increased urinary osmolality

When does hyponatremia cause CNS symptoms?
When serum sodium <130 mEq/L

What are some of the signs/symptoms of moderate hyponatremia?
Muscle twitching and increased tendon reflexes

What are some signs/symptoms of severe hyponatremia?
Convulsions, loss of reflexes, and hypertension

What is the sodium deficit?
(normal serum sodium − observed serum
sodium) × 0.6 × (total body weight)

How should the sodium deficit be corrected?
Half of the sodium deficit should be administered over 12-18 hours

The composition of intestinal fluid is closest to that of ____
Plasma

What ions does normal saline, 3% saline, and half normal saline have?
Na, Cl

How do you calculate pH based on changes in CO2?
Every change of 10 mmHg from 40 mmHg changes pH by 0.08 from 7.4.

What are the most common signs of zinc deficiency?
Skin lesions (scaly, hyperpigmented lesions)
Hypogonadism
Diminished wound healing
Immunodeficiencies

What are the effects of toxic megacolon?
Massive dilatation
Perforation
Fecal peritonitis
Death

USMLE Step 2 CK Surgery (Kaplan) I

Retroperitoneal air in the abdomen. DX?
Duodenal injury (2nd portion)
Evaluation of retroperitoneal air. DX WU?
CT scan with contrast or UGI w gastograffin (if neg. do barium study)

Describe how retroperitoneal air might occur?
blunt trauma > duodenal compression between external solid object & spine (ie. steering wheel) > perforation of duodenum
M/C injured portion of duodenum during trauma? Why?
2nd portion of duodenum b/c it is the most immobile
Duodenal injury is a common oversite b/c
of its retroperitoneal location
Indications that a duodendal injury has occured ?
retroperitoneal air and/or obliteration of the psoas margin
DPL / CT / USG are used in the dx of duodenal injuriees b/c
they are not sensitive enough to detect duodenal injury
How long should the 3 dose tetanus vaccine provide coverage?
10 years
Best study for revealing esophageal perforation?
?
Definitive management for esophageal perforation?
Primary closure & drainage of mediastinum w/n 6 hours
complication of esophageal perforation if not managed w/n 6 hours?
mediastinitis (may result)
In esophageal injury avoid
endoscopy (to prevent further rupture)
Obese boy w c/o rt knee pain, rt knee exam nl, restricted hip motion, external rotation of thigh with flexing of hip. DX?
slipped femoral capitis
Slipped femoral capitis. Management?
emergent external screws
Slipped femoral capitis is m/c in?
obese male adolescents
First step w high suspicion of posterior urethral injury. Management?
retrograde urethrogram, suprapubic catheter, delayed repair
Anterior / Posterior urethral injuries. Contrast Tx.
Anterior – stat surgical repair Posterior – retrograde urethrogram delayed repair
In setting of urethral injury. DO NOT
do not insert foley cather, do not use diuretics (may worsen problem)
Retrograde cystogram is used when there is high suspicion of?
bladder injury
Unonscious pt receives OT intubation. Reasoning?
establish airway, protection from aspiration
erythema & edema of non lactating breast. High on DDX?
locally advanced inflammatory cancer
High suspicion of locally advanced cancer merits DX W/U?
biopsy
erythema & edema of non-lactating breast. DDX?
inflammatory CA, cellulitis, mastitis
breast w fluctuating mass. M/L?
an abscess
breast w fluctuating mass. Management?
drainage & antibiotics
Atelectasis. Tx?
bronchoscopy c repeat CXRS
Weakness in upper extremities greater than lower extremeities. Syndrome?
Central cord syndrome
central cord syndrome is associated w?
hyperextension injury
syndrome associated w unilateral paralysis
?
Complete motor paralysis & loss of sensation distal to lesion.
Anterior cord syndrome
anterior cord syndrome is typically a result of what type of injury?
compression injury causes ant. cord syndrome
type of cerebral contusion that selectively causes Upper limb sparing & lower limb
None?
What is false about this statement: All penetrating wounds in middle zone of neck should be surgically explored.
Stab wounds to middle zone pt may be safely observed?
Zone 1 of neck. Boundaries?
lower zone: clavicle to cricoid cartilage
Zone 2 of neck. Boundaries?
middle zone: cricoid to angle of mandible
Zone 3 of neck. Boundaries?
upper zone: angle of mandible to base of the skull
general structures of concern in zone 2.
major vasculature, larygotracheal apparatus, pharyngoesophageal structures
complete: All ___ wounds should be surgically explored in zone 2.
gunshot
General division of the neck can be done to improve management by dividing into anatomic components
digestive, respiratory, cardiovascular
selective management may be considered in zones?
zone 1 and zone 3
Indications for surgery according to digestive component of neck.
dysphagia, crepitation, hematemisis, dysphonia, hemoptysis, palpable laryngeal injury
Indications for surgery according to respiratory component of neck.
subcutaneous emphysema, stridor, tracheal tear,
Indications for surgery according to cardiovascular component of neck.
persistent hemorrhage, expanding hematoma, coma, stroke
gunshot wound to zone 1 is an indication for
esophogram w bronchoscopy
gunshot wound to zone 3 is an indication for
esophogram w bronchoscopy
expanding neck hematoma. Management Zone 1
surgical intervention
stab wound in asymptomatic patient
observation zone 1 zone 2
a popping sound of the knee m/l indicates?
medial meniscal tear
contrast shapes of the menisci
medial meniscus – C shaped, lateral meniscus – O shaped
meniscal injury is commonly due to what type of injury?
twisting injuries w a fixed footing
Minimum database consists of what?
History, Physical Exam Findings, and Diagnostic Test R7esults
What 5 things make up the signalment?
breed, age, species, sex and reproductive status
What drug can cats tolerate given alone but will cause seizure-like activity in dogs?
Ketamine
Boxers and Giant breeds are sensitive to what drug?
Acepromazine
Sighthounds are sensitive to what class of drugs? Examples of this drug class include?
Barbiturates
Exs- Thiopental Sodium, Methohexital, Thiamylal, Pentobarbital, Secanol, and Phenobarbital
What 2 conditions are very young animals prone to?
Hypothermia and hypoxia
When is a patient considered geriatric?
when they have reached 75% of the normal lifespan of that spp/breed
Why do anesthetic drugs pose a risk to geriatric patients?
They are more likely to have difficulty metabolizing drugs because of liver or kidney dz/failure
Describe a lethargic patient
They have a mild decrease in loss of consciousness and can be aroused with minimal difficulty
Describe a obtunded patient
This patient more depressed than lethargic patients and cannot be fully aroused
Describe a stuporous patient
This patient is in a sleep-like state; can only be aroused with painful stimuli
Describe a comatose patient
This patient cannot be aroused and is unresponsive to all stimuli including pain
Describe the c/s a patient who is <5% dehydrated
not detectable
Describe the c/s a patient who is 5-6% dehydrated
mild loss of skin elasticity
Describe the c/s a patient who is 6-8% dehydrated
mild loss of skin elasticity
+ dry mucous membranes and depressed globes within orbits
Describe the c/s a patient who is 8-10% dehydrated
mild loss of skin elasticity,dry mucous membranes, depressed globes within orbits
+more persistent skin tent, and increased PCV/TP
Describe the c/s a patient who is 10-12% dehydrated
mild loss of skin elasticity,dry mucous membranes, depressed globes within orbits,more persistent skin tent, and increased PCV/TP
+ dry, pale MM and CRT >2 seconds
Describe the c/s a patient who is 12-15% dehydrated
all of those and signs of shock and death
Dehydration increases the risk of what 3 things? things done to body b/c of
Hypotension, poor tissue perfusion and kidney damage
What is the formula to figure out how much fluid is needed to get your dehydrated patient back to hydrated?
(Wt in kg) x (1000 mL/kg) x (% dehydrated) = how much to give
Fluid maintenance rate for dogs?
60 mls ****check
Where are some other places to check if gums are pigmented?
conjunctiva, inner vulva, or prepuce
Normal rest heart rate for dogs and cats?
Dogs= 60-180 bpm
Cats= 110-220 bpm
Normal respiration rate for dogs and cats?
Dogs= 10-30/min
Cats= 25-40/min
What are 4 problems associated with obese animals?
They can experience dyspnea, difficult to draw blood from, it is harder to assess the hydration status of them, and difficult to auscultate
What risk are associated with thin animals? What else should you be wondering?
Hypothermia. Does this animal have an underlying condition making them then that could put them in additional risk under anesthesia?
What is the 1st thing you should do after weighing your animal?
Compare the animals current weight to previous weights
Normal body temp for dogs and cats?
100-102.5
How long should you fast a adult dog for a normal procedure?
Food 8-12 hours before surgery
Water 2-4 hours
How long should a patient having a GI surgery be fasted?
Food- 24 hours
Water 8-12 hours
How long should a neonate/ pediatric patient be fasted? Why?
4-6 hours for both food and water because you risk causing dehydration and hypoglycemia
Why do we fast patients?
To avoid vomiting/regurgitation during surgery or recovery which can cause esophagitis causing strictures, respiratory pneumonia or aspiration pneumonia
What does Famotidine do and why would we give it before surgery?
Famotidine stops production of HCL acid in the stomach and it is given before surgery to prevent damage caused to the esophagus if the patient were to vomit or regurgitate
What can prolonged fasting lead to?
Longer recovery period, delays in healing, and other assoc. risks such as hepatic lipidosis
If the animal will not eat what are your options?
hand/syringe feeding, inserting feeding tubes, or total parenteral nutrition (in jugular vein)
What should you always do once your patient enters the facility and is taken from the owner?
Properly ID the animal with a cage card, ID collar or both
Name 6 diagnostic tests that are performed presurgery.
CBC, ECG, Urinalysis, chemistry panel, radiographs and clotting times
Why do we check PCV and RBC? What does an increase indicate? A decrease?
To determine the blood’s ability to deliver oxygen to tissues. Increase indicates usually dehydration (leads to inc. viscocity of blood, poor perfusion and decreased cardiac output) Decreased levels usually mean anemia
If your PCV/RBC is lower that __ in a dog &
__ in a cat you should report it immediately.
dog lower that 25%
cat lower than 20%
Why do we check Total plasma protein? What does an increase indicate? A decrease?
Decreased levels can lead to drug potency. Increased values indicate dehydration. Decreased values indicate possible decreased production by liver or a loss through the renal, hepatic or GI systems.
TP values lower than ___ should be reported immediately.
less than 4.0
Why do we do blood smears? What do you report?
To evaluate RBC and WBC morphology and plt estimation. also can perform coagulation test with blood in red top tube. Report all decreases in plt count or abnormal coagulation test results
What are the things we are most concened about in the urinalysis? What do they show?
Specific gravity(detect dehydration- high or renal insufficiency/failure- low, not concentrating), Glucose and ketones (used to detect diabetes), and WBC & RBC (can indicate crystalluria or UTI) can be normal in sml amounts
Do a urinalysis within how many minutes?
30 or less
Chemistry panels look at what 6 things?
ALT (liver), ALP/ALKP (liver), BUN (kidneys), Creatinine (kidneys), Glucose (diabetes screen), Electrolytes (Na, K, Ca)
ALT. increases caused by?
Associated with liver. increases indicate any injury to hepatocytes or from any illness like GI disease (like chronic diarrhea and vomiting) or inflammation and administration of steroids or anticonvulsants,
ALP (ALKP) increases caused by?
Associated with liver, or bone or GI tract. Increases caused by isoenzymes which come from many different places such as Osteoblasts- immature bone cells
Chondroblasts- immature cartilage cells
Liver
Placenta
Renal epithelium
Intestinal epithelium
BUN increased by? decreased by?
BUN is associated with the kidneys. increased from dehydration, kidney disease or blockages like blocked toms. BUN is decreased by liver failure because liver is not synthesizing it, also by not eating
What 3 tests can be done to determine a clotting abnormality and what are the results of these tests?
Buccal Mucosal Bleeding Time (BMBT), Short nail trim to the quick, or placing blood sample into a red top tube and waiting for a clot to form. In all cases clot formation should occur within 4 minutes.
Name 2 Diagnostic test to check the heart. When/ why will your decide to perform these?
ECK- to evaluate the electrical activity of the heart, pattern, rhythm. Ultrasound of heart. These are performed when heart dz is suspected, heartworm positive, history of trauma, electrolyte abnormalities, or if the animal is geriatric.
How many different Physical Status Classifications are there?
5
PI list the amount of risk, physical condition and examples
Minimal risk. Physical condition- normal, healthy animal w/o underlying disease. Examples- spay, neuter, declaw, hip radiographs for hip dysplasia
PII list the amount of risk, physical condition and examples
Slight risk, minor disease. Physical Condition- slight to mild systemic disturbances; animal compensates. Examples- neonates, geriatric, obese, unknown skin tumors, uncomplicated hernia, local infection.
PIII list the amount of risk, physical condition and examples
Moderate risk, obvious disease. Physical condition- moderate systemic, disease mild clinical signs. Examples- anemia, moderate dehydration, fever, low-grade murmur, or heart disease.
PIV list the amount of risk, physical condition and examples
High risk, significant disease. Physical condition- Preexisting systemic disease. Examples- severe dehydration, shock, uremia, high fever, severe heart or lung disease, diabetes, emaciation
PV list the amount of risk, physical condition and examples
Extreme risk, moribund- risky whether they have surgery or not. Physical condition- life threatening disease that may not be corrected by surgery, animal may not survive 24 hours. Examples- advanced heart, liver, kidney, lung or terminal disease, severe shock, head injury, severe trauma.
Why do we give the animal IV fluids during surgery?
Fluids are constantly being lost while operating, also to keep drugs circulating through and eliminate them as well and to increase blood pressure
What are some signs of overhydration?
Eye/nose discharge, swelling of conjunctiva, SQ edema, increased lung sounds and respiration rate (will sound wet), dyspnea, coughing, restlessness, and hemodilution (diluting RBCs).
What are the rates dogs and cats with excessive hemorrhage or low blood pressure be increased to?
Dogs- up to 40 ml/kg/hr max of 1 hr
Cats- up to 20 ml/kg/hr max of 1 hr
What are the rates dogs and cats in shock be increased to?
Dogs- up to 50-90 ml/kg/hr max of 1 hr
Cats- up to 40-60 ml/kg/hr max of 1 hr
1/4 of max dose given in 15 minute increments then patient is evaluated
Animals that are in shock may show what signs?
Pale MM, low BP with increased heart rate, slow heart rate (when the body is giving up)
How many mLs of blood can a 3×3 gauze hold? a 4×4?
3×3 can hole 5-6 mLs and a 4×4 can hold 10 mLs of blood
What type of drip set to patients less than 10 Kg receive?
60 gtt/mL
What type of drip set to patients greater than 10 Kg receive?
VTI uses 15 gtt/ mL so use this
Body fluids are made up of how much % water, other solutes and the % of water is located where? What % is blood volume in dogs and cats?
Water is 60% of body weight. Intracellular fluid (inside cells) is 40%, extracellular fluid (outside cells) is 20% it consists of 2 categories interstitial fluid (between cells) 15% or intravascular fluid (inside a blood vessel) 5%. The other 40% is solutes.
Blood volume is 8-9% in dogs and 6-7% in cats.
How much of the IV fluids administered will stay in the intravascular space (is a fraction)? How much and where will the rest of the fluid go?
1/3 will stay in the intravascular space. 2/3 will diffuse into the interstitial space.
Which kind of fluids cannot move readily out of the intravascular space?
Colloids
Osmolarity is what? Normal Osmolarity equals?
Osmolarity is the solute concentration maintained in all body fluids. Normal concentration is 300 mOsm/L
What is the most common fluid type?
Crystalloids
What are the 3 general categories for crystalloids?
Balanced electrolyte solutions, Saline solutions, and Dextrose solutions
posterior urethral injury

Involves prostatic or membranous urethra;superior to the urogenital diaphragm.

sx: blood in meatus, inability to void, high-riding prostate. Perineal/scrotal hematoma. Pelvic fracture can cause.

Dx- retrograde urethrogram.
Tx- suprapubic catheter until it heals

anterior urethral injury

Involves the bulbar or penile urethra, inferior to the urogenital diaphragm.

sx: Perineal tenderness or hematoma & bleeding from urethra but normal prostate. Usually 2/2 blunt trauma to perineum or instrumentation.

intraperitoneal bladder rupture
Blunt trauma to full bladder –> burst at bladder dome –> GROSS HEMATURIA in 98%. suprapubic pain and difficulty voiding. more likely in kids.
dx: cystogram shows leak.
Tx: operation and repair of defect followed by Foley drainage.,
traumatic renal injuries
hematuria, abd distension, flank pain, ecchymosis. May be palpable mass
PAD work up
ABI using doppler in high risk or asympto pts
gold standard – contrast arteriography
tx: aspiring and cilostazol (PDEi)
esophageal rupture
mc follows UE, less commonly with alcoholic vomiting
Signs: Pneumomediastinum (palpable crepitus –> homanns sign), fever, + pleural effusion, does not cause circulatory collapse
Dx: water-soluble contrast esophagography
Tx: Primary closure of esophagus and drainage of mediastinum within 6hrs to prevent mediastinitis,
broad spec Abx, +/- parenteral nutrition
mallory weiss tear
a longitudinal tear in mucosal membrane of the GEJ. Occur from a sudden powerful or prolonged force due to coughing, vomiting, seizures, prolapse of the stomach into the esophagus or CPR.
, Tx: usually heals on it’s own (stop NSAIDs, alcohol, reduce vomiting/coughing)
-fluids/blood transfusions
-endoscopic treatment > epi injection, cautery, compression (endoclip/band)
-surgery is rare
bowel ischemia
Always consider it as an early complication of operation on the abdominal aorta . Pt presents with bloody diarrhea and abdominal pain. Its due to infarction of Inferior Mesenteric artery, 1-2 daya post surgery.
CT – thickening of bowel wall
colonoscopy – cyanotic mucosa with hemorrhagic ulcerations
radiation proctitis

-damage to lower parts of colon after exposure to X-rays or other ioinizing radiation as part of radiation therapy

sx: diarrhea, rectal bleeding, urgency, tenesmus. Later strictures and fistulas may form

dx: lower endoscopy, colonoscopy or flexible sigmoidoscopy

tx: chronic: sucralfate enemas, endoscopic cauterization of bleeding vessels (APC: argon plasma coagulation or topical formaldehyde)

how do you monitor a circumferentially burned limb?
doppler US flow meter
acute mesenteric thrombosis
abdominal pain out of proportion to physical findings, N/V and bloody diarrhea d/t mucosal sloughing.
– numerous atherosclerotic RG
colonic angiodysplasia
Dilated malformed submucosal and mucosal blood vessels common in right colon. patients > 60. common cause of GI bleed in elderly.
proximal vs distal small bowel obstruction
proximal: v, abd pain, abnL air filling on x-ray
distal: colicky abd pain, vomiting, abd distension, constipation/obstination, dilated loops of bowel on abd x-raysimple: luminal occlusion
strangulation: loss of blood supply to bowel wall

humeral neck fracture
-acute onset, after elderly fall on outstreched arm. swelling, ecchymosis, and crepitus over fx
– axillary n damage may be present
-determine degree of displacement and neuro compromise- xray (axillary view r/o dislocation) 2 views, CT scan- surgical planning
-tx: ice, pain meds, sling, ortho referral for ORIF
adrenal insufficiency
n/v, abdominal pain, hypoglycemia, HOTN after stressful event (surgical event) in person who is steroid dependent
– suspect if PMH suggests exogenous steroid use (SLE)
myocardial contusion
-may cause hemorrhage, edema, cell necrosis
– tachycardia
CXR – may show rib fx, which is a common cause
-EKG will show PVCs, Twaves changes, ST elevation
-CPK & Troponin enzyme levels elevated
-overall mortality is 10%
post-op atelectasis signs
hypoxemia with borderline low pCO2, VSS
dec lung compliance,ph=7.44, PO2 = 64, PCO2 = 34

torus palatinus
congenital, benign bony growth (exostosis) on midline hard palate. fleshy, immobile
no medical or surgical tx unless growth becomes sympto or interferes with speech or eating
mc in young pts, womens and asians.
urinary calculi
flank or abd pain radiating to groin. n/v
dx: non-contrast spiral CT of abdomen and pelvis
stress fracture
a series of microscopic fissures in bone that forms without any evidence of injury to other tissues, and results from repeated, strenuous activities such as running or jumping
– sharp, localized pain over bony surface that is worse with palpation
morton neuroma
mc cause of pain in forefoot in women 25-50 usually b/c shoes
– a/w pain bw 3rd and 4th toes on plantar surface
– mulder sign: clicking sensation when simultaneously palpating this space and squeezing metatarsal joints
– tx injections, strength into flexion with nerve gliding and surgery last case scenario
which types of arm fractures cause these nerve damages
midshaft humerus fx: radial nerve
supra condular fx of humerous: brachial a
humeral fx: ulnar n (claw hand)
ways to reduce ICP
1. head elevation: Inc venous outflow from head
2. sedation: decrease metabolic demand and control HTN
3. IV manitol: extraction of free water out of the brain tissue –> osmotic diuresis
4. hyperventilation: CO2 washout, leading to cerebral VC
scaphoid fracture
– mc carpal bone fracture, typically seen in young adults.
– fall on an outstretched hand.
sx: tender in the anatomic snuffbox or with resisted supination, and has limited range of motion of the wrist and thumb.dx: X-ray is often negative. May require special scaphoid views or repeat x-ray 10 to 14 days after treatment.

tx: thumb spica and referral. Improper treatment may lead to avascular necrosis.

drug fever in postop pt
typically seen 1-2 post op.
mc a/w anticonvulsants and bactrim
neck trauma

all unstable, penetrating wounds – immediate surgery (regardless zone)

if stable
zone 1 – angiography with possible embolization
zone 2 – immediate surgery
zone 3 – angiography, soluble-contrast esophagram, esophagoscopy, bronchogram. even if asympto

if stabbled in upper and middle zones, and azympto, can observe for 12 hours

pulmonary contusion

severe blunt chest trauma (MVA). Dyspnea, chest pain, hypoxemia worse with IVF, patchy alveolar infiltrates.

-may not develop until 1-2 post-trauma

– give colloids, not crystalline. check ABGs, CXR. intubate with PEEP if needed

traumatic diaphragm rupture
MVA. moderately resp distress
PE: no breath sounds over entire left chest
xray: multiple air fluid levels on chest
tx: lap
3 things that cause subemphysema
1. ruptured esophagus
2. Tension PNX
3. rupture of trachea or major bronchus
traumatic rupture of trachea
subq air
dx: CXR shows presence of air in tissues
txL fiberoptic bronchoscopy to confirm dx and level of injury. surgery- t/c if putting out very lg amt of air through chest tube and collapsed lung not expanding

obstructive surgical janudice

– obese, fecund women in 40s has recurrent episodes of abd pain, high AP, dilated ducts on sonogram, non-dilated GB full of stones

dx u/s, confirm with ERCP
tx: sphicterotomy and remove common duct stone. follow with cholecystectomy

emphysematous cholecystitis
– males, 50-75 yo; RF: db, gallstones,
– acute cholecystitis that arises 2/2 infection with gas forming bacteria;
-sx: RUQ pain, n/v, low-grade fever, crepitus in abodominal wall near gallbladder;-dx: abdominal U/S w air fluid levels in GB, curvilinear gas shadowing in GB; mild unconjugated hyperbilirubinemia; mild inc LFT;
-comps: gangrene, perforation;

tx: fluid/electrolyte rescucitation, early CCK, parenteral abx effective against G+ anaerobic clostridium (Unasyn, Zosyn, AG/FQ + clinda/metro)

pre-op hepatic RF
BR>2
albumin<3 PT>16
encephalitis-if 3 RF, 85% mortality
if 4 RF, 100% mortality

cardiac pre-op rF
1. EF <35 – prohibits non-cardiac surgery
2. JVD – optimize meds
3. recent MI – defere 6 months
4. severe angina – perfect cath
pulmonary pre-op rf
smoking
high PCP2
FEV1 <1.5
nutritional pre-op risk
loss of 20% body mass
serum albumin <3
anergy to sking allergy
serum transferrin<200
db coma
hip fx and treatment

external rotation and shortened leg

femoral neck fx: femoral head replacement, high risk of avascular necrosis
intertrochanteric fx: open reduction and pinning
femoral shagt fxL intramedullary rod fixation

direct blow to ulnar (monteggia fx) or radius (Galeazzi fx)

a diaphyseal fx and displaced dislocation of nearby joint

tx: open reduction and internal fixation of diaphysial fx
closed reduction of dislocated joint

posterior dislocation of hip

internally rotated and shorted

emergency reduction

subclavian steal s/d
-arteriosclerotic stenotic plaque at origin of sublcavian allows enought blood to reach the arm in normal, but not vigorous activities. blood is then “stolen” from vertebral artery
-psterior neuro problems: visual sx, equilibrium problems
– claudification in the arm during exercisesdx: angiography
tx: bypass surgery

Retroperitoneal air in the abdomen. DX?
Duodenal injury (2nd portion)
Evaluation of retroperitoneal air. DX WU?
CT scan with contrast or UGI w gastograffin (if neg. do barium study)
Describe how retroperitoneal air might occur?
blunt trauma > duodenal compression between external solid object & spine (ie. steering wheel) > perforation of duodenum
M/C injured portion of duodenum during trauma? Why?
2nd portion of duodenum b/c it is the most immobile
Duodenal injury is a common oversite b/c
of its retroperitoneal location
Indications that a duodendal injury has occured ?
retroperitoneal air and/or obliteration of the psoas margin
DPL / CT / USG are used in the dx of duodenal injuriees b/c
they are not sensitive enough to detect duodenal injury
How long should the 3 dose tetanus vaccine provide coverage?
10 years
Best study for revealing esophageal perforation?
?
Definitive management for esophageal perforation?
Primary closure & drainage of mediastinum w/n 6 hours
complication of esophageal perforation if not managed w/n 6 hours?
mediastinitis (may result)
In esophageal injury avoid
endoscopy (to prevent further rupture)
Obese boy w c/o rt knee pain, rt knee exam nl, restricted hip motion, external rotation of thigh with flexing of hip. DX?
slipped femoral capitis
Slipped femoral capitis. Management?
emergent external screws
Slipped femoral capitis is m/c in?
obese male adolescents
First step w high suspicion of posterior urethral injury. Management?
retrograde urethrogram, suprapubic catheter, delayed repair
Anterior / Posterior urethral injuries. Contrast Tx.
Anterior – stat surgical repair Posterior – retrograde urethrogram delayed repair
In setting of urethral injury. DO NOT
do not insert foley cather, do not use diuretics (may worsen problem)
Retrograde cystogram is used when there is high suspicion of?
bladder injury
Unonscious pt receives OT intubation. Reasoning?
establish airway, protection from aspiration
erythema & edema of non lactating breast. High on DDX?
locally advanced inflammatory cancer
High suspicion of locally advanced cancer merits DX W/U?
biopsy
erythema & edema of non-lactating breast. DDX?
inflammatory CA, cellulitis, mastitis
breast w fluctuating mass. M/L?
an abscess
breast w fluctuating mass. Management?
drainage & antibiotics
Atelectasis. Tx?
bronchoscopy c repeat CXRS
Weakness in upper extremities greater than lower extremeities. Syndrome?
Central cord syndrome
central cord syndrome is associated w?
hyperextension injury
syndrome associated w unilateral paralysis
?
Complete motor paralysis & loss of sensation distal to lesion.
Anterior cord syndrome
anterior cord syndrome is typically a result of what type of injury?
compression injury causes ant. cord syndrome
type of cerebral contusion that selectively causes Upper limb sparing & lower limb
None?
What is false about this statement: All penetrating wounds in middle zone of neck should be surgically explored.
Stab wounds to middle zone pt may be safely observed?
Zone 1 of neck. Boundaries?
lower zone: clavicle to cricoid cartilage
Zone 2 of neck. Boundaries?
middle zone: cricoid to angle of mandible
Zone 3 of neck. Boundaries?
upper zone: angle of mandible to base of the skull
general structures of concern in zone 2.
major vasculature, larygotracheal apparatus, pharyngoesophageal structures
complete: All ___ wounds should be surgically explored in zone 2.
gunshot
General division of the neck can be done to improve management by dividing into anatomic components
digestive, respiratory, cardiovascular
selective management may be considered in zones?
zone 1 and zone 3
Indications for surgery according to digestive component of neck.
dysphagia, crepitation, hematemisis, dysphonia, hemoptysis, palpable laryngeal injury
Indications for surgery according to respiratory component of neck.
subcutaneous emphysema, stridor, tracheal tear,
Indications for surgery according to cardiovascular component of neck.
persistent hemorrhage, expanding hematoma, coma, stroke
gunshot wound to zone 1 is an indication for
esophogram w bronchoscopy
gunshot wound to zone 3 is an indication for
esophogram w bronchoscopy
expanding neck hematoma. Management Zone 1
surgical intervention
stab wound in asymptomatic patient
observation zone 1 zone 2
a popping sound of the knee m/l indicates?
medial meniscal tear
contrast shapes of the menisci
medial meniscus – C shaped, lateral meniscus – O shaped
meniscal injury is commonly due to what type of injury?
twisting injuries w a fixed footing

drug abuse 2 ( health)

euphoria is a feeling of well-being that amy not necessarily be based in reality
T

heroin
illegal derivative of morphine that is sold on the street as a white power

amphetamines
drugs that increase heart rate and suppress the appetite

lsd
can evoke fellings of terror and panic

tranquilizers

marijuana
causes user to experience a conscious dreamlike state

morphine
prescribed for pain involving serious injury or surgery

narcotics
pain killer drugs that are derived from opium

depressants
reduced the physical and psychological symptoms of anxiety by reducing brain activity

stimulants
increases the activity of the central nervous system

caffeine
found in coffee beans, tea leaves, and cocoa beans

barbiturates
suppress brain activity by blocking the ability of nerves in the brain to send or receive signals

cocaine
first used by europeans as local anesthetic; now abused for its euphoric effect

hallucinogens
naturally-occuring or synthetically-produced drugs that can cause hallucinations

Chapman Maternal-Newborn Nursing Ch 2

Duties and obligations of obstetric and neonatal nurses outlined by…
American Nurses Association ANA Code of Ethics and
specialty practice standards from AWHONN Association of Womens Health, Obstetrics and Neonatal Nurses

ANA Code of Ethics for Nurses
describes the most fundamental values and commitments of the nurse; boundaries of duty and loyalty; and aspects of duties beyond individual patient encounters

Autonomy
right to self determination

Respect for Others
principle that all persona are equally valued

Beneficence
obligation to do good

Nonmaleficence
obligation to do no harm

Justice
principle of equal treatment or that others be treated fairly

Fidelity
faithfulness or obligation to keep promises

Veracity
obligation to tell the truth

Utility
the greatest good for the individual or an action that is valued

Rights Approach
The focus is on the individual’s right to choose, and the rights include the right to privacy, to know the truth, and to be free from injury or harm.

Utilitarian Approach
This approach posits that ethical actions are those that provide the greatest balance of good over evil and provides for the greatest good for the greatest number.

Ethical Dilemma
is a choice that has the potential to violate ethical principles

Advocacy
action taken in response to our ethical responsibility to intervene on behalf of patients in our care

Ethics
determining what is good, right, and fair.

Paternalism
system under which an authority makes decision for others

Four Topics Method
Three ethicists Jonsen, Siegler and Winslade developed method with which to work through difficult clinical situations with ethical dilemmas.

Four Topics Method include
1. Medical Indications
2. Patient Preferences
3. Quality of Life
4. Contextual Features

Medical Indications
A review of diagnosis and treatment options

Patient Preferences
Clinical patients values preferences are integral to all clinical situations

Quality of Life
Objective is to improve, or at least address, quality of life for the patient

Contextual Features
In the wider societal context beyond care providers and patient, to include family, the law, hospital policy, insurance companies and so forth

Most litigious of all nursing fields
Maternity nursing

Risk Management
identify systems, analysis and treatment risks before a suit is brought

The organization that publishes standards and guidelines for maternity nursing is
Association of Women’s Health, Obstetrics and Neonatal Nursing

Autonomy is defined as the right to
self determination

Ethics involves determining what is
correct

Evidence based decision making should include consideration of
patients clinical state, clinical setting, clinical circumstances

Risk management is an approach to the prevention of
morbidity and mortality

Chapter 9 The Nurse as Leader and Manager

Challenges and Opportunities
• Limited access to healthcare services for many
• Limited resources for providing care
• Need to provide care for uninsured and underinsured
• Need to recruit and retain high-quality nurses
• Develop innovative approaches to nursing caredelivery and redefine the roles of professional nurses

Nursing Leadership

• Advocate for improvements in
– Client care quality
– Working environment
– Social well-being

Leadership occurs when influencing others to act
– Managers are assigned their roles
– Leaders attain their roles

Leadership characteristics
– Integrity
– Courage
– Positive attitude
– Initiative
– Energy
– Optimism
– Perseverance
– Balance
– Ability to handle stress
– Self-awareness
– Vision

American Nurses Association charges nurses with
leadership expectations
– Participate in professional organizations
– Communicate effectively
– Seek ways to advance nursing autonomy and accountability
– Participate in effort to influence healthcare policy
– Oversee nursing care by others while retaining accountability for quality of care
– Abide by vision, goals, and plan to implement and measure progress of clients
– Mentor colleagues
– Develop communication and conflict resolution skills

• Authoritarian leadership
– Makes the decisions for the group
– Directive, autocratic, or bureaucratic
– Negative connotations
-makes minimal openess and trust
-procedures well defined, predictbale, security
-supreses creativity
-can be effective when project must be completed quickly and efficiently

• Democratic leadership
– Participative leadership
Acts as a catalyst or facilitator
Seeks participation or consultation of subordinates
Actively guides the group toward achieving the group goals
Provides constructive criticism, offers information, makes
suggestions, asks questions

• Laissez-faire leadership
– Nondirectional leadership
– Minimal participation
– Group’s members act independently of each other
-inactive, inpassive, permissive

• Situational leadership
– Levels of direction and support vary depending on the maturity of the group
– Value placed on accomplishment of tasks and on interpersonal relationships
– Leadership style changes based on task, urgency, and individual needs

leader assumes one of four styles
-*directive*: clear direction and instruction to immature employees
– *coaching*: 2 way communicative, helps mature employee build confidence
– *supporting*: support mature emplyee use talents
– *delegating*: hands off, employees given responsibilities for carrying out plans

• Transactional leadership
– Traditional manager focused on the day-to-day tasks of
achieving organizational goals
– Relationship is based on exchange for some resource
valued by the follower

• Transformational leadership
– Emphasizes the importance of interpersonal relationships
– Leader serves as a role model who encourages and empowers team members to achieve team and personal goals
– Vital in creation of healthcare system that embodies community well-being, basic care for all, costeffectiveness, and holistic nursing care

4 factors of tranformational leader
-charisma: highly rescpected, inspires others
– inspirational motivation: shares visions with staff to go appeal to emotions and ideals
– intellectual stimulation: encourgae staff to question status quo
– contingent reward- recognizes mutual goals and rewards achievemnts

• Caring leadership
– An extension of transformational leadership
– Good management is a matter of love
– Proper management involves caring for people, not manipulation

• Quantum leadership
Humanistic interaction involving leader and followers
– Additional focus on problem to be solved or goal to be achieved
– Interaction and outcomes are affected by the leader, the followers, and the task to be accomplished
– Leader is creative, flexible, and encouraging
– Each team member adds value

Effective leadership
– a learned process requiring
an understanding of the needs and goals that motivate, knowledge to apply skills, and interpersonal skills to influence others
• Success is more than goal attained, also opportunity for growth

Nursing Management

Nurses as managers responsible for
– Planning
– Organizing
– Directing/delegating
– Controlling resources used in delivery of client care

• Resources used in delivery of client care
– Equipment and materials
– Technology
– Finances
– Environment
– Personnel

Management Roles

• Authority
– Official power given by organization to direct work of
others
– Conveyed through leadership action

• Accountability
– Ability and willingness to assume responsibility and consequences

• Planning
– First and most basic management function
– Four stages
Establishing goals and objectives
Evaluating current situation and predicting future trends and
events
Formulating a planning statement
Converting plan into an action statement

• Organizing
– Process of coordinating work to be done

• Leading
– Power is essential component of leading
– Power is the ability and authority to influence others
– Based on honor, respect, loyalty, and commitment

• Delegating
– Determine what is required, then identify help
– Development of the potential of nursing and support personnel
– Delegated individuals must be supervised and evaluated
– Provide ongoing feedback about performanc
– Getting work done through others
– Major tool in making most efficient use of time

– Five “rights” of delegation
Right task
Rights circumstances
Right person
Right direction and communication
Right supervision and evaluation

– Effective delegation requires nurses to be aware of
Needs and goals of the client and family
Nursing activities that can help the client meet the goals
Skills and knowledge of various nursing and support personnel

• Controlling
– Method to ensure that behaviors and performances are
consistent with expectations developed in planning
process
– Should be done with employees, not to employees
– Shared governance and team building help make
control easier

• Three levels of management
– First level
– Middle level
– Upper level
• Dependent on the type of organization

Management competencies described by American Organization of Nurse Executives
– Communication and relationship building
– Knowledge of healthcare environment
– Leadership skills
– Professionalism
– Business skills

• Magnet recognition
Program of American Nurses Credentialing Center
– Recognizes healthcare organizations for quality patient
care, nursing excellence, and innovations
– Identifies characteristics of hospitals that are successful
in recruiting and retaining nurses

• Pathway to Excellence Program
– Program of *American Nurses Credentialing Center*, launched in 2009
– Recognizes healthcare organizations and long-termcare
facilities for having positive practice environments
– Standards unique to long-term-care environment have been developed

Nursing Delivery Models

• Total patient care
– Case method
– Earliest model of nursing care
– Private-duty nurses
– Client-centered
– Client has consistent contact with one nurse during shift

• Functional method
– Evolved from concepts of scientific management
– Focuses on jobs to be completed
– Task-oriented approach
– Disadvantage is fragmentation of care
-ex. nurse and nursing assistant

• Team nursing
– Individualized nursing care given to clients by a nursing team led by a professional nurse
– Members include RNs, LPNs, nursing assistants
– Responsible for coordinated nursing during a shift
– Emphasizes humanistic values and individualized client care at a personal level
– Nurse leader motivates employees

• Primary nursing
– A system in which one nurse is responsible for total care of a number of clients 24 hours a day, seven days a week
– Provides comprehensive, individualized, and consistent
care
– Associates provide care, but the primary nurse plans and coordinates care

• Interdisciplinary team model
– Team consists of all disciplines required to provide quality care to client
– Each team member brings expertise to help client achieve quality outcome
– All members focus on client’s needs and collaborate to meet those needs

Case Management
pg 176
• Pioneered at the New England Medical Center
• Used in
– Insurance-based programs
– Employer-based health programs
– Workers’ compensation
– Maternal-child health
– Mental health
– Hospital-based practice

Case Management Defined as
– A collaborative process of assessment, planning,
facilitation, care coordination, evaluation, and advocacy to meet individual’s and family’s comprehensive health needs to promote quality, cost-effective outcome
– assist clients through complex
healthcare system

Differentiated Practice
178
• Differentiates nurses by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in
decision making
• Can improve client care and contribute to client safety
• Allows for the effective and efficient use of resources

Shared Governance
• Nurses participate in decision making at all levels of the organization
• Employees will be more committed to an organization’s goals if they have input
• Promotes involvement, investment, participation,
sharing of power, interdependence, cooperation, horizontal relationships, autonomy, and
accountability

• Mentor
– Wise and trusted adviser who guides others on particular journey
– Provides support, challenge, and vision
-• Process can promote professional growth of both mentor and mentee

• Three phases
– Invitational
– Questioning
– Transitional

• Preceptor
– An experienced nurse who orients a nurse who is new
to the nursing unit and organization
– Assigned to assist in improving clinical nursing skill and
judgment necessary for effective practice in her or his environment
– Assists new nurses in learning routines, policies, and procedures of the unit

Networking
• Professional network consists of people that nurses may call on for assistance, support of ideas, and guidance
• Networking builds linkages with people
• Long-term process for building relationships
• Requires time, commitment, and follow-through

Networking
• Opportunities include
– Active membership in professional organizations
– Continuing education and university classes
– Socializing with professional colleagues
– Keeping in touch with former professors and nursing
associates