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NURS 6550 / NURS6550 Advanced Practice Care Of Adults In Acute Care Settings I
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NURS 6550 Final Exam Study Guide / NURS6550 Final Exam Study Guide / NURS 6550N Final Exam Study Guide / NURS-6550N Final Exam Study Guide (Latest-2023)
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NURS 6550 / NURS6550 Advanced Practice Care Of Adults In Acute Care Settings I
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Walden University
NURS 6550 Final Exam Study Guide / NURS6550 Final Exam Study Guide / NURS 6550N Final Exam Study Guide / NURS-6550N Final Exam Study Guide (Latest-2023)
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NURS 6550 / NURS6550 Advanced Practice Care Of Adults In Acute Care Settings I
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NURS 6550 Final Exam Study Guide
Genitourinary, gynecologic, renal and acid/base conditions
o Carcinoma of the Cervix
Increased risk in women who smoke and those with HIV or high-risk HPV types.
Considered a sexually transmitted disease as both squamous cell and adenocarcinoma of
the cervix are secondary to infection with HPV; squamous cell accounts for 80 percent of
cervical cancers, 15 % adenocarcinoma, and 3-5 % neuroendocrine.
Prevention through vaccination- recombinant 4 or 9-valent HPV vaccination which target
HPV types that pose the greatest risk.
Prognosis- overall 5- year relative survival rate is 68 % for white women and 55 % in
black women- survival rates are inversely proportionate to the stage of cancer.
Signs/Symptoms-
Metrorrhagia, postcoital spoting, and cervical ulceration. Gross edema of the legs may be
indicative of vacular and lymphatic stasis due to tumor. Pain in the back (lumbosacral plexus
region) indicates neurologic involvement. Bladder and rectal dysfunction or fistulas are severe
late symptoms. Two to 10 years are required for carcinomas to penetrate the basement layer of
the membrane and become invasive- screening has decreased mortality.
Diagnostic Tools-
Cervical Biopsy- After a positive papnicolaou smear biopsy or endocervical curettage is
necessary to determine the extent and depth of the cancer cells. Surgery and radiation should be
delayed until biopsy results.
Imaging- CT, MRI, lymphangiography, fine-needle aspiration, ultrasound, and
laparoscopy are utilized for staging of invasive cancer. Allows for more specific treatment
planning.
Complications-
Metastases to regional lymph nodes occurs with increasing frequency from Stage I to
Stage IV. Extension occurs in all directions from the cervix.
Hydronephrosis (urine-filled dilation of the renal pelvis due to obstruction) and
hydroureters (dilation of the ureter), is a result of the ureters becoming obstructed lateral to the
cervix which can lead to impaired kidney function.
Treatment/Management- Refer all patients to Gynecologic Oncologist
, Carcinoma in situ (Stage 0)- women whom child-bearing is not a consideration, total
hysterectomy is definitive treatment.
Retain uterus- cryosurgery, laser surgery, LEEP, or cervical conizations are options. Close
follow-up with pap smears every 3 months for 1 year and every 6 months for another year after
cryo/laser surgery.
Invasive Carcinoma- treated with hysterectomy. Stage IA1, IBI, and IIA hysterectomy
and concomitant radiation and chemotherapy or with radiation and chemo alone; Stages IB2, IIB,
III, and IV cancers treated with radiation therapy plus concurrent chemotherapy.
Emergency presentation- vaginal hemorrhage- due to gross ulceration and cavitation of
cervix- late stage- packing, cautery, tranexamic acid to stop bleeding temporarily. Ligation and
suturing not an option due to diffused ulceration.
o Fibroid Tumor
Uterine leiomyomas are the most common neoplasm in the female genital tract- it is a
round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue.
Classification by anatomical location- 1. Intramural, 2. Submucous, 3. subserious, 4.
Intraliagmentous, 5. Parasitic (blood supply from an organ to which its attached) 6. cervical
In non-pregnant women, myomas are frequently asymptomatic- symptoms which prompt
for treatment include AUB and pelvic pain or pressure. Complications of fibroids include
miscarriage if they block the uterine cavity or preterm delivery and malpresentation.
Diagnostic-
Patients may present with iron deficiency anemia (blood loss). Imaging to include a
pelvic ultrasound and monitor growth. MRI can be delineate intramural and submucous myomas
and is required prior to uterine artery embolization to assess the blow flow to the fibroid.
R/O: subserous myomas from oviarian tumors
Treatment/Management
Small asymptomatic myomas can be evaluated annually- Patients who defer surgery,
non-hormonal therapies (NSAIDs and tranexamic acid) have been show to decrease menstrual
blood loss.
Hormonal therapies- GnRH agonists and SPRMs, shown to reduce myoma volume,
uterine size, and menstrual blood loss.
Surgical intervention should be based on patient’s symptoms and desire for future
fertility- uterine size is not an indication alone for surgery- cervical myomas 3-4 cm in diameter
that protrude through cervix, can cause infection, bleeding, pain, or urinary retention, which
require removal.
, Emergency Surgery- indicated for acute torsion of the pendunculated myoma. Marked
anemia, heavy menstrual period post-operative treatment includes DMPA IM q3 months. Only
indication for emergency surgery during pregnancy is torsion of a pendunculated fibroid.
Prognosis- Surgery is curative, however, women should be counseled regarding future fertility-
reoccurrence is common, and post-operative pelvic adhesions can impact fertility and may
require a cesarean delivery.
o Pelvic inflammatory disease-
PID is a polymicrobial infection of the upper genital tract associated the sexually
transmitted organism Neisseria gonorrhoeae and chlamydia trachomatis, as well as endogenous
organisms, including anaerobes, H. influenza, enteric gram-negative rods, and streptococci.
Most common in young, nulliparous, sexually active women with multiple partners.
Signs/Symptoms
Lower abdominal pain, chills, fever, menstrual disturbances, purulent cervical discharge
and cervical and adnexal tenderness. Right upper quadrant pain (Fitz-Hugh & Curtis sign) may
indicate associated peri-hepatitis.
Most women present with subtle or mild symptoms, such as urinary frequency, low back
pain, or postcoital bleeding.
Diagnostic Criteria
Women with cervical motion, urterine or adnexal tenderness should be treated as if they
have PID with antibiotics unless there is a competing diagnosis.
Symptoms including temp >38.3, abnormal cervical or vaginal discharge with white cells on
saline microscopy, elevated ESR, elevated CRP, and laboratory documentation of infection by N.
gonorrhea or C trachomatis, should prompt treatment with antibiotics while endocervical cultures
are processing.
Differential Diagnosis
Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or unrupture ovarian cyst.
PID is more likely to occur if there is a history of recent sexual contact, history of sexually
transmitted disease, recent onset of menses, sexual contact with someone with a sexually
transmitted disease.
Acute PID is unlikely if sexual intercourse has not occurred within the last 60 days.
Obtain a pregnancy test to rule out ectopic pregnancy, septic abortion,
Pelvic ultrasound can rule out ovarian cyst and ectopic pregnancy
, Laparoscopy is often utilized to diagnose PID and imperative if symptoms do not respond to
antibiotic therapy within 48 hours of imitating
Treatment/Management
Antibiotic coverage
Mild to moderative infection- treat outpatient
1. Single dose of cefoxitin, 2g IM, with probenecid 1g orally, plus doxycycline 100mg
orally twice a day for 14 days
OR
2. Ceftriaxone 250mg IM plus doxycycline 100 mg orally twice daily for 14 days.
3. Metronidazole 500 mg orally twice daily for 14 days can be added to either regimen.
Severe disease- meet criteria for hospitalization
1. Cefotetan 2g IV every 12 hours
OR
2. Cefoxitin 2g IV every 6 hours, plus doxycycline 100mg orally or intravenously every
12 hours.
OR alternative regiment is
3. Clindamycin 900 mg intravenously every 8 hours, plus gentamicin loading dose of
2mg/kg intravenously or IM followed by maintenance dose every 8 hours.
Either regiment should be continued for at least 24 hours after patient shows
symptom improvement and then transitioned to oral regimen for a total of 14 days
Surgical Management-
Tubo-ovarian abscess is a complication of PID and may require surgical intervention, unless
rupture is suspected high dose antibiotics can be initiated. Monitor therapy response with
ultrasound. 70 percent of cases respond to ABX, 30 percent require surgical intervention.
Admission criteria-
Tubo-ovarian abscess, pregnancy, patient is unable to follow outpatient regimen, patient has not
clinically improved with 72 hours from outpatient initiation of ABX, serve illness symptoms
including nausea/vomiting, or high fever.
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