Nrnp 6566 final exam questions and answers
Nrnp 6566 final exam questions
Nrnp 6566 final exam answers
nrnp 6566 final exam quizlet
walden nrnp6566 midterm exams
nrnp 6566 week 3 knowledge check
Describe cytochrome p450 system
Cytochrome p450 system is a series of enzymes used to metabolize medications
Inhibitors
block metabolic activity from one or more CYP450 enzymes
Inducers
increase CYP450 enzyme activity by increasing enzyme synthesis
Describe effect on low and high albumin levels on active drug levels especially for drugs that are highly protein bound
Albumin is the plasma protein with the greatest capacity for binding drugs. Binding plasma proteins affect drug distribution into tissues, because only drug that is not bound is available to penetrate tissues, bind to receptors, and exert activity. As free drug leaves the blood stream, more bound drug is released from binding sites.
Low albumin levels
malnutrition, chronic illness
Highly protein bound drugs can lead to
toxicity in patients with low albumin levels, example malnutrition or chronic illness. This is because there are fewer than the normal sites for the drug to bind
Describe the ways the hepatic first pass effect- which is metabolism during first pass through the liver
Alternative routes include:
suppository
intravenous
intramuscular
inhalational aerosol
transdermal
sublingual
These allow drugs to bypass the first-pass effect and be absorbed directly into systemic circulation
Be able to calculate creatinine clearance using Cockgraft Gault equation:
Male = 140-age times weight in kilograms divided by serum creatinine times 72.
Women = CRCL (male) times 0.85
Describe what determines the frequency of drug administration
half life
plasma concentration
Be familiar with the beers criteria and how to use it
Potentially Inappropriate Medication Use in Older Adults
to call attention to medications that are most commonly problematic and thus should be avoided in older adults
Describe factors that affect absorption
low blood state (shock or arrest), contact time with GI tract too fast (diarrhea = cant absorb), delayed stomach emptying (large meal = delayed absorption)Drug- to drug or drug to food interactions
Describe the factors that affect distribution
low albumin levels, body composition, cardiac decompensation (heart failure), age
Describe the factors that affect metabolism
genetics, age, organ function
Describe factors that affect excretion
affected by abnormal kidney or liver function, age, drug interactions
Define narrow therapeutic index. How would you monitor a patient with a narrow therapeutic index?
Therapeutic index is the dose range of effiency of med is optimized while side effects are minimized
Narrow therapeutic index drugs are defined as those drugs where small differences in dose or blood concentration may lead to dose and blood concentration dependant, serious therapeutic failures or adverse drug reactions.
You will need to monitor blood tests to monitor blood concentrations and dose adjustments accordingly.
Describe how aging can affect absorption, distribution, metabolism and excretion
decreased organ function, poorly tolerate drugs that require metabolism, lower rates of excretion
decrease in small-bowel surface area, slowed gastric emptying, increase in gastric PH, changes in drug absorption
With age, body fat generally increases and total body water decreases. Increased fat increases the volume of distribution for highly lipophilic drugs (for example, diazepam and chlordiazepoxide), which may increase their elimination half-lives.
Serum albumin decreases and alpha 1 acid glycoprotein increases — Phenytoin and warfarin are examples of medications with a higher risk of toxic effects when serum albumin increases
hepatic metabolism of many drugs through cytochrome P enzyme system decreases with age; decreasing 30-40%
decreased renal elimination
Identify 1st degree heart block
cardiologist consult
Order echo to rule out structural diagnosis, check thyroid levels, medications, electrolytes and identify and treat cause
Identify 2nd degree heart block
permanent pacemaker, continuous tele monitoring, possible transcutaneous pacing, determine cause; IV atropine if poor perfusion s/s every 3-5 minutes with max of 3mg if poor perfusion. No response to atropine, use dopamine, epinephrine, isoproterenol
Identify 3rd degree heart block/complete heart block
Permanent pacemaker, telemetry monitoring and transcutaneous pacing if needed, identify cause, IV atropine if s/s poor perfusion. If no response to atropine, use dopamine, epinephrine and isoproterenol
Atrial fibrillation
Stable- rate control versus rhythm control strategy (example: AV nodal blockers, antiarrhythmics, anticoagulation). Ablation may be needed if no response to medications
Unstable- DCC/ cardioversion
Atrial Flutter
Cardioversion
Rate control not as responsive as Afib
Ventricular fibrillation
Defibrillate and CPR
Ventricular Tachycardia
Stable- betablocker
Amiodarone, sotalol, mexiletine to reduce number of shocks
MG if torsades
EPS / ablation
Unstable – CPR, epinephrine vasopressin, amiodarone, lidocaine, magnesium, airway management
Tachycardia
vagal manuever, adenosine (6 or 12 mg), betablocker or calcium channel blocker. Know what conditions each class would be used to treat
Dihydropyridine Calcium Channel Blockers
nefedipine, amlodipine
these primarily act on vascular smooth muscles
Use this for hypertension
Non-Dihydropyridine Calcium Channel blocker
Diltiazem < verapamil
Primarily act on the heart
Use these for CP, SVT (verapamil), controlling irregular heart rate and lowering blood pressure (Diltiazem)
CHADS 2 score
anything greater than 3 is high risk and start anticoagulant
1 point for each with history of heart failure, hypertension, and diabetes mellitus
Stroke is 2 points
and greater than 75 years old is one point
Hyperthyroidism
heat intolerance
fatigue
anxiety
nervousness
manic
confusion / restless
emotional liability
fine tremors
diaphoresis
hyperreflexia of deep tendon reflexes
resting tachycardia, palpitations, afib
exterional dyspnea
low-grade fever
increased appetite
weight loss
fine thin hair
exopthalamus
Graves
Abnormal labs with hyperthyroidism
elevated T3, T4, thyroid resin uptake, and free thyroxine index. Sometimes T4 is normal but T3 is always high
Elevated sed rate
Elevated antinuclear antibody, without evidence of lupus or autoimmune disorder
Hypercalcemia and low h/h
Treatment for hyperthyroidism
propanolol (inderal) 10mg 4 times a day (up to 80 mg)
Metoprolol 25 mg by mouth (Up to 50 mg) every 6*8 hours
Antithyroid medications- methimazole (tapazole) initial dose is 30 to 60mg a day in three doses, and then maintenance of 5 to 15 mg daily
If intolerant to tapazole, propylthiouracil initial dose is 300 to 600 mg a day in 4 doses, maintenance dosage is 100 to 150 mg daily in three doses
Identify when cardioversion is indicated and relevant testing that should occur prior to it
Unstable afib / flutter causing RVR, MI, hypotension or heart failure; WPW syndrome in a fib
TEE should always proceed DCCV to rule out valve disease or thrombus
Hypertension definition
sustained BP of 140’s over 90’s for a sustained period of time
Stage 1 is 140-159; and 90-99 diastolic
Stage 2 is equal or greater than 160 over greater or equal to 100 diastolic
Essential hypertension
unknown cause
95% cases; onset 25 years old – 55
Secondary hypertension- related to known cause or disease process. This could be from estrogen uses, renal disease, pregnant, endocrine disorders
Isolated systolic blood pressure- hypertension and systolic blood pressure greater than 140 over 90
Effectively treated with diuretics and long-acting calcium channel blockers
Signs and symptoms of hypertension: headache in the morning, epitaxis, lightheadedness, visual disturbances, S4 present related to left ventricular hypertrophy, retinal changes, hematuria (which is rare)
Hypertensive urgency
severely elevated blood pressure
180 over 110 or higher without progressive target organ dysfunction
signs and symptoms: severe headache, shortness of breath, epistaxis, severe anxiety
treatment includes Clonidine (alpha-adrenergic stimulant 0.2 mg initial dose, then 0.1 mg every hour until controlled or total of 0.8 mg
May experience sedation, possible rebound hypertension once stopped
Captopril – ACE dose of 12.5 to 25mg
Hypertensive emergency
Severely elevated blood pressure
180 over 120
can occur with lower blood pressure if impending or progressive target organ dysfunction ( example : encephalopathy, intracranial hemorrhage, acute myocardial infarction, pulmonary edema with acute LV failure, unstable angina, dissecting aortic aneurysm or eclampsia
First intervention – goal is to get blood pressure down to 160-180 or less than 105 diastolic. First drug choice is nicardipine 2.5 to 1.5 mg hour intravenously. Side effects include headache, hypotension, tachycardia, nausea/vomiting, fever, neck pain, indigestion
Second medication is nipride 0.25 to 10 micrograms per kilogram per minute intravenously. Side effects include brady or tachycardia, nausea, abdominal pain, twitching, dizziness, headache, flushing, sweating, IV site irritation. This medication can cause rapid profound hypotension. Do not give this medication longer than 72 hours as there is a risk for cyanide poisoning.
Nitroglycerin- 5 to 220 micrograms a minute intravenously. Side effects include dizziness, headache, hypotension, orthostatics, numbness/tingling, flushing, nausea/vomiting
Other medications:
Esmolol hydrochloride
Lebetalol – commonly used with pregnant patients
Apresoline- do not give to patients with Coronary artery disease and aortic dissection. this is a vasodilator, which decreases blood pressure but increases heart rate and retains fluid
Minoxidil is another vasodilator. good for end stage renal patients
Fenolodopam
Hypertension medications based on history
Non-African Americans can take thiazide diuretics, calcium channel blockers, ace inhibitors, ARBs (grade B)
African Americans need thiazides, calcium channel blockers (grade b); grade c for patient with diabetes mellitus
Adults equal to or greater than the age of 18 with chronic kidney disease- ace inhibitors, ARBS grade b – regardless of race or other comorbidities