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NRNP 6566 WK1-5 Midterm Exam
Describe cytochrome p450 system - Correct answer Cytochrome p system is a series of enzymes used to metabolize medications Inhibitors - Correct answer block metabolic activity from one or more CYP450 enzymes Inducers - Correct answer 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 - Correct answer 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 - Correct answer malnutrition, chronic illness Highly protein bound drugs can lead to - Correct answer 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 - Correct answer 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: - Correct answer Male = 140-age times weight in kilograms divided by serum creatinine times 72. Women = CRCL (male) times 0. Describe what determines the frequency of drug administration - Correct answer half life plasma concentration Be familiar with the beers criteria and how to use it - Correct answer 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 - Correct answer 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 - Correct answer low albumin levels, body composition, cardiac decompensation (heart failure), age Describe the factors that affect metabolism - Correct answer genetics, age, organ function Describe factors that affect excretion - Correct answer 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? - Correct answer 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.
Ventricular Tachycardia - Correct answer 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 - Correct answer 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 - Correct answer nefedipine, amlodipine these primarily act on vascular smooth muscles Use this for hypertension Non-Dihydropyridine Calcium Channel blocker - Correct answer 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 - Correct answer 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 - Correct answer 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 - Correct answer 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 - Correct answer 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 - Correct answer 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 - Correct answer 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 - Correct answer 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
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 - Correct answer 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
