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NRNP 6566 Midterm Exam / NRNP 6566 Midterm Exam Study Guide. Latest 2024
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NRNP 6566 Midterm Exam / NRNP 6566 Midterm Exam Study Guide. Latest 2024
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NRNP il6566Key ilConcepts ilWeek il1 ilto il5
Week il1
1. Describe ilthe ilcytochrome ilP450 ilsystem. i l Describe ilhow ilinducers iland ilinhibitors
ilaffect ilthe ilcytochrome ilsystem iland ilhow ilthat ilaffects ilthe ilhalf-life ilof ilmedications.
a. Cytochrome ilp450 ilsystem ilis ila ilseries ilof ilenzymes ilused ilto ilmetabolize ilmedications.
b. Drugs ilthat ilcause ilCYP450 ilmetabolic ildrug ilinteractions ilare ilreferred ilto ilas ileither
ilinhibitors ilor ilinducers. ilInducers ilincrease ilCYP450 ilenzyme ilactivity ilby ilincreasing
ilenzyme ilsynthesis
c. Inhibitors ilblock ilthe ilmetabolic ilactivity ilof ilone ilor ilmore ilCYP450 ilenzymes
2. Describe ilthe ilaffect ilon illow iland ilhigh ilalbumin illevels ilon ilactive ildrug illevels ilespecially ilfor
ildrugs ilthat ilare ilhighly ilprotein ilbound.
a. Albumin ilis ilthe ilplasma ilprotein ilwith ilthe ilgreatest ilcapacity ilfor ilbinding ildrugs.
i. Binding ilto ilplasma ilproteins ilaffects ildrug ildistribution ilinto iltissues, ilbecause
ilonly ildrug ilthat ilis ilnot ilbound ilis ilavailable ilto ilpenetrate iltissues, ilbind ilto
ilreceptors, iland ilexert ilactivity. ilAs ilfree ildrug illeaves ilthe ilbloodstream, ilmore
ilbound ildrug ilis ilreleased ilfrom ilbinding ilsites.
b. Highly ilprotein ilbound ildrugs, illow ilalbumin illevels il(w/ ilmalnutrition, ilor ilchronic ilillness)
ilmay illead ilto iltoxicity ilbecause ilthere ilare ilfewer ilthan ilthe ilnormal ilsites ilfor ilthe ildrug
ilto ilbind
3. Describe ilways ilto illessen ilthe ilhepatic ilfirst ilpass ileffect: ilmetabolism ilduring ilfirst ilpass
ilthrough ilthe illiver
a. Alternative ilroutes il(suppository, ilintravenous, ilintramuscular, ilinhalational ilaerosol,
iltransdermal, iland ilsublingual) ilavoid ilthe ilfirst-pass ileffect il ilallow ildrugs ilto ilbe
ilabsorbed ildirectly ilinto ilthe ilsystemic ilcirculation
4. Be ilable ilto ilcalculate ilcreatinine ilclearance ilusing ilthe ilCockgraft ilGault ilequiation:
a. Male il i l = il([140-age] il× ilweight ilin ilkg)/(serum ilcreatinine il× il72)
b. Female il il= ilCrCl il(male) il× il0.85
5. Describe ilwhat ildetermines ilthe ilfrequency ilof ildrug iladministration:
a. Drug ilhalf-life, ilplasma ilconcentration
6. Be ilfamiliar ilwith ilthe ilBeers ilcriteria iland ilhow ilto iluse ilit:
a. Potentially ilInappropriate ilMedication ilUse ilin ilOlder ilAdults
i. to ilcall ilattention ilto ilmedications ilthat ilare ilcommonly ilproblematic, iland ilthus
ilshould ilbe ilavoided ilin ilmost ilolder iladults
7. Describe ilfactors ilthat ilaffect ilabsorption, ildistribution, ilmetabolism iland ilexcretion:
a. Absorption il illow ilblood ilstate il(shock ilor ilarrest); ilcontact iltime ilwith ilGI iltract iltoo ilfast
il(diarrhea il= ilcan’t ilabsorb); ildelayed ilstomach ilemptying il(large ilmeal il= ildelayed
ilabsorption); ildrug-drug ilor ildrug-food ilinteractions
b. Metabolism il ilgenetics, ilage, ilorgan ilfunction
c. Distribution il illow ilalbumin illevels, ilbody ilcomposition, ilcardiac ildecomp il(HF), iland ilage
d. Excretion il ilaffected ilby ilabnormal ilkidney ilor illiver ilfunction; ilage, ildrug ilinteractions
8. Define ilnarrow iltherapeutic ilindex i l How ilwould ilyou ilmonitor ila ilpatient ilwith ila ilnarrow
iltherapeutic ilindex?
, a. Therapeutic ilindex: ildose ilrange ilwhere ilefficacy ilof ilmed ilis iloptimized ilwhile ilside
ileffects ilminimized
b. Narrow iltherapeutic ilindex il(NTI) ildrugs ilare ildefined ilas ilthose ildrugs ilwhere
ilsmall ildifferences ilin ildose ilor ilblood ilconcentration ilmay illead ilto ildose iland ilblood
ilconcentration ildependent, ilserious iltherapeutic ilfailures ilor iladverse ildrug
ilreactions.
c. Blood iltests ilto ilmonitor ilblood ilconcentrations iland ildose iladjustments ilaccordingly
9. Describe ilhow ilaging ilaffect ilabsorption, ildistribution, ilmetabolism, iland ilexcretion
a. Decreased ilorgan ilfunction, ilpoorly iltolerate ildrugs ilthat ilrequire ilmetabolism, illower
ilrates ilof ilexcretion
b. decrease ilin ilsmall-bowel ilsurface ilarea, ilslowed ilgastric ilemptying, iland ilan
ilincrease ilin ilgastric ilpH, ilchanges ilin ildrug ilabsorption
c. With ilage, ilbody ilfat ilgenerally ilincreases iland iltotal ilbody ilwater ildecreases.
ilIncreased ilfat ilincreases ilthe ilvolume ilof ildistribution ilfor ilhighly illipophilic ildrugs
(eg, il diazepam, il chlordiazepoxide) il and il may il increase il their il elimination il half-lives.
d. Serum il albumin il decreases il and il alpha il 1-acid il glycoprotein il increases
i. Phenytoin iland ilwarfarin ilare ilexamples ilof ildrugs ilwith ila ilhigher ilrisk ilof iltoxic
ileffects ilwhen ilthe ilserum ilalbumin illevel ildecreases
e. hepatic ilmetabolism ilof ilmany ildrugs ilthrough ilthe ilcytochrome ilP-450 ilenzyme ilsystem
ildecreases ilwith ilage. ilFor ildrugs ilwith ildecreased ilhepatic ilmetabolism ilclearance
iltypically ildecreases il30 ilto il40%.
i. Drugs il metabolized il in il phase il 1 il reactions il likely il prolonged
ii. First-pass ilmetabolism il(metabolism, iltypically ilhepatic, ilthat iloccurs ilbefore ila
ildrug ilreaches ilsystemic ilcirculation) ildecreasing ilby ilabout il1%/yr ilafter ilage
il40.
1. Thus, ilfor ila ilgiven iloral ildose, ilolder iladults ilmay ilhave ilhigher ilcirculating
ildrug ilconcentrations.
f. Decreased il renal il elimination
Week il2 iland il3
1. Identify iland ildescribe il12 illead ilEKGs ilthat ildemonstrate:
a. 1st, il2nd, iland il3rd ildegree ilAV ilblocks
i. 1st ildegree ilHB cards ilconsult
ii. 2nd ildegree ilHB il iltype il1 il& il2
1. Type il1: ilEcho il(r/o ilstructural ildx), ilThyroid illevels, ilmeds, illytes ilto ilidentify
iland iltreat ilcause
2. Type il2: ilPPM, ilcontinuous iltele ilwith iltranscutaneous ilpacing ilif ilneeded,
ildetermine ilcause; ilIV ilatropine ilif ilpoor ilperfusion ils/s ilq il3-5m ilwith ilmax
il3mg ilif ils/s ilpoor ilperfusion;
3. If ilno ilresponse ilto ilatropine ildopa, ilepi, ilisoproterenol
rd
iii. 3 ildegree/ ilcomplete ilHB: ilPPM; iltele iland iltranscutaneous ilpace ilif ilneded;
ilidentify ilcause; ilIV ilatropine ilif ils/s ilpoor ilperfusion; ilIf ilno ilresponse ilto
ilatropine ildopa, ilepi, ilisoproterenol
b. STEMI ilin ilany illead il(know ilwhat ilarea ilof ilthe ilheart ilis ilaffected ilbased ilon illead illocation)
c. Atrial ilfibrillation:
, i. Stable il ilRate ilcontrol ilvs ilrhythm ilcontrol ilstrategy il(AV ilnodal
ilblockers, ilantiarrhythmics, ilanticoagulation); ilablation ilif ilno
ilresponse ilto ilmeds;
ii. unstable il ilDCC/CV
d. Atrial ilflutter
i. CV; ilrate ilcontrol ilnot ilas ilresponsive ilas ilafib
e. Ventricular ilfibrillation:
i. Defibrillate iland ilCPR
f. VT: ilstable
i. Stable/nonsustained il ilBB
ii. Amiodarone, ilsotalol, ilmexiletine ilto ilreduce il# ilshocks
iii. Mg ilif iltorsades
iv. EPS/ablation
v. Unstable il ilCPR, ilepi ilvaso il(2nd ildose), ilamio, illidocaine, ilmg, ilairway
ilmanagement
g. Tachycardia:
i. Vagal ilmaneuver, iladenosine il(6/12mg), ilBB ilor ilCa ilchannel;
ilablation; ilantiarrhythmics ilif ilno ilresponse ilto ilBB ilor ildon’t ilwant
ilablation
h. Asystole: ilCPR
2. Distinguish ilbetween ildihydropyridine iland ilnon-dihydropyridine ilcalcium ilchannel ilblocker.
i l Know ilwhat ilconditions ileach ilclass ilwould ilbe ilused ilto iltreat.
a. dihydropyridine ilcalcium ilchannel ilblocker: il(e.g., ilnifedipine, ilamlodipine) ilprimarily ilact
ilon ilvascular ilsmooth ilmuscles
i. use ilfor ilHTN
b. non-dihydropyridine ilcalcium ilchannel ilblocker: il(diltiazem il< ilverapamil) ilprimarily ilact
ilon ilthe ilheart
i. use ilfor ilCP, ilSVT il(verap); ilcontrolling ilirregular ilrapid ilHR iland illowering
ilBP il(Diltiazem)
3. Describe ilthe ilmedications ilto iltreat ilatrial ilfibrillation il(rate, ilrhythm, iland ilembolus
ilprevention). ilKnow ilthe ilside ileffects, ilneeded ilmonitoring, iland ilinteraction ilfor ileach ilof
ilthese ilmedications.
a.
4. Calculate ila ilCHADS2 ilscore iland ildescribe iltreatment ilbased ilon ilthe ilscore:
a. 1 ilpoint ilfor ilthe ilfollowing ilh/o: ilHF, ilHTN, ilDM, ilstroke/TIA il(2 ilpt) iland ilage il>/= il75
i. 0 il= illow ilrisk, il1-2 il= ilmod ilrisk, il>3 il= ilhigh ilrisk il ilstart ilanticoag
5. Calculate ila ilHASBLED ilscore iland ildescribe iltreatment ilbased ilon ilthe ilscore:
a. 1 ilpoint ilfor ileach ilof ilthe ilfollowing:
i. Hypertension
ii. Uncontrolled, il>160 ilmmHg ilsystolic
iii. Renal ildisease il(Dialysis, iltransplant, ilCr il>2.26 ilmg/dL ilor il>200 ilµmol/L)
iv. Liver ildisease il(Cirrhosis ilor ilbilirubin il>2x ilnormal ilwith ilAST/ALT/AP il>3x ilnormal)
v. Stroke ilhistory
vi. Prior ilmajor ilbleeding ilor ilpredisposition ilto ilbleeding
vii. Labile ilINR il(Unstable/high ilINRs, iltime ilin iltherapeutic ilrange il<60%)
viii. Age il>65
ix. Medication ilusage ilpredisposing ilto ilbleeding il(Aspirin, ilclopidogrel, ilNSAIDs)
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