AGACNP Exam Complete Study Guide Review Containing 909 Questions with Definitive Solutions, Exams of Nursing

Download AGACNP Exam Complete Study Guide Review Containing 909 Questions with Definitive Solutions and more Exams Nursing in PDF only on Docsity! AGACNP Exam Review AGACNP Exam Complete Study Guide Review Containing 909 Questions with Definitive Solutions 2024-2025. Scope of Practice - Answer: Based on legal allowances in each state, individual state nurse practice acts providing guidelines for nursing practice Key elements of the NP role include - Answer: integration of care across the acute illness continuum with collaboration and coordination of care; research based clinical practices, clinical leadership, family assessment, and discharge planning Standards of Advanced Practice are delineated by... - Answer: American Nurses Association which measure quality of practice, service, or education 1 AGACNP Exam Review State Practice Acts - Answer: Authorize Boards of Nursing in each state to establish statutory authority for licensure of RNs State Practice Acts - authority includes: - Answer: use of title, authorization for scope of practice including prescriptive authority, and disciplinary grounds States vary in practice requirements, such as - Answer: certification Prescriptive authority - Answer: Ability and extent of NPs ability to prescribe meds DEA has ruled that nurses in advanced practice may obtain.. - Answer: registration numbers, state practice acts dictate level of prescriptive authority allowed Credentials encompass... - Answer: required education, licensure and certification to practice as an NP Credentials establish... - Answer: minimal levels of acceptable performance Credentialing is necessary to: - Answer: ensure that safe healthcare is provided by qualified individuals; comply with federal and state laws r/t APN Credentials also... - Answer: acknowledges the scope of practice of NP, mandates accountability, enforces professional standards for practice 2 AGACNP Exam Review Risk mgmt - Complaints: Risk mgmt plan should delineate tracking, analyzing, and managing complaints by clearly identifying: - Answer: ppl notified after receiving complaint; ppl responsible for responding; ppl responsible for monitoring follow up Action taking initiatives: - Answer: Prevention, correction (corrective steps must be monitored and audited), documentation, education, departmental coordination Medical Futility - Answer: Interventions that are unlikely to produce significant benefit for pt - "Does the intervention have any reasonable prospect of helping this pt?" Two kind of medical futility: - Answer: Quantitative futility: likelihood that intervention will benefit pt is extremely poor Qualitative futility: quality of benefit an intervention will produce is extremely poor Informed consent - competence (decisional capability) - Answer: state that pt is able to make personal decisions about their care competence implies that ability to: - Answer: understand, reason, differentiate good and bad, and communicate 5 AGACNP Exam Review informed consent - Answer: pt has received adequate instruction or info regarding aspects of care to make prudent, personal choice regarding such tx Informed consent includes: - Answer: discussing benefits and risk consent is assumed if... - Answer: pt's condition is life threatening Danforth Amendment 1991 - Answer: pts are informed at time of admission to federally funded institution (such as hospital, nursing home, hospice, HMO, etc) that they have the right to refuse care as long as the pt has decisional capability (competence) Ethics - Answer: study of moral conduct and behavior protecting the rights of an individual 1st priority is the - Answer: most salvagable pts. Most critically injured cared for last. Key ethical principles are: - Answer: nonmaleficence, utilitarianism, beneficence, justice, fidelity, veracity, autonomy Nonmaleficence - Answer: duty to do no harm Utilitarianism - Answer: the right act is the one that produces the greatest good for the greatest number 6 AGACNP Exam Review Beneficence - Answer: duty to prevent harm and promote good Justice - Answer: duty to be fair Fidelity - Answer: duty to be faithful Veracity - Answer: duty to be truthful (tends to be in conflict with fidelity) Autonomy - Answer: duty to respect an individual's thoughts and actions (tend to be in conflict with beneficence) Dismissing/discharging a pt or closing practice - Answer: NP cannot withdraw from caring for a pt without notification Examples of reasons for discharging a pt from practice: - Answer: abuse, refusal to pay, persistent non-adherence to care Steps for discharging a pt from practice: - Answer: send a certified letter with return receipt (copy for chart), provide general healthcare coverage for 1st 15-30 days post termination deadline, obtain release of info to provide copies of all needed records for next care provider 7 AGACNP Exam Review True or False: A patient has the right to see their medical record - Answer: True The Privacy Rule: Patient's Rights - Answer: See/have their medical record Corrections added to medical record Patient Safety and Quality Improvement Act (PSQIA) - Answer: Voluntary reporting system improve patient safety outcomes through anonymous reporting by providers of patient safety outcomes and events Duty to Warn - Answer: Patient's condition may endanger others overrides confidentiality Patient is diagnosed with HIV. Duty to Warn applies how? - Answer: Can notify providers not family Invasion of Privacy - Answer: Damaging one's reputation as a result of sharing patient information without their permission When can invasion of privacy charge not be made - Answer: in good faith accurate information receiver has valid reason to obtain information 10 AGACNP Exam Review Initiating any change in heathcare - Answer: Begin at most local level and expand outward What comes first when treating a patient with a medical and psychosocial condition - Answer: Medical condition strongest method to evaluate teaching - Answer: returned demonstration when to transfer to teritary care facility - Answer: seriously ill or injured patients that cannot be cared for at your institution stabilize and ship Patient reluctant to undergo procedure. you should? - Answer: Fully educate patient and tell them why Primary care screening exams that are not emergent - Answer: do not delay hospital discharge refer to PCP most powerful data collected from patient - Answer: subjective or data you observed as the np RN calls you as the night shift NP and states patient is decompensating. You would? - Answer: Call primary MD when patient status changes 11 AGACNP Exam Review Code goes bad and all involved are talking badly about it on the unit. You should? - Answer: Hold a one time debriefing with everyone invovled What is a response that would suggest admitting a patient to a SNF would be the best action? - Answer: Needing assistance with ADLs Goals of Healthy People 2020 - Answer: increase the quality and years of healthy life eliminate health disparities among americans Healthy People 2020 purpose - Answer: used to understand health status of the nation and plan prevention programs NP must notify department of health with what dx - Answer: Gonorrhea Chlamydia Syphillis HIV TB NPs must report to state - Answer: Criminal acts and injury from dangerous weapon (GSW) Gonorrhea Chlamydia Syphillis HIV 12 AGACNP Exam Review Root Cause Analysis - Answer: Tool for identifying prevention strategies to ensure safety Culture of safety and not culture of blame Root Cause Analysis involves - Answer: Interdisciplinary experts those who are most familiar with the situation continually asking why at each level of cause and effect Identifying changes Impartial process Debriefing after an event is an example of - Answer: root cause analysis Sentinel Events - Answer: Unexpected occurrences involving death or serious physical injury or psychological injury or risk thereof immediate investigation and response Sentinel Event and medical error - Answer: not synonymous not all sentinel events occur because of an error not all medical errors result in a sentinel event Response to Sentinel Event - Answer: Root Cause Analysis Scope of Practice - Answer: Based on legal allowances in each STATE 15 AGACNP Exam Review Provides guidelines for nursing practice How can the ACNP demonstrate and advocate for full scope of practice? - Answer: ACNP bills independently State Practice Acts - Answer: STATE Board of Nursing grants authority includes title, authorization of scope including prescriptive authority, disciplinary grounds What dictates the nurse practitioners prescriptive authority - Answer: State Nurse Practice Acts State Board of Nursing Credentials - Answer: Encompass required education, licensure and certification to practice as an NP Establish MINIMAL levels of acceptable performance Licensure - Answer: GOVERNMENT STATE BOARD OF NURSING Establishes a person is qualified to perform Certification - Answer: NONGOVERNMENTAL AGENCIES ANCC Establishes a person has met certain standards which signify mastery of specialized knowledge and skills 16 AGACNP Exam Review Licensure vs. Certification - Answer: Government state board of nursing vs. nongovernmental agencies ancc Credentialing and Privileging - Answer: Process by which a nurse practitioner is granted permission to practice in an inpatient setting Hospital Credentialing Committee - Answer: Comprised of physcians Credentialing with hospital privileges grant Most common method of documentation in Risk Management - Answer: Incident Reports Medical Futility - Answer: Interventions that are unlikely to produce any significant benefit for the patient Quantitative Futility - Answer: Where the likelihood that an intervention will benefit the patient is extremely poor Qualitative Futility - Answer: Where the quality of the benefit an intervention will produce is extremely poor Competence - Answer: Decisional capability State in which patient can make personal decisions about their care 17 AGACNP Exam Review Longitudinal study - Answer: Multiple measures of a group over an extended period of time Experimental Research Design - Answer: Manipulation of variables using randomization and control groups to test the effects of an intervention or experiement Quasiexperimental Research - Answer: Manipulation of variable but lacks randomization and control group Qualitative Research - Answer: Case studies Open ended questions field study participant observations Used to explore through detailed descriptions of people, events, situations or observed behavior Drawback of qualitative research - Answer: researcher bias Level of significance - Answer: p value the probability of false rejection of the null hypothesis in a statistical test p value - Answer: level of significance 20 AGACNP Exam Review t value - Answer: the mean of two groups Reliability - Answer: Degree to which an instrument measures the same way over time p <.05 - Answer: experimental and control groups are considered to be significantly different Validity - Answer: Degree to which a variable measures what it is intended to measure ANCC is creating questions for boards and is trying to make sure that these questions they are asking are correctly for ACNP's. Is this reliability or validity? - Answer: Validity. The degree to which a variable measures what it is intended to measure Liability - Answer: Legal responsibility that a nurse practitioner has for actions that fail to meet the standard of care Standards of care - Answer: criteria to measure whether negligence has occured Negligence - Answer: Failure of an individual to do what a REASONABLE person would do resulting in injury to the patient 21 AGACNP Exam Review NP fails to do an EKG on a patient presenting with chest pain. This is an example of - Answer: negligence Malpractice - Answer: Failure to render services with the degree of care, diligence and precaution that another member of the same profession under same circumstances would do to prevent injury to patient Malpractice involves - Answer: professional misconduct unreasonable lack of skill illegal/immoral conduct Assault - Answer: threatening gesture Shaking a fist at someone or making the motion of injecting someone against their will is an example of - Answer: assault Battery - Answer: Violent contact Striking a person, pulling on clothes or anything in which they have contact is an example of - Answer: battery can someone commit assault on an unconscious person - Answer: no Defamiation - Answer: Communication that causes someone to suffer a damaged reputation 22 AGACNP Exam Review The Federal 1999 Balanced Budget Act allowed for: - Answer: Medicare reimbursement for advanced practice nurse services The ACNP is involved in outcomes research. All of the following are examples of patient outcomes EXCEPT: a. patient satisfaction b. length of stay c. mortality statistics d. peer review - Answer: D. Peer review is not a patient outcome The nurse practitioner role in research includes: - Answer: Utilizing research findings in implementation of guidelines for patient care The Patient Self-Determination Act: - Answer: assures patient's rights to participate in and direct their healthcare decisions The ethical principle of "first do no harm" is called: - Answer: nonmaleficence 35 yo. M is admitted to the hospital with viral PNA. During his hospitalization, a HIV test is drawn and it is positive. Pt is married with two small children and states that he will not tell his wife or you have to do it. What is the most appopriate next step in the management of his care? - Answer: Explain to him the importance of informing his wife and offering support. Telling the wife would be a breach of confidentiality. 25 AGACNP Exam Review The Medicare program is administered by the: - Answer: Health Care Financing Agency A healthcare plan in which nurse practitioners and MDs are employed directly by the health plan is: - Answer: a staff-model health maintenance organization (HMO) Which of the following services are reimbursed by Medicare: a. home health aids b. physical therapy c. skilled nursing services d. all of the above - Answer: D. all of the above Health Maintenance Organizations (HMOs): - Answer: provide both inpatient and outpatient services through a referral system The most common mental illness in young adults: - Answer: schizophrenia Acute Pain - Answer: Pain caused by tissue damage, usually < 6 months Chronic Pain - Answer: Continual or episodic pain of longer duration (> 6 months); combination therapy usually needed Cutaneous Pain - Answer: Localized on skin or surface of body. Herpes or sunburn. 26 AGACNP Exam Review Visceral Pain - Answer: Poorly localized such as with internal organs. Gallbladder. Somatic Pain - Answer: Non localized; originates in muscle, bone, nerves, blood vessels and supporting tissue. Neuropathic Pain - Answer: Frequently caused by a tumor; involves nerve pathway injury or compression. Sciatica Step 1 of WHO's Ladder of Pain Management - Answer: -ASA -APAP -NSAIDS +/- adjuvants Step 2 of WHO's Ladder of Pain Management - Answer: -APAP or ASA -Codeine -Hydrocodone -Oxycodone -Dihidrocodeine -Tramadol (not available with APAP or ASA) +/- Adjuvants Step 3 of WHO's Ladder of Pain Management - Answer: -Morphine -Dilaudid -Methadone -Levorphanol 27 AGACNP Exam Review 8. Sinusitis 9. Abscess (ie: intra-abdominal) Initial Treatment of Post-Operative Fever - Answer: In the absence of infection- first step is hydration and lung expansion Treatment of Infectious Post-Op Fever - Answer: 1. Supportive therapy and APAP 2. Treat the apparent underlying source 3. Gram stain and C&S all invasive lines or catheters, as indicated Differential Value Indicative of Allergic Reaction - Answer: Increased eosinophil count Components of Headache Evaluation - Answer: 1. Chronology **most important** 2. Location, duration and quality should also be evaluated 3. Associated activity: exercise, sleep, tension, relaxation 4. Timing of menstrual cycle 5. Presence of associated symptoms 6. Presence of "triggers" Most common type of headache - Answer: Tension Headache Tension Headache Signs and Symptoms - Answer: 1. Vise-like or tight in quality 2. Usually generalized 30 AGACNP Exam Review 3. May be most intense around the back of the head 4. No associated focal or neurological symptoms 5. Usually lasts for several hours Tension Headache | Management - Answer: 1. OTC analgesics 2. Relaxation Migraine Headaches - Answer: Dilation and excessive pulsation of the branches of the external carotid artery, usually lasting 2-72 hours along the Trigeminal nerve pathway Migraine Headaches | Classifications - Answer: 1. Migraine with aura "classic" 2. Migraine without aura "common" Migraine Headaches | Causes/Incidence - Answer: 1. Onset is usually in adolescence or early adult years 2. Often + family history 3. Females > Males 4. A variety of triggers 5. Nitrate containing foods 6. Changes in the weather Migraine Headaches | Triggers - Answer: - Emotional/Physical stress - Lack or excess of sleep - Missed meals 31 AGACNP Exam Review - Specific Foods (Nitrate containing, wines, cheeses...) - ETOH - Menstruation - oral contraceptives Migraine Headaches | Symptoms - Answer: - Unilateral, lateralized throbbing headache occurring episodically - Dull or throbbing - Build up gradually and last for several hours or longer - Focal neurologic disturbances may precede or accompany migraines - Visual disturbances occur commonly: visual field changes, luminous visual hallucinations - Aphasia, numbness, tingling, clumsiness or weakness may occur - Nausea and vomiting - Photophobia and phonophobia Migraine Headaches | Physical Exam Findings - Answer: - Often normal with the exception of neuro deficits - Appears Ill - Careful neuro exam for focal deficits or findings supportive of tumor Migraine Headaches | Laboratory & Diagnostics - Answer: 1. Baseline studies important to rule out other organic causes 2. Blood chemistries, BMP 3. CBC 32 AGACNP Exam Review Nutritional Considerations | Clinical Observations indicative of proper nutrition - Answer: - Hair not easily plucked - Pink mucous membranes - Clear nail beds free of ridges - Musculature Hgb:Hct Ratio - Answer: 1:3 Complications of Enteral Nutritional Support - Answer: 1. Aspiration 2. Diarrhea 3. Emesis 4. GI Bleeding 5. Mechanical obstruction of the tube 6. Hypernatremia 7. Dehydration Complications of Parenteral Nutritional Support - Answer: 1. Pneumothorax 2. Hemothorax 3. Arterial laceration 4. Air emboli 5. Catheter thrombosis 6. Catheter sepsis 7. Hyperglycemia 8. HHNK 35 AGACNP Exam Review If patient will be receiving nutritional support > 6 weeks: - Answer: Enterostomal tube Aspiration risk with enteral feeding? - Answer: Nasoduodenal tube Parenteral nutritional support for > 2 weeks? - Answer: - Central vein Evaluation of the patient with hyponatremia includes: - Answer: 1. Urine sodium 2. Serum osmolality Clinical status Normal Urine Sodium - Answer: 10-20 meq/L Normal Serum Osmolality - Answer: 275-285 mosm/kg Safe average of 280 2x the sodium Hypertonic - Answer: > 290 mosm/kg Hypotonic - Answer: < 280 mosm/kg In evaluation of hyponatremia, a urine sodium > 20 meq/L suggests: - Answer: Problem with the kidneys, renal salt wasting 36 AGACNP Exam Review In evaluation of hyponatremia, a urine sodium <10 meq/L suggests: - Answer: Renal retention of sodium to compensate for extra renal fluid losses A problem outside the kidney Isotonic Hyponatremia " aka " - include treatment - Answer: Pseudohyponatremia - laboratory artifact Serum Osmolality 284-295 mosm/kg - occurs with extreme hyperlipidemia or hyperproteinemia - body water is normal and patient is asymptomatic - cut down fat Hypotonic Hyponatremia - Answer: - serum osmolality < 280 mosm/kg - state of body water excess - dilution of all body fluids Steps in evaluating hypotonic hyponatremia - Answer: - Assess volume status hypovolemic/hypervolemic - If hypovolemic: assess whether hyponatremia is due to extra renal salt losses or renal salt wasting - Urine Sodium > 20 = renal salt wasting - Urine Sodium < 10 = extrarenal fluid losses 37 AGACNP Exam Review Severe Hypernatremia with Hypovolemia treatment: - Answer: NS IV followed by ½ NS Hypernatremia with euvolemia treatment: - Answer: D5W Hypernatremia with hypervolemia should be treated with: - Answer: Free water and loop diuretics - may need dialysis In hypervolemic and hypernatremic patients in the ICU who have an impaired renal excretion of sodium and potassium (eg, after renal failure) an addition of a loop diuretic to free water boluses increases renal sodium excretion Hypokalemia - Answer: K < 3.5 Hypokalemia causes - Answer: - Diuretics - GI loss - Excess renal loss - Alkalosis Hypokalemia Signs and Symptoms - Answer: - Muscular weakness, fatigue and muscle weakness - Constipation or ileum due to smooth muscle involvement Severe Hypokalemia and Symptoms - Answer: < 2.5 flaccid paralysis 40 AGACNP Exam Review tetany hyporeflexia rhabdomyolysis Hypokalemia Lab/Diagnostics - Answer: Multifocal PVCs Decreased amplitude on ECG Broad T waves Prominent U waves PVC's, VT or VF Hypokalemia Management - Answer: Oral replacement if greater than 2.5 and no EKG abnormalities IV replacement at 10meq/hr if cannot take PO If < 2.5 or severe S&S may give 40meq/hr IV and check Q3 with continuous EKG monitoring *Make sure to watch magnesium level - low magnesium can impair K correction Hyperkalemia & Causes - Answer: > 5.0 Excess intake Renal failure Drugs (NSAIDS) Hypoaldosteronism Cell death Shifts of K into the extracellular space occur with acidosis 41 AGACNP Exam Review Hyperkalemia S&S - Answer: - weakness - flaccid paralysis - abdominal distension - diarrhea Hyperkalemia Labs/Diagnostics - Answer: - EKG not always sensitive - Tall peaked T's = classic finding Hyperkalemia Management - Answer: - Exchange resins - kayexelate - > 6.5 or cardiac toxicity or muscle paralysis is present, consider: 10 U regular insulin and 1 amp D50 Emergent Hyperkalemia Treatment! - Answer: 10 U regular insulin and 1 amp D50 Calcium Norms - Answer: Serum: 2.2-2.6 mmol/L or 8.5-10.5 mg/dL Ionized: 1.1-1.4 mmol/L or 4.5-5.5 mg/d Academia increases ionized calcium Alkalemia decreases ionized calcium Ionized calcium does not vary with albumin level; serum does Hypocalcemia Causes - Answer: - hypoparathyroidism - hypomagnesemia 42 AGACNP Exam Review - increased cerebral blood flow causes increased CSF pressure causing increased ICP Respiratory Acidosis Lab/Diagnostics - Answer: - Low arterial pH < 7.35 - PCO2 > 45 - Serum HCO3 > 26 - Low serum chloride < 93 (chronic respiratory acidosis) Respiratory Acidosis Management - Answer: - Naloxone 0.04 to 2 for patient's with no other obvious cause - Improve ventilation; intubate if necessary - Increase ventilatory rate Respiratory Alkalosis - Answer: Hyperventilation causes CO2 to drop and increases pH Clinical symptoms are related to decreased cerebral blood flow Respiratory Alkalosis S&S - Answer: - Light headedness - Anxiety - Paresthesias - Stocking/glove tingling - Tetany if very severe Respiratory Alkalosis Lab/Diagnostics - Answer: - Increased pH > 7.45 - Low pCO2 < 35 45 AGACNP Exam Review - Serum HCO3 low, if chronic Respiratory Alkalosis Management - Answer: - Manage underlying cause - if acute hyperventilation syndrome, have patient breath into paper bag - Decrease vent rate if needed - Sedation? - Rapid correction may result in metabolic acidosis Metabolic Acidosis - Answer: Hallmark sign is LOW HCO3 (Bicarb) Measurement of anion gap helps evaluate cause Anion Gap Calculation - Answer: Na - (Cl + HCO3) Normal: 10-14 Metabolic Acidosis | Increased Anion Gap Causes - Answer: G — glycols (ethylene glycol & propylene glycol) O — oxoproline, a metabolite of paracetamol L — L-lactate, the chemical responsible for lactic acidosis D — D-lactate M — methanol A — aspirin R — renal failure K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis 46 AGACNP Exam Review M — Methanol U — Uremia (chronic kidney failure) D — Diabetic ketoacidosis P — Propylene glycol ("P" used to stand for Paraldehyde but this substance is not commonly used today) I — Infection, Iron, Isoniazid, Inborn errors of metabolism L — Lactic acidosis E — Ethylene glycol (Note: Ethanol is sometimes included in this mnemonic as well, although the acidosis caused by ethanol is actually primarily due to the increased production of lactic acid found in such intoxication.) S — Salicylates Metabolic Acidosis | Normal Anion Gap Causes - Answer: Diarrhea Ileostomy Renal Tubular Acidosis (Infrarenal Failure) Recovery from DKA Treatment of Metabolic Acidosis - Answer: Increased gap causes & treatments: - Underlying disorder must be treated - Fluid resuscitation - HCO3 generally not indicated if the acidosis is due to hypoxia or DKA - HCO3 is indicated if significant hyperkalemia is present Normal gap causes & treatments: (common in renal failure) 47 AGACNP Exam Review 4. ½ of all fluid in first 8 hours, ¼ in 8, ¼ in 8 5. Monitor for metabolic acidosis in first 24-48 hours 6. Monitor for hyperkalemia in first 24-48 hours of burn injury; then monitor for hypokalemia following fluid resuscitation/diuresis around 3 days post burn Burns | Parkland Formula - Answer: - ~ 4ml/kg x TBSA during first 24 hours - ½ of all fluid in first 8 hours, ¼ in 2nd 8, ¼ in 3rd 8 Burns | Indications for prophylactic intubation - Answer: Intubation should occur with any evidence of the findings that suggest Laryngeal edema: - burns to face - singed nares or eyebrows - dark soot/mucous from nares and/or mouth Burn Management Pearls - Answer: 1. submerge injured area in clean water ASAP 2. no ice, lotions, toothpaste, lard, butter or anything else 3. wrap in clean wet towel 4. sterile normal saline initially only 5. affected areas covered in sterile towels 6. maintain normal body temperature (37-37.5) 7. manage pain 8. special consideration with tar burn: use petroleum based products to remove tar and cool it ASAP 9. Silvadene: common topical antibacterial/antifungal used to treat second and 3rd degree burns 50 AGACNP Exam Review American Burn Association Criteria for Burn Center Referral - Answer: 1. Partial thickness > 10% 2. Burns involving: face, hands, feet, genitalia, perineum, major joints 3. Third degree in any age group 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation Injury 7. Pre-existing medical disorders 8. Burn + trauma 9. Burned children 10. Special requirements with social or emotional rehabilitation Bites (Dog, Cat, Human) - Answer: - cat bites = infection - copious pressure irrigation of bite with LR - rabies status - X-rays if face bitten - primary closure still controversial - wounds on hands/legs should be left open - consult plastics - prophylactic antibiotics : AUGMENTIN SSTI's | Most common causes of OUTPATIENT cellulitis - Answer: 1. Strep. pyogenes (gp A strep) usually 2. Staph Aureus less common 51 AGACNP Exam Review 3. Other strep (B, C, G) rare SSTI's | Most common causes of INPATIENT cellulitis - Answer: 1. Gram negatives : E. coli, Klebsiella, Pseudomonas, Enterobacter 2. Staph Aureus; MSSA, CA-MRSA, MRSA 3. Strep SSTI's | Treatment for Community Acquired- MRSA - Answer: 1. TMP-SMZ 2. Doxy/Minocycline 3. Clindamycin Treatment for Group A Strep - Answer: 1. TMP-SMZ + Beta Lactam (PCN, amoxicillin, 1st generation cephalosporin (Keflex/Cephalexin)) 2. Doxy/Mino + Beta Lactam (PCN, amoxicillin, 1st generation cephalosporin(Keflex/Cephalexin)) 3. Clindamycin GI contamination - Answer: - History most important piece of information - serum, gastric and urine tox screens to aid in assessment of ingested substance GI contamination | Ipecac - Answer: - at home ingestions of solid matter (pills, capsules) - not used in emergency settings GI contamination | GI lavage - Answer: - "lavage until clear" 52 AGACNP Exam Review Antidepressant Toxicity/Anticholinergic Toxicity (Amitryptaline, Fluoxetine, Imipramine, Nortryptaline, Bupropion) Signs and Symptoms - Answer: 1. Confusion, hallucinations, blurred vision 2. Urinary retention 3. Hypotension, tachycardia, dysrhythmias 4. Hypothermia 5. Seizures Antidepressant Toxicity (Anticholinergic Toxicity - Answer: 1. Admit to ICU if CNS or cardiac toxicity is evident 2. GI lavage/activated charcoal 3. Sodium Bicarbonate IV to counter dysrhythmias and maintain pH 4. Benzo's IV to control seizures 5. Serotonin Syndrome-dantrolene sodium Serotonin Syndrome treatment - Answer: -Dantrolene Sodium - Klonopin for rigor - cooling blankets for temperature Narcotic Toxicity -Codeine -Heroin -Morphine -Opium 55 AGACNP Exam Review Signs/Symptoms - Answer: 1. Drowsiness 2. Hypothermia 3. Respiratory depression, shallow respirations 4. Miosis: pinpoint pupils 5. Coma Relaxed Euphoria - Answer: pinpoint pupils; miosis heroine Elevated Euphoria - Answer: dilated pupils; mydriasis cocaine Narcotic Overdose Management - Answer: 1. Emetics contraindicated 2. GI lavage/ activated charcoal 3. Naloxone 4. Stadol Benzodiazepine Overdose | Signs and Symptoms -Diazepam -Lorazepam -Clonazepam - Answer: 1. Drowsiness 2. Confusion 3. Respiratory Depression 4. Hyporeflexia 56 AGACNP Exam Review Benzodiazepine Overdose | Management - Answer: 1. Respiratory and BP support 2. Flumazenil (Romazicon) IV 3. GI lavage/Activated charcoal Benzo Antidote - Answer: Flumazenil #1 consideration with transplant patients - Answer: Immunosuppressed Acute Organ Rejection - Answer: - Immediate failure of that organ - Flu-like symptoms (fever, chills, malaise) - Immediate biopsy of the transplanted organ is usually warranted as soon as possible Anti-rejection induction agents do what: - Answer: lower and almost abolish circulating lymphoid cells that mount the immune response Standard anti-rejection therapy - Answer: calcineurin inhibitor + antimetabolite + steroid Calcineurin Inhibitor in anti-rejection therapy - Answer: Tacrolimus (prograf) or cyclosporine Antimetabolite in anti-rejection therapy - Answer: Azathioprine (Imuran) or Mycophenolate mofetil (Cellcept) 57 AGACNP Exam Review 2. median age at diagnosis=40 3. may metastasize to any organ ABCDE to Melanoma - Answer: Asymmetry Border irregularity Color variation Diameter > 6mm Elevation Enlargement 2+ = malignant melanoma Melanoma Treatment: - Answer: biopsy and surgical excision Brain Death considerations - Answer: 1. criteria 2. family education and support brain death=death (functionally and legally) Brain Death Criteria - Answer: Terminal Extubation Concerns - Answer: 1. family preparation, education and support 2. morphine or opioids: for tachypnea and/or respiratory distress 3. Scopolamine: to reduce excessive secretions - atropine eyedrops 60 AGACNP Exam Review Acute Pain - Answer: Duration is usually less than 6 months, Caused by tissue damage Chronic Pain - Answer: Continual or episodic pain of longer than 6 months Cutaneous - Answer: Localize on the skin or surface of the body Visceral Pain - Answer: Poorly localized such as with internal organs Somatic Pain - Answer: Originates in muscle, bones, nerves, blood vessels, and supporting tissue. Soft tissue Neuropathic Pain - Answer: Frequently caused by a tumor, involves the nerve pathway Subjective Findings of pain - Answer: Most reliable indicator of the existence and intensity of acute pain WHO's pain management ladder Step 1 - Answer: ASA, APAP, NSAIDs, and +- adjuvants WHO's pain management ladder Step 2 - Answer: APAP or ASA, Codeine, Hydrocodone, oxycodone, dihidrocodeine, tramadol, +- adjuvants 61 AGACNP Exam Review WHO's pain management ladder Step 3 - Answer: Morphine, Hydromorphone, methadone, levorphanol, fentanyl, oxycodone, +- Non opioid analgesics, +- adjuvants Fever definition - Answer: Increased body temp above normal (37C) Causes of fever - Answer: Autoimmune, CNS, Malignant neoplastic disease, hematologic disease, CV disease, GI disease, Endocrine disease, Neuroleptic malignant syndrome (anti-psychotics) Causes of non-infectious post-op fever - Answer: #1: Post-op atelectasis, increased metabolic rate, dehydration, and drug reactions Drugs that can cause fever - Answer: Amphotericin B, trimethoprim sulfamethaxazole, beta-lactam antibiotics, procainamide, isoniazid, alpha- methyldopa, quinidine Infectious indicators of post-op fever? What are the WBC indicators? - Answer: Usually accompanied by subjective complaints and a WBC elevation with left shift. Increased 5-10000 is normal for elderly and immunocompromised. >20,000 septic shock. >40,000 leukemia Causes of infections post-op fever - Answer: Surgical incisions, IV sites, UTI, Lungs, abcess **sinusitis: NG tubes associated with increased incidence 62 AGACNP Exam Review Causes s/s of Cluster H/A - Answer: No family hx, ETOH, occurs at night, lasts less than 2 hours, severe unilateral periorbital pain occurring daily for several weeks, Ipsilateral nasal congestion, rhinorrhea and eye redness may occur Treatment of Cluster H/A - Answer: inhalation of 100% O2, Imitrex 6mg SQ Normal Albumin level - Answer: 3.5-5 Hgb/Hct Ratio - Answer: 1:3 Complications of enteral feeding - Answer: Aspiration, diarrhea, emesis, GI bleed, mechanical obstruction, hypernatremia, and dehydration Complications of parenteral nutrition - Answer: Pneumothorax, hemothorax, arterial laceration, air emboli, catheter thrombosis, catheter sepsis, hyperglycemia, HHNK What is the most common electrolyte abnormality - Answer: Hyponatremia Urine sodium normal value - Answer: 10-20 Sodium Osmolality normal value - Answer: 2xs Na 275-285 65 AGACNP Exam Review Urine sodium >20 suggestive of what? - Answer: Suggests renal salt wasting (problem with kidneys) Urine sodium <10 suggestive of what? - Answer: Suggests renal retention of sodium to compensate for extrarenal fluid loss (problem other than kidneys) Isotonic hyponatremia what is it's other name? Lab value and causes and treatment - Answer: Pseudohyponatremia; serium osmo 284-295: lab artifact Occurs with hyperlipidemia or hyperproteinemia, body water is normal and pts are asymptomatic Treatment: Cut down fat (no fluid restriction) Hypotonic Hyponatremia normal lab value and definition - Answer: Osmo <280. State of body water excess diluting all body fluids: clinical signs arise from water excess. Hypovolemic w/urine Na+ <10 causes? - Answer: Dehydration, diarrhea, vomiting Hypovolemic w/urine Na+ >20 is caused by? - Answer: Low volume and kidneys cannot conserve Na Diuretics, ACE inhibitors, and mineralocorticoid deficiency Hypervolemic, hypotonic hyponatremia treatment? What causes it? - Answer: (restrict water) Edematous states, CHF, Liver disease, advanced renal failure 66 AGACNP Exam Review Hypertonic Hyponatremia lab value? What causes it? - Answer: (Serum osmo >290) Hyperglycemia: Usually HHNK Osmo is high and Na is low Management of hyponatremia - Answer: Treat cause if hypovolemic: give NS if urine sodium > 20 treat cause if hypervolemic: restrict water If symptomatic : give NS with IV loop diuretic If CNS symptoms: give 3% with loop diuretic Hypernatremia what causes it what are the indications - Answer: Due to excess water loss. Always indicates hyperosmolality (deficit of water) excessive sodium intake is rare Treatment of Hypernatremia - Answer: Free water if euvolemic Hypernatremia with hypovolemia treatment - Answer: Give NS followed by 1/2 NS Hypernatremia with euvolemia Treatment - Answer: Treat with free water Hypernatremia with hypervolemia treatment - Answer: Treat with free water (D5NS) and loop diuretics....may need dialysis 67 AGACNP Exam Review Management of hypocalcemia - Answer: Check pH for alkalosis, if acute give IV calcium gluconate, if chronic give oral supplements, vitamin d, and aluminum hydroxide Acidemia _____Ionized calcium - Answer: increases Alkalemia_____ionized calcium - Answer: decreases Hypercalcemia causes - Answer: Causes: hyperparathyroidism, hyperthyroidism, Vitamin D intoxication, prolonged immobilization, thiazide diuretics S/S of hypercalcemia - Answer: Fatiguability, muscle weakness, depression, anorexia, n/v, constipation, severe hypercalcemia can cause coma or death. Serum Ca >12 is considered medical emergency Management of Hypercalcemia - Answer: Calcitonin if impaired cardiovascular or renal fx, dialysis, if >12 begin NS and loop diuretics. Respiratory Acidosis PH and PCO2 levels - Answer: pH <7.35 with pCO2 >45 Causes of Resp Acidosis what happens in acute And what happens in chronic states - Answer: Decreased alveolar ventilation In acute resp failure there is a sharp rise in pCO2 with only a small increase in plasma HCO3. 70 AGACNP Exam Review Afte 6-12 hours the increase in pCO2 will evoke the renal compensatory mechanism, this takes several days to manifest S/S of Resp. Acidosis - Answer: Somnolence and confusion Myoclonus with asterixis increased cerebral blood flow causes increased CSF pressure causing increase ICP Lab/Diagnostics of Resp Acidosis - Answer: Low arterial pH PCO2> 45 Serum HCO >26 Low serum chloride (<93) in chronic patients Management of Resp Acidosis - Answer: Narcan 0.4-2mg Improve ventilation, intubate if necessary increase vent rate Respiratory Alkalosis causes - Answer: Hyperventilation decreases arterial PCO2 and increases pH. Clinical symptoms are related to decreased cerebral blood flow S/S of resp alkalosis - Answer: light headedness, anxiety, paraesthesia, stocking/glove tingling, tetany if very severe Lab/ Diagnostics of Resp Alkalosis - Answer: Increased pH >7.45 Low PCO2 < 35 Serum HCO3 low if chronic 71 AGACNP Exam Review Management of Resp Alkalosis management if acute and chronic - Answer: Manage underlying cause If acute hyperventilation, have pt breath into paper bag decrease rate of vent sedation may be necessary rapid correction of chronic alkalosis may result in metabolic acidosis Metabolic Acidosis Hallmark sign - Answer: Hallmark sign is a low serum HCO3 Anion Gap normal values. What does an increase indicate? - Answer: Normal: 7 to 17 12 - or +5 either way If gap is increased the clinical situation is generally more acute Increased anion gap causes - Answer: DKA, Alcoholic Keto Acidosis, Lactic Acidosis, Drug or chemical anion anion gap can still be normal in these conditions - Answer: diarrhea, ileostomy, renal tubular acidosis, recovery from DKA Increased gap treatment - Answer: underlying disorder, fluid resuscitation HCO3 not indicated if acidosis is due to hypoxia or DKA HCO3 is indicated if significant hyperkalemia is present 72 AGACNP Exam Review Each Leg=18 Thorax= 18 front and 18 back Head=9% Perineum/genitals=1 Fluid resuscitation for burns parkland formula - Answer: 4ml/kg X TBSA in the first 24 hours 1/2 of all fluid should be given in the first 8 hours the remaining fluid given over the next 16 hours. ALL NS or LR **Fluid resuscitation begins at time of burn injury Monitor what electrolyte during fluid resuscitation for burns? - Answer: Monitor for hyperkalemia during the first 24-48 hours then monitor for hypokalemia following fluid resuscitation/diuresis around 3 days post burn. Indication for prophylactic intubation post burn - Answer: burns to the face singed nares or eyebrows dark soot/mucous from nares and/or mouth Emergent management of burns - Answer: submerse injured area in clean water as soon as possible wrap area in clean wet towel and transport sterile NS in initial treatment Affected areas wrapped with sterile towels 75 AGACNP Exam Review maintain normal tem IV fentanyl and/or morphine Silver Sulfadiazine- used to treat second- and third-degree burns Tar burn treatment - Answer: use petroleum-based product to remove the burning tar What wounds should be left open - Answer: wounds of hands or lower extremities or any wound older than 6 hours Abx given for what type of bite - Answer: Human and animal bites, give 3-7 day course of p.o prophylactic abc for coverage of both staph and anaerobes (Augmentin) Most common causes of cellulitis Inpatient and Outpatient - Answer: Outpatients: Strep pyogenes (Gp A Strep) --Usual cause S aureus--less common Inpatients: Gram negative organisms (E Coli, Klebisiella, Pseudomonas, Enterobacter), S. Aureus (MRSA, CA-MRSA), Strep Meds for CA-MRSA cellulitis - Answer: Trimethoprim-Sulfamethoxazole (Bactrum) Doxy/minocycline Clindamycin 76 AGACNP Exam Review Meds for Group A strep cellulitis - Answer: Trimethoprim-Sulfamethoxazole+ beta lactam Doxy/minocycline+ beta lactam Clindamycin S/S of acetaminophen intoxication - Answer: asymptomatic in early phase around 24-48 hours, nausea and vomiting will occur right upper quad pain signs of hepatotoxicity: Jaundice, elevated LFTs, prolonged PT, altered mental status, delirium Management of acetaminophen - Answer: Emesis for recent ingestions; gastric lavage/activated charcoal N-Acetylcysteine (mucomyst) with loading dose p.o should be ordered as needed S/S of Salicylate intoxication - Answer: Nausea, vomiting, tinnitis, dizziness, h/a, dehydration, hyperthermia, apnea, cynaosis, metabolic acidosis, elevated LFTs Normal LFT - Answer: 35-40 Management of salicylate intoxication - Answer: emesis for recent ingestions; gastric lavage/activated charcoal sodium bicarbonate IV to correct sever acidosis <7.1 Oranophosphate poisoning - Answer: insecticide poisoning 77 AGACNP Exam Review organ transplant anti-rejection agents what do they do - Answer: lower circulating lyphoid cells that are critical to rejection response Transplant rejection drug combos - Answer: calcineurin inhibitor+ antimetabolite+steriod CI=tacrolimus or cyclosporine Antimetabolite=Azathioprine, or Mycophenolate (cellcept) Steroid=deltazone,prednasone,orazone,Metocorten Herpes Zoster (Shingles) define - Answer: Vesicular eruption due to infection with varicella-zoster wires; maybe life-threatening in immunocompromised adults S/S of Herpes Zoster - Answer: Pain along a dermatomal distribution, usual on the trunk grouped vesicle eruption of erythema and exudate along the dermatomal pathway Regional lymphadenopathy may be present Management of Herpes Zoster - Answer: Treatment: Acyclovir, famciclovir, valaciclovir If suspected ocular involvement, immediate referral to ophthalmologist Post herpetic neuralgia: Gabapentin and pregabalin Zostavax @ 50 80 AGACNP Exam Review Actinic Keratoses define, treatment - Answer: Small patches on sun exposed parts of body Premalignant Asymptomatic Rough, flesh colored, pink or hyper pigmented Treatment: liquid nitrogen Squamous Cell Carcinoma come from what? Treatment? - Answer: Arise out of actinic keratoses firm, irregular papule or nodule Develop over a few months; 3-7% metastasis Prolonged, sun-exposed areas in fair skin people Keratotic, scaly bleeding Treatment: Biopsy and surgical excision Seborrheic Keratoses define? Treatment? - Answer: Benign non painful lesions Beige, brown or black plaques "stuck on" appearance 3-20mm in diameter Treatment: None or liquid nitrogen Basal Cell Carcinoma define? Treatment? - Answer: Most Common Slow Growing Waxy, pearly appearance (may be shiny red) Central depression or rolled edge 81 AGACNP Exam Review May have telangiectatic vessels Treatment: Shave/punch biopsy & surgical excision Malignant Melanoma? Define? Treatment? - Answer: Mortality rate highest of all skin cancers Median age at diagnosis = 40 May metastasize to any organ Treatment: Biopsy and surgical excision ABCDEE of melanoma - Answer: A: asymmetry B: border irregularity C: Color variation D: diameter >6mm E: elevation E: enlargement 2 or more of ABCDEE = 90% sensitivity End of life considerations brain death criteria - Answer: rewarmed,absent crainial reflexes terminal extubation considerations - Answer: morphine for tachypnea and resp distress, scopolomine for secretions Diabetes (Type I) - Answer: Most common in adolescents by may occur in adulthood 82 AGACNP Exam Review Lactic acidosis is a potential side effect Alpha-glucosidase inhibitors how do they work? - Answer: less glucose is absorbed by the gut Acarbose and miglitol Thiazolidinediones "glitazones" how do they work? - Answer: decrease gluconeogenesis Rosiglitazone maleate (Avandia) (Increase MI and HF) Pioglitazone hydrochloride (Actos) (increase bladder CA) Non-sulfonylurea "Glinide"s insulin release stimulators how do they work? - Answer: Rapidly absorbed from the intestine and mimics the effect of rapidly acting insulin Repaglinide (Prandin) Nateglinide (Starlix) Somogyi Effect define: - Answer: Nocturnal hypoglycemia. Patients is hypoglycemic at 0300 but rebounds with elevated blood glucose at 0700 Treatment: Reduce or omit the at bedtime dose of insulin Dawn Phenomenon define: - Answer: Results when tissue becomes desensitized to insulin nocturnally. Blood glucose becomes progressively elevated throughout the night, resulting in elevated glucose levels at 0700 Treatment: Add or increase the at bedtime of insulin 85 AGACNP Exam Review DKA define: - Answer: Intracellular dehydration as a result of elevated blood glucose levels often an acute complication of type 1 DM Lab/Diagnostic of DKA - Answer: Glucose >250, Ketonemia and/or ketonuria, glycosuria, acidosis (metabolic) <7.30, low HCO3, Low PCO2, elevated Hct, BUN/Crt, Hyperkalemia, Leukocytosis, hyperosmolality S/S of DKA - Answer: **Kussmaul Respirations (blowing off CO2), fruity breath, weakness/fatigue, polydipsia, orthostatic hypotension, poor skin turgor Management of DKA - Answer: Protect Airway, O2, Isotonic fluids (NS) at least 1L in the first hour then 500ml/hr. If glucose >500 use 1/2 NS after first hour. When glucose drops below < 250 change to D51/2 to prevent hypoglycemia. DKA insulin management cont. - Answer: 0.1u/kg regular insulin IV bolus followed by 0.1u/kg/hr. if glucose does not fall by at least 10% after the first hour, repeat bolus. DKA how to correct the acidosis - Answer: Correct severe acidosis (<7.1) with bicarb gtt (44-48mEq in 900ml 1/2 NS until pH reaches >7.1) DO NOT treat hyperkalemia HHNK define it. 86 AGACNP Exam Review Who does it occur with? - Answer: Hyperosmolar Hyperglycemic Nonketoacidosis. State of intracellular dehydration as a result of greatly elevated BG. Usually occurs as a complication of type 2 DM. Pts cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion S/S of HHNK - Answer: Polyuria, weakness, changes in LOC, hypotension, tachycardia, other signs of dehydration HHNK Labs - Answer: Elevated serum glucose (>600; commonly >1000) Hyperosmolality (>310) elevated BUN and Cr, elevated Hgb A1C, normal pH, normal anion gap. MOST DEHYDRATED 6-10L down HHNK management - Answer: NS IV for massive fluid replacement (overall fluid deficit may be 6-10L). Once pt is hemodynamically stable or serum Na reaches 145 change to 1/2 NS (expect 4-6L in first 8-10hrs of therapy) HHNK management parameters for plasma glucose - Answer: When plasma glucose reaches 250 add D5 to IV solution 15U regular insulin IV followed by 10-15U SQ (immediately) Hyperthyroidism who gets it? What are their age groups? - Answer: More common in women (1:8) Onset 20-40 y/o, Graves disease most common presentation 87 AGACNP Exam Review S/S of Addison's - Answer: Hyperpigmentation in buccal mucosa and skin creases, fever (acute) change in LOC, scant axillary and pubic hair, orthostasis and hypotension Lab/Diagnostic of Addison's - Answer: Hypoglycemia, Hyponatremia, hyperkalemia (Addison's disease), Elevated ESR, lymphocytosis, plasma cortisol <5mg Outpatient Management Addison's - Answer: Glucocorticoid and mineralocorticoid replacement. Hydrocortisone (glucocorticoid) Fludrocortisone acetate (Florinef) Inpatient Management of Addison's - Answer: Hydrocortisone 100-300mg IV initially with NS; replace volume with D5NS at 500cc/hr x4 hours and then taper per condition. treat underlying cause: Often infection SIADH define: What disease states get it? - Answer: Inappropriate Water RETENTION, release of ADH occurs independent of osmolality or volume dependent stimulation, tumor production of ADH, CNS disorder, Chronic lung disease S/S of SIADH - Answer: Neurologic changes: mild H/A, seizures, coma (D/T hyponatremia) Decreased DTRs, hypothermia, weight gain/edema, n/v, cold intolerance 90 AGACNP Exam Review Lab/Diagnosis of SIADH - Answer: Hyponatremia: yet euvolemic Decreased serum osmolality (<280) Increased urine osmolality (>100) Urine Sodium >20 Renal, cardiac, thyroid function normal Diabetes Insipidus - Answer: Central: Related to pituitary or hypothalamus damage resulting in ADH deficiency Nephrogenic: due to defect in the renal tubules resulting in renal insensitivity to ADH. Acquired due to phelonephritis, K+ depletion, sickle cell anemia, chronic hypercalcemia, medications S/S of DI - Answer: Fluid intake 5-20L/day, polyuria 2-20L/day, weight loss, fatigue, tachycardia, hypotension Lab/Diagnosis of DI - Answer: Hypernatremia, elevated BUN/Creat, serium osmo >290urine, urine osmo >100, urine specific gravity <1.005 If Central DI is suspected DDAVP challenge test 0.05-0.1ml nasally or 1 SQor IV. If no apparent cause MRI should be ordered to look for mass or lesion Normal Labs BUN Creatine and Bun/creatine ratio and Specific Gravity - Answer: BUN: 10-20 Creat: .5-1.5 Bun/Creat Ratio: 10:1 91 AGACNP Exam Review Specific gravity: 1.010- 1.030 Management of DI - Answer: If Na+ >150 give D5W IV to replace 1/2 volume deficit in 12-24 hours. When Na+ < 150,substitute 1/2 or .9 NS DDAVP 1-4 IV or SQ every 12-24 hours to acute situations Maintenance dose of DDAVP is 10 every 12-24 hours intra nasally Management of SIADH - Answer: If serum Na+ >120 restrict total fluids to 1000ml/24hr and monitor. If serum Na+ 110-120 without neuro symptoms, restrict fluids to 500 ml/24hr If serum Na+ <110 or neuro symptoms present, replace with isotonic or hypertonic saline and lasix. Pheochromocytoma what is it? What does it do? - Answer: Resulting from excessive catecholamine release (epi & norepi) characterized by paroxysmal or sustained hypertension; almost always due to a tumor of the adrenal medulla (tumor in adrenal) Pheochromocytoma S/S - Answer: Hypertension (labile), tremor, tachycardia, weight loss, diaphoresis, hyperglycemia, palpitations; profuse sweating Lab/Diagnostics of Pheochromocytoma - Answer: TSH is normal, Plasma free metanephrines; plasma concentration of normetanephrine >2.5 or metanephrine levels .1.4 92 AGACNP Exam Review NYHA Class 2 - Answer: Slight limitation of physical activity NYHA Class 3 - Answer: Marked limitations of physical activity NYHA Class 4 - Answer: Severe; inability to carry out any physical activity without discomfort. Symptomatic all the time. S/S of Left heart Failure (Acute) - Answer: Dyspnea at rest, Coarse rales over all lung fields, wheezing frothy cough, murmur of mitral regurgitation (systolic murmur loudest at apex) S/S of chronic heart failure (Left) - Answer: JVD, Hepatomeglay, splenomegaly, dependent edema (as a result of increase capillary hydrostatic pressure), paroxysmal nocturnal dyspnea, abdominal fullness, appears chronically ill Lab/Diagnostics of heart failure - Answer: hypoxemia, hypocapnia on ABG, echo will show contractile/relaxation, valve function, ejection fraction PFTs for wheezing during exercise, BMP usually normal unless chronic failure is present, urinalysis ,Chest X-Ray: pulmonary edema, Kerley's B lines, effusions Systolic Heart failure definition - Answer: also known as Congestive heart failure. Left ventricle doesn't have inability to contract or shorten patient will be on an inotrope fro contractility like Digoxin 95 AGACNP Exam Review Diastolic heart failure - Answer: heart is relaxing and has no ability to relax stiffening beta blockers give heart time to fills. CA+ channel blockers like verapmil can decrease rate and stiffness ACE inhibitors are used under control to prevent cardiac remodeling but cautiously to avoid hypotension Non-Pharm management HF - Answer: Sodium Restriction, rest/activity balance, weight reduction. Pharm management HF - Answer: ACE inhibitors (#1) Diuretic: Thiazides, loop, etc Anticoagulation therapy for atrial fibrillation Management of Acute Pulmonary Edema - Answer: O21-2L/min, Morphine 2-4mg IVP repeat 20-30 min PRN, Furosemide 40mg IVP repeat in 10min if no response, if severe, after load and preload reduction with nitroprusside, hydralazine . If Cardiac index remains low, dobutamine 2.5-20mcg/kg/min; if SBP <100 dopamine 5-20mcg/kg/min is preferred. Hypertension definition - Answer: Sustained elevation of systolic BP >140 or diastolic BP >90 at least three times on two different occasions Two Types of HTN - Answer: Primary/Essential: 95% of all cases; onset usually <55 y/o 96 AGACNP Exam Review Secondary: 5% of all cases; secondary to other known causes such as estrogen use, renal disease, pregnancy, endocrine disorders, renal artery stenosis (RAS); most common cause of secondary S/S of HTN - Answer: often none suboccipital pulsating h/a, occurring early in the morning and resolving throughout the day epistaxis, dizziness/lightheadedness S4 related to left ventricular hypertrophy Lab/Diagnostic of HTN - Answer: CX ray,ECG, renovascular disease studies, plasma aldosterone, AM/PM cortisol levels to rule out Cushing's syndrome, UA, CBC, BMP, calcium, phos, uric acid, cholesterol, triglycerides Classifications of HTN - Answer: JNC 8 patients under 60- 140/90, 60 and over 150/90, ckd, dm- 140/90 Pharm Management of HTN - Answer: Stage I HTN: Thiazide diuretics for most Stage II HTN: Two drug combo; usually a thiazide and ACEI, or ARB, or BB, or CCB Beta Blockers what are they used for - Answer: Effective in pts with migraines and angina; monitor for potential wheezing Ex: metoprolol, propranolol, atenolol, nadolol, acebutolol Decrease workload of heart 97