NRNP 6566 FINAL EXAM PREP ADVANCED CARE OF ADULTS IN ACUTE SETTINGS ANSWERED 20232024, Exams of Nursing

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NRNP 6566 FINAL EXAM

PREP

ADVANCED CARE OF

ADULTS IN ACUTE

SETTINGS

ANSWERED

2023/

1. What are the main components of the comprehensive geriatric assessment (CGA) and why is it important for older adults? (5 marks)

• The CGA is a multidimensional, interdisciplinary diagnostic process that evaluates the medical, functional, psychological, and social aspects of older adults. It is important because it can identify the strengths and limitations of older adults, guide individualized care plans, prevent or delay functional decline, improve quality of life, and reduce hospitalization and institutionalization. (5 marks)

2. What are some common causes and risk factors of delirium in older adults? How can nurses prevent and manage delirium in this population? (10 marks)

• Some common causes of delirium in older adults are infections, medications, dehydration, electrolyte imbalances, surgery, pain, sensory impairment, sleep deprivation, and environmental changes. Some risk factors are dementia, cognitive impairment, frailty, comorbidity, polypharmacy, and malnutrition. Nurses can prevent and manage delirium by identifying and treating the underlying cause, avoiding or minimizing the use of anticholinergic and sedative medications, ensuring adequate hydration and nutrition, maintaining normal sleep-wake cycles, providing orientation and reassurance, optimizing sensory input, and creating a safe and familiar environment. (10 marks)

3. What are the differences between pressure ulcers and diabetic foot ulcers in terms of etiology, pathophysiology, classification, and treatment? (15 marks)

• Pressure ulcers are caused by prolonged pressure or shear forces on the skin and underlying tissues, especially over bony prominences. Diabetic foot ulcers are caused by neuropathy, ischemia, or infection in the feet of patients with diabetes mellitus. Pressure ulcers are classified according to the depth of tissue damage, from stage I (non- blanchable erythema) to stage IV (full-thickness tissue loss with exposed bone or muscle). Diabetic foot ulcers are classified according to the presence or absence of infection and ischemia, from grade 0 (pre-ulcerative lesion) to grade 5 (gangrene of the whole foot). Treatment of pressure ulcers involves relieving pressure and shear forces, debridement of necrotic tissue, wound dressing, infection control, nutrition support, and pain management. Treatment of diabetic foot ulcers involves glycemic control, debridement of necrotic tissue, wound dressing, infection control, revascularization if indicated, off-loading pressure from the ulcer site, and education on foot care. (15 marks)

4. What are the indications and contraindications of mechanical ventilation in critically ill patients? What are the modes and settings of mechanical ventilation and how do they affect the patient's respiratory physiology? (15 marks)

• Mechanical ventilation is indicated for patients who have respiratory failure (hypoxemic or hypercapnic), respiratory distress (increased work of breathing or dyspnea), or impaired consciousness (coma or sedation). Mechanical ventilation is contraindicated for patients who have irreversible brain damage or terminal illness with no chance of recovery. The modes and settings of mechanical ventilation include volume-controlled ventilation (VCV), pressure-controlled ventilation (PCV), pressure support ventilation (PSV), continuous positive airway pressure (CPAP), positive end-expiratory pressure (PEEP), tidal volume (VT), respiratory rate (RR), inspiratory time (IT), inspiratory to expiratory ratio (I:E), fraction of inspired oxygen (FiO2), peak inspiratory pressure (PIP), plateau pressure (Pplat), mean airway pressure (MAP), trigger sensitivity

1. Describe the cytochrome P450 system. Describe how inducers and inhibitors affect the cytochrome system and how that affects the half-life of medications. Cytochromes P450 (CYPs) are a superfamily of enzymes containing heme as a cofactor that function as monooxygenases. In mammals, these proteins oxidize steroids, fatty acids, and xenobiotics, and are important for the clearance of various compounds, as well as for hormone synthesis and breakdown. Cytochrome P450 enzymes can be inhibited or induced by drugs, resulting in clinically significant drug-drug interactions that can cause unanticipated adverse reactions or therapeutic failures. Fluoxetine, sertraline, and fluvoxamine are believed to inhibit cytochrome P450 2C because of observed interactions with phenytoin, diazepam, and other drugs metabolized by these enzymes. Rifampicin and isoniazid are key drugs used in the treatment of tuberculosis, while rifampicin is highly effective in inducing hepatic, drug metabolic P450 enzyme. The mnemonic SICKFACES.COM can be used to easily remember common cytochrome P450 inhibitors.
2. Sodium valproate.
3. Isoniazid.
4. Cimetidine.
5. Ketoconazole.
6. Fluconazole.
7. Alcohol & Grapefruit juice.
8. Chloramphenicol.
9. Erythromycin.
10. Describe the affect 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 to plasma proteins affects 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 bloodstream, more bound drug is released from binding sites. Some drugs have a high affinity for binding to serum proteins and may be 95% to 98% protein bound. With highly protein bound drugs, low albumin levels (as in protein-calorie malnutrition, or chronic illness) may lead to toxicity because there are fewer than the normal sites for the drug to bind. The amount of free drug is significantly increased in that case. Competition for binding sites is one important way that drugs might interact. If a patient is using two highly protein bound drugs at the same time, there will be competition for binding sites on the albumin. The drug with the greatest affinity for the albumin

will bind, and is thought to disrupt the normal ratio of free to bound drug for the second medication. As a result, the second medication will be more available to distribute to the site of action and potentially cause side effects.

3. Describe ways to lessen the hepatic first pass effect Some drugs, such as propranolol or enalapril, undergo significant metabolism during a single passage through the liver. This is called the first-pass effect. When drugs are highly susceptible to the first-pass effect, the oral dose needed to cause a response will be significantly higher than the intravenous dose used to cause the same response. Alternative routes of administration, such as suppository, intravenous, intramuscular, inhalational aerosol, transdermal, or sublingual, avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation.
4. Be able to calculate creatinine clearance using the Cockgraft Gault equation The Cockcroft-Gault formula for estimating creatinine clearance (CrCl) should be used routinely as a simple means to provide a reliable approximation of residual renal function in all patients with CKD. The formulas are as follows:

• CrCl (male) = ([140-age] × weight in kg)/(serum creatinine × 72)
• CrCl (female) = CrCl (male) × 0.

5. Describe what determines the frequency of drug administration Plasma concentration data collected from this type of study is plotted against time and analyzed in order to understand the behavior of a specific drug in the body. This type of pharmacokinetic data, collected from average adults, is the basis for determining dose, dosing intervals, and limitations on the safe use of a drug. Absorption, distribution, metabolism, and elimination or ADME.
6. Be familiar with the Beers criteria and how to use it The 2019 update uses the five criteria outlined in 2015; these include medications that should typically be avoided in most older patients, medications that should be avoided in older patients with certain conditions, medications that should be used with caution because of benefits that may offset risks, medication interactions, and changes in dosing based on kidney function. In addition to these criteria, decisions about medications should take into account a variety of factors, including stopping medications when they are no longer beneficial.
7. Describe factors that affect absorption, distribution, metabolism and excretion The rate and extent of absorption depends on the route of administration, the formulation and chemical properties of the drug, and physiologic factors that can impact the site of absorption. The acid environment or presence of food in the stomach, the solubility and other chemical properties of the drug, and the effect of the initial exposure to metabolic processes in the liver may all reduce the amount of drug that reaches the systemic circulation after oral administration, thereby reducing the bioavailability of the drug. Patient variables that can affect distribution

include body composition, cardiac decompensation (heart failure), age of the patient, and albumin levels. Factors affecting metabolism include genetics, age, and drug/drug reactions.

8. Define narrow therapeutic index How would you monitor a patient with a narrow therapeutic index? Narrow therapeutic index (NTI) drugs are defined as those drugs where small differences in dose or blood concentration may lead to dose and blood concentration dependent, serious therapeutic failures or adverse drug reactions. We defined the following drugs to be NTI- drugs: aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline and warfarin. Frequent lab monitoring would be needed to maintain the narrow index.
9. Describe how aging affect absorption, distribution, metabolism, and excretion With age, body fat generally increases and total body water decreases. Increased fat increases the volume of distribution for highly lipophilic drugs and may increase their elimination half-lives. Aging results in a number of significant changes in the human liver including reductions in liver blood flow, size, drug-metabolizing enzyme content, and pseudocapillarization. Drug metabolism is also influenced by comorbid disease, frailty, concomitant medicines, and genetics. Organ function gradually declines with age and the elderly may poorly tolerate drugs that require metabolism. Usually, age does not greatly affect clearance of drugs that are metabolized by conjugation and glucuronidation (phase II reactions). First-pass metabolism (metabolism, typically hepatic, that occurs before a drug reaches systemic circulation) is also affected by aging, decreasing by about 1%/yr after age 40.

Week 2 and 3

1. Identify and describe 12 lead EKGs that demonstrate: a. 1 st, 2 nd, and 3 rd^ degree AV blocks b. STEMI in any lead (know what area of the heart is affected based on lead location) c. Atrial fibrillation and flutter d. Ventricular fibrillation and tachycardia e. Asystole EKG strips page 351.
2. Identify and describe the medications to treat each one of the EKGS listed in # 1 st^ degree – Rarely needs treatment, Pacemaker if symptomatic. 2 nd^ degree – Rarely needs treatment, Evaluate meds, electrolytes, and thyroid function. Echo to R/O heart disease. 3 rd^ degree – IV atropine can be given for S/S of poor perfusion, immediate EP consult for pacemaker placement STEMI – MONA Afib/flutter – AV node blockers, beta blockers, antiarrhythmics. Cardioversion. Rate vs Rhythm V-fib – D-fib first followed by 1 mg Epinephrine, Amiodarone 300 mg, Mg 2 g. V-tach – Amiodarone, Mexiletine, Sotalol
3. Distinguish between dihydropyridine and non-dihydropyridine calcium channel blocker. Know what conditions each class would be used to treat. Dihydropyridines are more selective to smooth muscle. Because they reduce systemic vascular resistance and arterial pressure, dihydropyridines are used to treat hypertension. Two examples of medications in this class are amlodipine and nifedipine. Non-dihydropyridines are more selective to the myocardium. Verapamil has a very important role in treating angina (by reducing myocardial oxygen demand and reversing coronary vasospasm) and arrhythmias.

Diltiazem is intermediate between verapamil and dihydropyridines because it is selective for vascular calcium channels. By having both cardiac depressant and vasodilator actions, diltiazem is able to reduce arterial pressure with a lower degree of reflex cardiac stimulation caused by dihydropyridines. Dihydropyridine causes peripheral vasodilation, while non-dihydropyridine calcium channel blockers directly relax the heart. Non-dihydropyridine calcium channel blockers should not be used on patients with heart failure or patients taking beta-blockers, diltiazem, or verapamil. Dihydropyridine can be used for patients with heart failure and patients on beta-blockers but can be associated with pedal edema. Dihydropyridine and non-dihydropyridine calcium channel blockers are used for hypertension, hypertensive crisis, angina, sinus tachycardia, PACs, atrial tachycardia, AVNRT, and AVRT.

4. Describe the medications to treat atrial fibrillation (rate, rhythm, and embolus prevention). Know the side effects, needed monitoring, and interaction for each of these medications for rate control. Beta blockers such as metoprolol, Inderal, or esmolol or Non-dihydropyridine calcium channel blockers, such as diltiazem or verapamil for rate control. Antiarrhythmics such as amiodarone for rhythm control. Anticoagulants such as ASA, coumadin, NOACs, or DOACs for embolus. A-fib treatment - Page 333. Monitor renal function & chest x-ray for pulmonary fibrosis.
5. Calculate a CHADS2 score and describe treatment based on the score
6. Calculate a HASBLED score and describe treatment based on the score

7. Describe the symptoms of hyperthyroidism, lab values that are altered, and medications to treat the disease and symptoms. Symptoms include: Hypermetabolism, heat intolerance, fatigue, anxiety, nervousness, manic behavior, confusion/restlessness, emotional lability, fine tremors, diaphoresis, hyperreflexia of DTRs, resting tachycardia. Exertional dyspnea, low-grade fever, weight loss, frequent bowel movements, fine/thin hair, smooth velvet skin, exophthalmos, eyelid lag, infrequent blinking, or irregular menstruation. Labs: TSH is low, while T3 and T4 are elevated. Elevated ESR and ANA. Hypercalcemia and anemia cause decreased granulocytes. High iodine uptake. Meds: Propranolol or metoprolol if resting HR >90. Tapazole 30 - 60 mg daily divided in 3 doses. 5 - 15 mg daily for maintenance. Propylthiouracil 300-600 mg daily in 4 doses, 100-150 mg daily for maintenance. Radioactive iodine or thyroid removal.
8. Identify when cardioversion is indicated and relevant testing that should occur prior to it. Afib or A-flutter, WPW, VT, V-fib without a pulse, and SVT and all rhythms that can indicate cardioversion. A TEE or anticoagulation for at least 3 weeks.
9. Describe ACLS guidelines

Week 4

1. Know the diagnostic criteria for hypertension, hypertensive urgency, and hypertensive emergency. Describe goals of treatment (goal BP) Normal BP - 120/<80; Pre-HTN – 120 - 129/<80; HTN Stage 1 – 130 - 139/80-89; HTN Stg 2

140/>90. HTN urgency – Severe BP elevation without impending change in organ damage or dysfunction. Often caused from non-compliance. Treatment includes oral meds: Captopril, Clonidine, & Labetalol. HTN Emergency – Severe elevation >180/120 with new or worsening organ damage. Should be lowered to SBP of 160-180. IV meds nicardipine, clevidipine, nitro, hydralazine, esmolol, labetalol. Asymptomatic markedly elevated blood pressure (formally known as hypertensive urgency) is defined as an elevated BP with systolic reading above 180 and diastolic above 120 WITHOUT end organ damage. Patients with hypertensive emergency require immediate intervention with IV medication. Labetalol can be used at a bolus of 10-20 mg or can be infused at 1 mg/min until the desired BP is obtained. Initial BP goal is 25% reduction in mean arterial pressure. Once the target BP is obtained, oral therapy can be initiated, and parental agent weaned off. Patients with asymptomatic markedly elevated blood pressure can be treated with oral medication and close follow that reduces the blood pressure in hours to days. Potential BP lowering agents include captopril, labetalol, amlodipine, felodipine, and prazosin.

2. Identify medications to treat hypertension based on ethnicity and co-existing conditions. Be very familiar with JNC guidelines. Be familiar with dosing and side effects of each medication class (ACE-I, ARB, Beta blockers, diuretics) JNC 8 defines hypertensive emergency as a markedly elevated BP with systolic reading above 180 and diastolic above 120 AND end organ damage. Current JNC guidelines indicate that systolic blood pressure above 140 and / or diastolic blood pressure over 90 is indicated of hypertension. The JNC 8 guideline indicates that first line treatment would be a thiazide diuretic, ACE-I, ARB or combination of diuretic and ACE-I or ARB. ACE-I and ARB are virtually never prescribed at the same time. The JNC 8 guideline indicates that first line treatment for an African

• American patients would be a thiazide diuretic, calcium channel blocker, or combination of the two medications. One additional consideration is that all patients (without regard to race) with hypertension and chronic kidney disease should be treatment with an ACE-I due to the renal protective effectives of this group of medications. BP goal for individuals 65 years and younger is less than 140/90. For individuals 65 and over, than 150/90 is acceptable. Meds start on p 183.

3. Describe medication, side effects, and drugs for IV treatment of hypertensive emergencies. Patients with hypertensive emergency require immediate intervention with IV medication. Labetalol can be used at a bolus of 10-20 mg or can be infused at 1 mg/min until the desired BP is obtained. Initial BP goal is 25% reduction in mean arterial pressure. Once the target BP is

obtained, oral therapy can be initiated, and parental agent weaned off. IV meds nicardipine, clevidipine, nitro, hydralazine, esmolol, labetalol. IV meds on p 187.

4. Describe end organ damage related to hypertension. Identify what diagnostics are indicated and medications to treat hypertension (all stages listed in #1). Examples of end organ damage would include encephalopathy, CVA, subarachnoid / intracranial hemorrhage, myocardial ischemia / infarction, acute pulmonary edema, aortic dissection, acute renal failure, retinopathy, eclampsia, hemolytic anemia. CMP - evaluate electrolytes and kidney function. Especially important when considering what medication to order and ensuring there is not a renal cause of the hypertension. CBC - evaluate for Hemoglobin and Hematocrit. Looking to establish a baseline and assess for anemias. Other testing that could be considered - lipid profile - high risk due to his smoking, obesity, and hypertension, ECHO - assess heart structure and function in light of his displaced PMI.
5. Identify the 4 types of shock and be able to distinguish between all four. Know the classic presentation (symptoms), medications to treat, and hemodynamic readings that would lead to diagnosis of each. Treatment includes treating the cause. Antibiotics, IV fluids, Pressors, Electrolytes

6. Know the Surviving Sepsis guidelines for diagnosis, monitoring, and medications to treat.
7. Be able to distinguish the 4 stages of sepsis. Differentiate the stages by symptoms. There are 4 stages of sepsis. Systemic Inflammatory Response Syndrome (SIRS) Sepsis Severe Sepsis Septic Shock Criteria – any 2 of the following: Meet SIRS criteria and have a possible or Sepsis criteria plus evidence of organ Severe sepsis criteria plus any one of the

*Temperature over 100.9 or less than

*Heart rate over 90 *Respirations over 20 per minute *WBC over 12,000 or less than 4, documented source of infection *positive cultures or possible infection site system dysfunction *new need for invasive or non-invasive respiratory intervention *BP less than 90 systolic, MAP less than 65, or Systolic BP 40 mmHg less than previous documented BP *New altered mental status *Cr greater than 2 or urine output less than 0.5cc/kg/hour for 2 hours *Plateletssless than 100, *Lactate greater than 2 mm/L following: *Tissue hypoperfusion persists despite crystalloid fluid administered. *need for vasopressors documented by BP less than 90 systolic, MAP less than 65, or Systolic BP 40 mmHg less than previous documented BP

• Lactate greater than 4 mm/L

8. Interpret a WBC differential. Distinguish between a bacterial and viral infections based on the differential. There are five different type of white blood cells (also called leukocytes) in the blood. They are neutrophils (40-60%), lymphocytes (20-40%), monocytes (2-8%), eosinophils (1-4%), and basophils (0.5-1%). Bands are basically young neutrophils and account for 0-13%. The WBC differential reports the percentage of each type of cell in the blood. Neutrophils fight infection and typically increase in bacterial infection. Lymphocytes usually increase in cases of viral infections. An increase in one type of cell means another type of cell as to decrease. For instance, in a bacterial infection you may have 80% neutrophils and 10% lymphocytes. You may also see a significant increase in bands as the bone marrow starts releasing immature cells to help fight infection. In a viral infection, you may have 30% neutrophils and 60% lymphocytes.
9. Explain the mechanism of action and common side effects of dobutamine, norepinephrine, labetalol, and amiodarone. Dobutamine – Increase cardiac output, therefore increase BP. Side effects: hypokalemia, myocardial ischemia, hypotension/vasodilation, immune system disorders, hypersensitivity Norepinephrine – Vasoconstrictor. Side effects: arrythmias, tissue/myocardial ischemia, renal failure, tachycardia, headache, anxiety, HTN

Labetalol - Alpha & beta blocker. Relaxes heart, reducing HR & BP. Reduces afterload and systemic vascular resistance. Side Effects: Dizziness, itchy, weakness, difficulty peeing Amiodarone - Prolongs conduction through the AV node for rate control. Side Effects: Cough, dizziness, numbness, tingling, sensitivity to sunlight, trouble walking, bradycardia, thyroid issues, pulmonary fibrosis.

10. Distinguish the actions and effects between dopamine and dobutamine. Dobutamine reduces SVR and PVR. Dopamine increases SVR and PVR. Both improve cardiac contractility. Dopamine is recommended for patients with kidney disease due to its ability to increase renal blood flow. Dopamine can increase blood pressure through low infusion rates. Unlike dopamine, dobutamine does not have any effect on the α2‐adrenergic receptors. Dobutamine is preferred when there is a need to improve low cardiac output. Dobutamine should be avoided in patients affected by outflow obstructions, pulmonic stenosis, or hypertrophic obstructive cardiomyopathy.

Week 5

1. Be very familiar with the CHEST guidelines on anticoagulation management CHEST recommendations via the 2 week 5 CHEST articles. Discusses DVT/PE/VTE treatments and recommendations. Duration of at least 3 months.
2. Identify medications and dosages to treat an acute pulmonary embolism. Include the medications, dosages, and transition from injectable to oral medications PE treatments on page 448. CHEST articles. Transition to oral page 899
3. Describe medications used to prevent PE in surgical, orthopedic, and trauma patients. Know dosages and length of treatment suggested. PE treatments on page 448. CHEST articles
4. Describe how to manage warfarin (initiation, monitoring, and dose adjustments) PE Warfarin page 450; DVT Warfarin page 267
5. Identify what patients would not be eligible for oral anticoagulants GI bleed or PUD, Addison’s Disease, ITP, DIC, Intraocular hemorrhage, hemorrhagic shock, spinal anesthesia or lumbar puncture, fall risk, and end-stage liver disease. HAS-BLED criteria: Hypertension, Abnormal renal or liver function, Stroke, Bleeding tendency, Labile INR, Elderly, Drugs/alcohol
6. Describe how to bridge a patient taking warfarin that is undergoing a procedure. Warfarin should be stopped 5 days before a scheduled procedure

7. Distinguish between HIT, TTP, ITP, and DIC. Describe diagnostics and treatment for all three ITP page 894, HIT page 897, DIC page 900 / ITP – Platelet count, Exclusion testing such as bone marrow biopsy, antinuclear antibody, peripheral blood smear, HIV test, HIC test, PT, aPTT, Helicobacter pylori testing, thyroid function, vitamin B12 and folate levels, and liver function tests. Initial treatment would be prednisone 1-2 mg/kg/day and dexamethasone 40 mg daily for 4 days. IVIG can be given in emergency situations and Rituximab may be given when prednisone and IVIG treatment has failed. When all other treatments fail, a splenectomy may be needed. HIT – Heparin-induced platelet aggregation assay, serotonin release assay, Platelet C SRA, Heparin PF4 enzyme-linked immunosorbent assay, Immunoassay. Treatment – DC heparin, argatroban, fondaparinux, apaxiban, or dabigatran. DIC – Platelet count, D-dimer, fibrinogen, thrombin time, PT, aPTT, factor V & VII. Treatment – correct hypotension, control sepsis, deliver fetus or placenta, PRBC infusion, platelet infusion, Cryoprecipitate, FFP

8. Describe appropriate labs and monitoring guidelines for all anticoagulant medications. Lovenox – Platelet count, liver & renal function / Coumadin – INR, PT / Heparin – aPTT, Xa / Apixiban and rivaroxaban - Xa
9. Identify INR goals for all diagnosis Coumadin for PE INR is 2 - 2.5 / Afib INR of 2.0-3.0 / VTE INR 2.0-3.0 / MI or mechanical heart valve INR 2.5-3.5 x normal
10. Treatment recommendations for patients that had coronary stent placement and is on Plavix (duration of treatment) Plavix 75 mg PO daily for at least 12 months. If necessary, Plavix can be stopped at 3 months with a bare metal stent or 6 months with a drug-releasing stent. Any scheduled surgical procedure should be scheduled at least 6 weeks post bare metal stent or 6 months after drug- releasing stent, if possible.