AGACNP board prep Questions and Answers

AGACNP board prep Questions and Answers Normal WBC count 4-11 or 4,000-11,000 Neutrophils ROLE Destroy bacteria Lymphocytes ROLE Destroy viruses Monocytes Role Clear cellular debris. They eat dead cells Eosinophils ROLE Combat allergens/parasites Basophils ROLE Undetermined. Have a role in anaphylaxis BANDS on a WBC differential Immature neutrophils. They sneak out before they are fully developed. Increase in Bands means something bad is happening. Usually bacteria Legal Authority: Certification Does not provide legal authority to practice. it just shows that you have a knowledge base Legal authority: State licensure Grants the NP the authority to practice in a state. Defined by the individuals state's nurse practice act Legal authority: prescriptive authority Changes from state to state. Most need a license to prescribe. Most need a collaborative agreement. Legal authority: credentialing Provide practice authority in a particular institution. Enables insurance reimbursement. Defines hospital privileges. Systematic review (meta analysis) #1 Highest form of research. A massive review of published research, in one place. Randomized controlled trial #2 Evaluates the effectiveness of an intervention Cohort study #3 prospective or retrospective study that evaluates variables and outcomes. Case-Control Study #4 a retrospective study which evaluates cases. Compares risk factors Case series #5 Retrospective study examining the experiences of a group Case Report #5 CLinical narrative of a single patient case Editorial #6 An essay that addresses a specific topic from a qualified individual or group of individuals Expert opinion #6 Essay of a topic of concern from a qualified individual Null hypothesis What you are trying to DISPROVE alternative hypothesis What you are trying to prove P value 0.05 Fail to reject the null hypothesis. The null hypothesis is true. You are unable to disprove what you wanted to disprove P value 0.05 reject the null hypothesis. The alternative hypothesis is true. You are able to disprove what you wanted to disprove. This result is statistically significant Quantitative studies Used to establish a correlation by evaluating the null hypothesis and alternative hypothesis. Relies on numerical and measurable data Qualitative studies Rely on personal accounts or details in how people think and respond. You want data saturation with no new ideas emerging. NO STATISTICS What three things need to happen for an issue to be malpractice? 1) there needs to be a duty to the patient 2) Violation in standard of care 3) injury or death resulted due to that violation of care Beneficence Obligation to help people in need Best thing to do for the patient Autonomy Patients right to make decisions veracity being truthful and giving the patient full disclosure non-malfeasance Ethical concept requiring that an action do no harm, or do less harm than good justice patient gets what they deserve Insurance: Claims made policy Cheapest form of insurance. Will cover you when the claim is made if it was also the same policy in effect at the time of the incident. Insurance: Occurrence based policy Basically as long as the policy was active during the event, you are covered Insurance: Tail coverage Extends the life of the claims made policy up until the end of the statue of limitations. Most expensive coverage WBC differential: Left shift Significant increase in neutrophils. Most likely a bacterial infection WBC differential: Right shift Significant increase in lymphocytes. Most likely a viral infection Most common cause of fever in the acute care setting Bacterial infections Most common cause of fever in immunocompromised patients Fungal infection. insidious onset that last much longer. Non-infectious causes of fever Autoimmune Inflammatory Drug reactions Post operative causes of fever: Bacterial Will see: fever (high fever), leukocytosis with neutrophilla (left shift), surgical site drainage Diagnostic workup: Pan cultures TX: ANTBX only with signs of bacterial infection. Remove offending items Post operative causes of fever: Volume contraction Will see: fever (mild), azotemia, decreased skin tugor (except in elderly), decreased PO intake, inadequate IV hydration Diagnostic workup: Metabolic panel, replace EBL, eval I&O. Urine output is the best indicator of tissue perfusion TX: Isotonic IV fluids and increase PO intake Post operative causes of fever: Atelectasis Will see: fever (mild), Atelectasis present on CXR, Lack of incentive spirometer use, cough, SOB, decreased lung sound Diagnostic work up: eval incentive spirometer use diagnostic exclusion may consider CXR TX: encourage use of incentive spirometer, OOB to chair and ambulation, educate on splinting, eval med use STreptococcus pneumoniae Gram-positive. anaerobic Common sites we see streptococcus pneumoniae bacterial menigitis otitis media community acquired pneumonia URI sinusitis What drugs would treat streptococcus pneumonia beta-lactam haemophilus influenza Gram negative anaerobe Common site for haemophilus influenza bacterial mengitis pneumonia URI sinusitis What drugs treat haemophilus influenza Amoxicillin rifampicin co-trimoxazole ciprofloxacin aztreonam cefalosporins pipercillin-tazobactam carbapenems Aminoglycosides Streptomycin, Gentamycin. Gram - coverage Bacteremia, abdominal infections Tetracyclines Tetracycine, Doxycycine Gram -/+ coverage Lyme Disease, PID, STIs Penicillins Ampicillin, Amoxicillin Gram +/- ENT, Skin, Urinary infections Sulfonamides Sulfasalazine, Sufamethoxazole Gram +/- coverage UTI, Burns, eye infections Fluoroqunilones Ciprofloxacin, Levofloxacin Gram -/+ respiratory and urinary infections Macrolides Azythromycin, erythromycin Gram + pneumonia, sinus ENT, STI Carbapenems Meropenem, ertapenem Gram -/+ urinary, abdominal infections Licosamides Cindamycin Gram + Skin, bone, lung infections glycopeptides Vancomycin Gram + MRSA, Skin, endocarditis MRSA Gram + Clindamycin Rifampicin Vancomycin/teicoplanin linezolid daptomycin Co-trimoxazole Gentamicin Staphylococcus epidemidis Gram + Rifampicin Vancomycin/teicoplanin linezolid daptomycin Co-trimoxazole Moxifloxacin MSSA: Will NOT be covered with Gram + WILL NOT BE COVERED WITH: Penicillin Amoxicillin trimethoprim ciprofloxacin azetreonam ceftazidime Streptococcus WILL NOT BE COVERED with Gram + Will NOT be covered with: metronidazole trimethoprim gentramycin tobramycin ciprofloxacin aztreonam ceftazidime GLAM/ "ides" Glycopeptides -- Gram (+) Lincosamides-- Gram (+) AmiNOglycosides -- Gram (-) Macrolides-- Gram (+) everything else is both Gram +/- Neisseria Meningitis Gram negative cocci Bacterial meningitis staphylococcus Gram + Cocci Skin infections UTIs Eye infections Food posioning Escherichia Coli Gram negative bacilli UTIs, Food poisoning Chlamydia trachomatis Gram negative, anaerobic STIs Eye infections atypical pneumonia pseudomomas aeruingosa Gram negative bacilli Triad for temporal arteritis Fever elevated ESR (Normal20-30) headache Normal WBC TX: temporal artery biopsy glucosteroids Uncomplicated UTI Negative for fever, nausea, vomiting, cva tenderness TX: TMP-SMX (Bactrim) 1 tab PO BID for 3 days OR nitrofurantoin (Macrobid) 100 mg PO BID for 5 days Complicated UTI Positive for fever, nausea, vomiting, cva tenderness TX: Ciprofloxacin 500 mg PO BID for 5-7 days Levofloxacin 750 mg PO BID for 5-7 days or ceftriaxone 1 gm IM + gentamycin or tobramycin 5-7 mg/kg X 1 dose IV Inpatient TX: ciprofloxacin 400 mg IV BID or levofloxacin 750 mg IV daily if the patient does not respond to initial therapy for uncomplicated UTI continue therapy for 2 weeks. if patient fails 10-14 day therapy, consider hospitalization Treatment for CAUTI Remove catheter ampicillin + gentamycin or pipercillin-tazobactam CATHETER THINK ZOSYN Cellulitis treatment ( Non MRSA) Streptococcus pyogenes (NON MRSA) Usually dont see drainage outpatient TX: Penicillin V-K 500 mg PO QID or amoxicilin 500 mg TID for 10 days Can use cephalexin 500 mg PO QID for 10 days Inpatient TX: Penicillin G 1-2 MU IV Q 6 Cefazolin (Ancef) 1 gram IV Q 8 Treat until afebrile then Penicillin V-K 500 mg PO QID for 10 days Cellulitis Treatment (MRSA) Outpatient: Bactrim 1-2 tab PO daily for 7-10 days Doxycycline 100 mg PO BID for 7-10 days Inpatient: Vancomycin 1 gm IV BID (trough concentration goal 15-20 mcg/ml) MRSA risk factors Recent hospitalization long term care facility recent antibiotic therapy incarceration injection drug use diabetes HIV HIV diagnostic tests ELISA screening: for R/O disease. Cannot confirm disease. 99% seNsitivity Western Blot to confirm disease. 99% sPecificity Sensitivity means seNsitivity If it is negative, then you can rule out the disease. If it is positive it means than you cannot rule it out, but also doesnt confirm it. Like a D.Dimer Specificity means sPecificity if it is positive, then it confirms a disease What is PrEP and when to start it Preexposure Prophylaxis for HIV Prevention recommended for those at substantial risk for acquiring HIV. tenofovir disoproxil fumarate (TDF) 300 mg + emtricitabine (Truvada) 200mg Daily with F/U in 3 months What is PEP and when to start it Postexposure prophylaxis for HIV tenofovir disoproxil fumarate (TDF) 300 mg + emtricitabine (Truvada) 200mg QID + raltegravir 400 mg BID or dolutegravir 50 mg QD Should be initiaed ASAP, wihtint 72 hrs of exposure and should be administered for 4 weeks. HIV testing should be at time of exposure, 6 weeks, 12 weeks and 6 months after Right atrial pressure Preload the pressure in the right atrium reflected the amount of blood returning to the heart Normal 2-6 mm Hg Central venous pressure (CVP) Preload the amount of blood returning to the heart. often a good appromixation of RA pressure normal 2-6 mm Hg Right ventricular pressure Direct measurement of RV function and general fluid status. Increased RVP indicates PHTN, RV failure, CHF. Pressure can be estimated on echo Normal 15-30 systolic/ 2-6 diastolic Pulmonary artery pressure Reflects pressure in the PA. Increased pressure can indicate Left-Right cardiac shunt, PA HTN, COPD, PE, Pulmonary edema, LV failure Normal 20-30 systolic/ 5-10 diastolic/ 10-20 mean Pulmonary capillary wedge pressure Preload Measures the LV pressure when the mitral valve is open during diastole High wedge can indicate LV failure, Mitral vale issue, Cardiac insufficiency and cardiac compression Normal 8-12 mm Hg Systemic vascular resistance Afterload increased SVR can indicate vasoconstriction, hypovolemia, late septic shock. Decreased SVR can be caused by early septic shock, vasodilators, morphine, nitrates or hypercarbia Normal is 900-1400 Cardiac Output Contractility the volume of blood pumped by the heart in one minute Increased CO indicates high circulating volume Decreased CO indicaes decreased circulating volume, decreased strength in ventricular contraction Normal is 4.8-6.4 Cardiac index CO that uses the BSA Normal 2.5-4.2 Saturation of mixed venous oxygen SvO2 amount of oxygen returning to cardiopulmonary circulation. Reflective of the person ability to balance O2 supply and demand at the tissue level Normal 70-75% Hypovolemic shock Pathophysiology multiple organ failure due to low circulating volume and inadequate tissue perfusion. Often seen in acute hemorrhage, severe dehydration, severe burns Cardiac pressures in hypovolemic shock CVP decrease (no fluid to circulate) PAOP decreased (no fluid to fill) CO/CI decreased (no fluid to put out) SvO2 decreased (because no fluid) SVR increased (constricts to compensate) Treatment of hypovolemic shock identify cause volume replacement transfuse as needed Most common cause is trauma surgery most common cause of negative outcomes in trauma Cardiogenic shock pathophysiology inadequate tissue perfusion secondary to a loss of contractile function. Common causes are acute MI, acute HF, dysrhythmia. The pump is not working Cardiac pressures in cardiogenic shock CO/CI decreased ( not pumping) SvO2 decreased ( due to pump failure CVP increased ( not pumping blood through, its backed up) PAOP increased ( backed up) pumping) SVR increased ( fluid back up) Cardiogenic shock treatment Treat cuase support cardic output with inotropic agents support oxygenation Distributive shock pathophysiology Systemic event causing the loss of normal responses of vascular smooth muscle to vasoconstrict with a direct vasodilating effect. Common causes: Septic shock anaphylactic shock neurogenic shock