Final MN 650 Specialized Pharmacology for the AGACNP Questions and Answers

Final MN 650 Specialized Pharmacology for the AGACNP Questions and Answers Antifungals metabolize through the Liver ▪An antibiogram is: overall profile of antimicrobial susceptibility testing results of a specific microorganism to a battery of antimicrobial drugs Cultures and sensitivity tell you Tells you: -Identifies bacteria/fungus present -Sensitivity results based on data Cultures and sensitivity DONT tell you: -Infection vs. colonization vs. contamination -You would not treat colonization or contamination -Which ABX to use. MIC (Minimum inhibitory concentration) min. concentration of an ABX needed to inhibit proliferation & is important for definitive TX. Cultures and sensitivity reports start with: Start w/ beta-lactam if possible, especially in severe infections (best data supporting their use) -Exception: atypical infections ▪You are reviewing a report on a urine culture of a 55 year old female with pyelonephritis. A culture was done which has revealed growth of Ecoli Susceptibility testing show minimum inhibitory concentration (MIC) score of 1 for Ciprofloxacin 2 for Levafloxacin 4 for Ceftriaxone and 16 for Nitrofurantoin. Considering the MIC score the most appropriate antibiotic to prescribe would be ciprofloxacin. Chose lower MIC score Fluroquinolones (ex: ciprofloxacin) are most associated with causing: pseudomembranous colitis. S/S of pseudomembranous colitis recent ABX use followed by diarrhea with possible blood To prevent further development of ABX resistance, it is recommended that fluoroquinolones be reserved for treatment of: CAP with comorbidities. If your patient is allergic to sulfonamides, they most likely will have a cross-sensitivity to: loop diuretics, sulfonylureas, & thiazide diuretics. If you patient cannot reliably take PO ABX, ___ or ___ would be an appropriate treatment option. IM or IV Prebiotics are recommended to be co-administered with: ABX Rx half-life is longer in: older adults (watch for atypical reactions) Monitor liver enzymes when on __ tx. long term antifungal tx Patients taking isoniazid for TB may experience peripheral neuropathy. To prevent, prescribe: pyridoxine (vit B6). Because microbiological results do not become available for 24 to 72 hours, initial therapy for infection is often _____ and guided by the clinical presentation. empiric empiric is broad-spectrum & treats: ____ Once C&S is received, a more narrowed focused ABX can be prescribed. gram-positive and gram-negative, diverse fungi, or parasites How soon should newly diagnosed HIV patients should start antiviral treatment? as soon as the positive diagnosis is given Initiation of ARV can prevent complications of AIDS-related diseases, such as: PCP pneumonia. (pneumocystis jiroveci pneumonia) When a Herpes Simplex 2 Dx is suspected ___ is the Rx of choice. Acyclovir You are evaluating a patient in the ER who is complaining of pain to his right leg that developed yesterday. The pain has become increasingly worse in the last few hours to the point that the patient's wife called EMS to the house to transport him to your ER. His wife tells you he has not been acting right over the last few hours and seems "out of it.". You, the AGACNP suspect an infection and order labs/cx/start abx. While initiating therapy the patient becomes hypotensive and is given a fluid bolus. You preform an in-depth exam on this patient and notice crepitus on the patient's right thigh. You admitted him to your ICU and write orders to initiate broad spectrum antibiotics for this patient. The best antimicrobial combination to begin on this patient is _______ Doribax (for nec fasc) Twenty-year-old Annie comes to the clinic complaining of copious yellow-green eye discharge. Gram stain indicates she most likely has gonococcal conjunctivitis. While awaiting the culture results, the plan of care should be: IM ceftriaxone Although MRSA is uncommon in animal bites, ABX Tx is needing in cat bites due to their oral flora. Initial cat bite treatment would be: A thorough cleansing and debridement, Xray, and amoxicillin-clavulanic acid/7-day regimine. Pharmacokinetics is: The branch of pharmacology concerned with the movement of drugs within the body. UTI in the geriatric population most commonly caused by: E. coli most common cause (80-86%) UTI in the geriatric population complicated by: male gender, immunodeficiency, and comorbidities Tx UTI in the geriatric population with: -Bactrim DS -Macrobid -Cipro if allergic to PCN and sulfonamides For UTI in the geriatric population, rule out: R/O Sepsis, meningitis, stroke, hypoglycemia... UTI may lead to urosepsis. Caution with aminoglycosides (ex: gentamicinin) in ______ patients. acute renal failure (aminoglycosides can cause AKI) BPH incident increases with age: - 60yo 50% - 80yo 88% Some medications mimic symptoms of BPH: UTI, over-hydration, caffeine, diuretics For UTI in older males order: Order urinalysis, PSA, renal studies (could be prostate or renal obstruction) Dehydration can cause: Tachycardia, thirst, hyper-lab values Over-hydration can cause: Crackles, elevated BP, dilute/low lab values loop diuretics are associated with low __ & __ electrolyte levels low Na+/low K+ Diuril (Thiazide diuretic) is a __ & __ blocker. Na+ & Cl- If using diuretics, know ___ level to see how well diuretic may work. BUN You are providing care for a 63-year-old male admitted for hyperkalemia. He has a history of renal insufficiency and was recently placed on an ACE inhibitor for HTN by his PCP. He is lethargic and ECG shows Sinus Bradycardia with a widened QRS of .18. Your initial treatment should be calcium gluconate. Why? Calcium gluconate protects the heart as electrolytes are shifting. What could slow down H2O reabsorption? -Medications (i.e. mannitol) -Disease processes (hyperglycemia) If your patient has N/V and presents to you with hyponatremia, what would you do? Consider bolusing NS and then ordering a continuous infusion. What is psuedohyponatremia? Measured serum Na+ reduced by the actual plasma Na+ is normal. (actual vs serum) AKD is more commonly:. reversible CKD is more commonly long-term and associated with other disease processes such as __ & __. AKD can lead to CKD. DM & HTN How to calculate GFR with the Cockcroft Gault formula: CrCl (male) = ([140-age] × weight in kg)/(serum creatinine × 72) If Ca+ level comes back from the lab as 7.7, what would be your next step? Verify!! Use the calcium correction formula for low albumin to calculate the correct Ca+ level and check the ionized Ca+ level. Patient with dialysis-dependent renal failure would most likely exhibit ___ gap acidosis. normal Rx levels, like Digoxin, need to be monitored closely, especially in older adults with decreased _____. renal function INRs are best drawn in the ____ when the patient takes their dose at HS. morning urinary incontinence is ___ an indication for an indwelling urinary catheter. NOT (consult skin team and provide frequent skin care) Pseudomonas aeruginosa (gram negative) frequent cause of nosocomial infections, can be life threatening UTI preferred treatment: Parenteral aminoglycosides are generally preferred, though quinolones are used; monotherapy is appropriate in most cases UTI alternative tx: alternatives include: - antipseudomonal penicillins and cephalosporins, - carbapenems, and aztreonam; - ciprofloxacin is the preferred oral agent Pseudomonal infections are increasingly resistant to certain antibiotics, and the organism may acquire resistance during therapy. Two agents from different classes should be used when the risk of antibiotic resistance is high. Like in... in severe sepsis, septicemia, and inpatient neutropenia). Pseudomonas infection can be treated with a combination of: - antipseudomonal beta-lactam (eg, penicillin or cephalosporin) and an aminoglycoside. - Carbapenems (eg, imipenem, meropenem) with antipseudomonal quinolones may be used in conjunction with an aminoglycoside. Pseudomonas infection with fever and neutropenia will need __ tx. monotherapy with ceftazidime or a carbapenem (eg, imipenem, meropenem) is used, a 2-drug regimen is recommended. What is the "triad" of the pathogenesis of COPD? - Oxidative stress, - protease-antiprotease imbalance - chronic inflammation Hypokalemia is often found in ___ patients alkalotic COPD made up of ___, ___, & ___ conditions. Empyhesema, bronchitis, & asthma Inhaled bronchodilators in COPD. Combination treatment with ___/___ reduces exacerbations compared to mono-therapy LABA/LAMA ____ have a greater effect on COPD exacerbation reduction compared to LABAs and decrease hospitalizations. LAMAs Criteria for ABX use in COPD exacerbation: Criteria: - Under 65yo - Forced expiratory volume: FEV150% predicted - Under 4 acute exacerbations per yr. - No significant comorbid disease. - 5-day course (PO) ABX use in COPD exacerbation options: First-line: - Bactrim DS one tablet PO BID - Doxycycline 100mo PO TID - Amoxicillin 500mg PO TID COPD exacerbation treatment: pair ABX with corticosteroid Fluoroquinolones (like Levofloxacin) risk for: spontaneous tendon rupture Antibiotics in COPD Exacerbations Protocol: Two parenteral drug combination - Drug 1: Cephalosporin (ex Ceftriaxone) or Antipseudomonal Penicillin (ex Piperacillin-Tazobactam) - Drug 2: Fluoroquinolone (ex Levofloxacin) or Aminoglycoside (Tobramycin) A patient with COPD presents with increased frequency of cough, worsening shortness of breath and increase in amount and purulence of sputum. The patient has not been hospitalized in the past year or had repeated courses of antibiotics. The CXR shows no obvious pneumonia, but clearly he's experiencing a COPD exacerbation. What would be the MOST appropriate management plan? add a short course of oral steroids, a course of a second or third generation cephlasporin antibiotic, increase use of bronchodilators and supplemental O2 as appropriate Steroid & Oxygen therapy. Co-administer Corticosteroids for COPD Initially use intravenous Corticosteroids - Methylprednisolone (Solumedrol) 60 mg IV every 6 hours - Avoid high doses (e.g. 125 mg) as they offer no added benefit Transition to oral Corticosteroids as soon as prudent - Prednisone 30-40 mg orally daily - Taper off over 2 weeks (no benefit to previously used longer taper over 8 weeks) Pneumonia is the ___ leading cause of death in the U.S. 8th Pneumonia can be: CAP, HAP, VAP, & HCAP Rx of choice in CAP? Azithromycin Many PNA tx meds are nephrotoxic, so be sure to hydrated during ABX. (Tx by taking in plenty of PO fluids or starting maintenance IVF) Asthma requires a stepwise approach to determine the pharmacologic management of asthma beginning with: determining the severity of asthma and assessing asthma control. Acute asthma exacerbation tx: - Inhaled bronchodilators - Systemic corticosteroids - Supplemental O2 Asthma inhaler order: Beta-agonist first, then inhaled corticosteroid. ___ adults are more likely to have serious side effects from chemotherapy. Older adults Chronic lymphocytic leukemia s/s: Swollen areas, malaise, low WBC, high lymphocytes. Pain control in cancer patients, use the ___ to determine course of pain treatment. WHO Pain Relief Ladder A 43 yo patient with a recent history of breast cancer received her first chemotherapy infusion 24 hours ago. The patient has been having syncopal episodes, nausea/vomiting and mild edema. The patient is diagnosed with Tumor Lysis Syndrome. The ACNP would order: continuous NS (hypovolemia) and Lasix (improve diuresis and prevent edema). If chronic renal failure is causing anemia, use ___. Epogen Epogen may cause thrombocytopenia Anemia initial treatment 325mg ferrous sulfate TID Pernicious anemia monitor for ___. - Monitor for leukopenia (low WBC) 1-3 weeks into Tx. - Monitor K+ (check med hx- PPI?) Thrombocytopenia (low platelets) can occur if pt on heparin gtt on day __ of treatment. With initiating a heparin gtt, thrombocytopenia can occur on day 4. (Be sure to monitor platelets every 2-3 days) What is pancytopenia? Low RBC, WBC, & Platelets Some ABX have been linked to thrombocytopenia, like ___. Bactrim DS atrial fibrillation rhythm is: Irregular and often rapid rhythm caused by the atria beating out of coordination with the ventricles. - QRS irregular - Mostly asymptomatic - Patient loses 10% of EF Afib tx -Tx w conscious sedation synchronized cardioversion (assess echocardiogram first for clot, chock could dislodge clot) - Diltiazem- great choice CCB for dysrhythmia (metoprolol for breakthrough) - Pt can be symptomatic and/or dangerous. Leading to PE or CVA ___ panels need to be ordered prior to amiodarone tx. Order thyroid panels bc amio can cause hypothyroidism Atrial flutter tx amiodarone (if pt has allergy use metoprolol) Non-selective BBs should NOT be used in patients with ___. Asthma Supraventricular Tachycardia (SVT) definition ▪Rapid heart rhythms originating in the atrium or atrioventricular node ▪Transmit via the bundle of His and result in rapid ventricular response Supraventricular Tachycardia (SVT) causes: Afib, Stimulants, drugs, Alcohol, PE, Electrolyte imbalances, Tension pneumothorax, Foods (i.e. valerian tea) Procainamide Rx S/P AMI- monitor for: dyspnea, JVD, and peripheral edema (may indicate the onset of CHF) If your AMI patient is pregnant & on heparin, you will need to monitor: Xa levels. (Other measurements may be altered by the pregnancy, i.e. coags) Pt on heparin in the hospital and dc home on warfarin, educate about: the transition period and why you are prescribing two "blood thinners." Foods containing Vit K need to be reviewed. Patients on coag meds need to be educated that: no more than 1 serving of spinach should be eaten daily.