NR 565||(NR 565 ) Final Exam/ MIDTERM EXAM Questions with accurate answers

What labs are used to diagnose Thyroid?

TSH, total T4 and T3, free T4 and T3

Timeframe for re-check of labs after starting levothyroxine

6-8 wks after starting therapy

Signs and symptoms of hypothyroidism

Face: Pale, puffy, expressionless

Skin: Cold and dry

Hair: Brittle and hair loss

Heart rate and temp are lowered

Complaints by patient: lethargy, fatigue, intolerance to cold

Mentation may be impaired

Thyroid enlargement if ↓'d levels of T3 and T4 promoting excessive release of TSH

Treatment of thyroid storm

High dose potassium iodide or strong iodine solution to suppress thyroid hormone release,

methimazole to suppress thyroid hormone synthesis,

beta blocker to reduce heart rate, sedation cooling glucocorticoids and IV fluids

Result of not treating hypothyroidism during pregnancy

permanent neurological defects, ↓'d IQ, large protruding tongue, potbelly dwarfish stature, impaired development of nervous system bone teeth and muscles.

Medication to treat symptoms of hyperthyroidism (notice this is treating symptoms and not the hyperthyroidism itself)

Metoprolol could be used to treat tachycardia experienced with hyperthyroidism, but it does not treat hyperthyroidism itself.

Drug/Food/Supplement interactions with levothyroxine Absorption REDUCED by:

Histamine 2 receptor blockers (Cimetidine [Tagamet])

Proton pump inhibitors (Lansoprazole)

Sucralfate (Carafate)

Cholestyramine (Questran)

Colestipol (Colestid)

Aluminum containing antacids (maalox, mylanta)

Calcium supplements (tums, os-cal)

Iron supplements

Magnesium salts

Orlistat (Xenical)

* 4 hours between levothyroxine and the above meds is recommended and food reduces absorption as well

How to confirm a diagnosis of DM prior to beginning treatment

Hemoglobin A1C > 6.5%,

Fasting plasma glucose ≧ 126 mg/dL, Random plasma glucose ≧200 mg/dL plus symptoms of diabetes,

Oral glucose tolerance test (OGTT):

2-h plasma glucose ≧200 mg/dL

A1C General goals

less than 7%, less than 8% in patients with severe hypoglycemia, limited life expectancy, or advanced microvascular or macrovascular complications

A1c - Older Adult goal

When should insulin be considered?

Type 1 Diabetics All are on insulin

Type 2 Diabetics

Step 3 - Three drug combination (inclusive of metformin)

Step 4 - Three drug therapy and basal insulin fails to reach goals after 3-6 months - injectable regimen inclusive of insulin and possibly GLP-1 receptor agonist.

EXCEPTIONS: patient with A1C greater than 9% or greater start dual therapy (start at step 2) and patients with A1C greater than 10 % and fasting blood glucose of 300 or more or symptomatic may be started on combination injectable therapy immediately

At what time interval should A1c be re-checked?

every 3 months until A1C drops below 7% and then every 6 months thereafter.

Action of Insulin

Anabolic-promotes conservation of energy and buildup of energy stores (Glycogen)

Stimulates cellular transport (Uptake) of glucose, amino acids, nucleotides & K

Promotes synthesis of complex molecules

Glucose ⇒ Glycogen, Amino Acids ⇒ Proteins, Fatty Acids ⇒ Triglycerides

Promotes cellular growth and division

Energy conservation

Pioglitazone contraindications

Pioglitazone is contraindicated in patients with severe heart failure and should be used with caution in patients with mild heart failure. Should not be used in patients that have active bladder cancer or history of bladder cancer

Be familiar with abbreviations of diabetic drug classifications (GLP-1, TZD, DPP4-I, SGLT2i)

GLP-1: Glucagon-like Peptide -1 Receptor Agonist

TZD: Thiazolidinediones (Glitazones)

DPP-4i: Dipeptidyl Peptidase- 4 Inhibitors (Gliptins)

SGLT2i: Sodium-Glucose Cotransporter 2 Inhibitors

Which drug class should be considered for diabetes prior to insulin?

Biguanides (Metformin)

Ratio of basal insulin to rapid-acting insulin in total daily dose (TDD) of insulin

•Basal insulin replacement encompasses approximately 50% of the total daily insulin dose which replaces insulin from fasting (overnight) and between meals. This dose is usually constant. Bolus insulin replacement encompasses approximately 50% of the total daily insulin dose

Know the carbohydrate-to insulin ratio when calculating basal insulin

500 / TDD : 1 unit

TDD = 0.6 units/kg/day

Mechanism of Action o GLP-1

GLP-1: Augment effects of incretin hormone GLP-1 can ↑ insulin production and inhibits postprandial glucagon release

Which diabetic medication(s) come with a concern of hypoglycemia?

sulfonylureas, glinides, GLP-1, amylin mimetics, glitazones

Methylxanthines o Who is at risk for toxicity and why?

Older patients are at much higher risk for toxicity when taking methylxanthines (Systemic anticholinergics are included in BEERS criteria for potentially inappropriate use for older adult Wk. 6 module.)

Patients with liver dysfunction (increased risk for toxicity)

Untreated seizure disorder or peptic ulcer disease

Asthma & COPD o Step 1 therapy

•SABA → PRN

Complete this sentence: Manage with a ______ as needed.

SABA

Symptoms associated with Intermittent classification of asthma

*Symptoms

*Nighttime Awakening

*SABA USE

*2 d/week or less

*2 times/month or less

*2 d/week or less

Know examples of drug classes (SABA)

oAlbuterol (Proventil), Levalbuterol (Xopenex)

SABA Benefits of use

Activate the beta-adrenergic receptors in smooth muscle of the lung, thereby promoting bronchodilation and relieving bronchospasm. Beta 2 agonist limit role in suppressing histamine release in the lung and increasing ciliary motility

Why is it important to know the frequency a patient is using their SABA?

To be able to assess the severity of asthma symptoms in each patient, and if they need adjunct treatment in more severe cases

LABA Benefits of use Use in COPD by Category

A (few symptoms low risk) Symptom control SABA, 1st Choice LAMA or LABA

B (Increased symptoms, low risk) Symptom control SABA, 1st Choice LAMA or LABA and management of persistent symptoms of further exacerbations combination LAMA/LABA

C (few symptoms, high risk) Symptom control SABA, 1st Choice LAMA and management of persistent symptoms of further exacerbations combination LAMA/LABA or LABA/IGC

D (Increased symptoms, high risk) Symptom control SABA, 1st Choice LAMA or LAMA/LABA or IGC/LABA and management of persistent symptoms of further exacerbations combination LAMA/LABA/IGC, if exacerbations continue, consider adding Roflumilast Azithromycin

Inhaled Corticosteroid (ICS) Benefits of use

reduction and suppression of inflammation of airway

At what point would an oral steroid be prescribed?

Only when symptoms cannot be controlled with safer medications.

May be required for patients with moderate to severe persistent asthma or for management of acute exacerbations of asthma or COPD.

When would roflumilast be indicated for a COPD patient?

*Not 1st Line.

*Used for exacerbation prophylaxis in patients with severe COPD with a primary chronic bronchitis and Hx of frequent exacerbations.

*Not prescribed alone, needs to have a LAMA or SABA with it

*can cause suicidal hallucinations, no black box warning

Nicotine replacement How it works

Allows smokers to substitute a pharmaceutical source of nicotine in replacement of the nicotine found in cigarettes. Levels will rise slowly, but help relieve the sx of withdrawal. Success rates highest when combined with counseling.

Patient education needed for various types • Patch

Apply new patch daily in a clean, dry, non-hairy skin on upper part or arm/body. Patch left in place for 24 hrs. Rotate sites everyday & don't use same site for at least a week.

Start with larger patches & progressively wean down over weeks.

Those <100 lbs, with CAD, or smoke < ½ pack per day, should start with a smaller patch.

Wellbutrin Contraindications

Taken off the market in the US

Bupropion Recommended length of treatment

Daily for 12 weeks, if abstinence is achieved, an additional 12 weeks of treatment is warranted. Treatment should begin 8-35 days before smoking cessation.

What constitutes drug resistant TB

MDR- TB is TB that is resistant to both isoniazid and rifampin

XDR-TB is a sev. Form of MDR-TB & is resistant to not only isoniazid and rifampin, but also ALL fluoroquinolones AND at least one of the injectable second line anti-TB drugs (amikacin or capreomycin)

Treatment of TB in a pregnant person, what all should be included?

oINH & Rifabutin(safest), along with pyridoxine supplements.

Isoniazid (INH) is a drug that can be used to prevent TB in people that have been exposed.

o

Examples of decongestant

Phenylephrine (Neo-synephrine)

Pseudoephedrine (Sudafed)

Naphazoline (Privine)

Oxymetazoline (Afrin, Dristan)

Tetrahydrozoline (Tyzine)

Xylometazoline (Otrivin)

Which cold and cough drug class has no significant drug interactions

Intranasal CROMOLYM.

Expectorants

H2 receptor antagonists o Examples

Cimetidine (Tagamet)

Famotidine (Pepcid)

Nizatidine (Axid)

Ranitidine (Zantac)

Which H2 receptor is most likely to interact due to CYP450 enzyme system?

Cimetidine (Tagamet)

Proton Pump Inhibitors o Associated vitamin and/or mineral deficiencies

Decreased absorption of calcium, magnesium, and vitamin B12 have also been associated with long-term PPI use;

PPI Short term use increases risk of what?

Fractures, pneumonia, acid rebound, and, possibly, intestinal infection with C-Diff

How to treat moderate to severe GERD

oPPI Therapy

What medication for GERD to avoid in older adults and why?

Ranitidine (Zantac) and Cimetidine (tagamet) = causes mental status changes.

Older adults are often taking several prescription and over-the-counter drugs that increase number of drug interactions

o PPIs are associated with increased risk for fractures from osteoporosis and cause medication interactions and vitamin or mineral deficiencies

*Treating GERD during pregnancy

*Which cytoprotective agents would be used

*Esomeprazole, and Ranitidine are safe

*Sucralfate (Carafate)

When to test for h. Pylori

o

How to treat h. Pylori

Treatment is not recommended for asymptomatic individuals who test positive for H. pylori.

Otherwise treat with clarithromycin, amoxicillin, bismuth, metronidazole, and tetracycline. Drug resistance may occur, so the recommendations is to use at least two antibiotics preferably three, and an antisecretory agent or H2RA.

PUD o Lifestyle modifications to support ulcer healing

change in eating pattern

consumption of five or six small meals a day, rather than 3 large ones, can reduce fluctuations in intragastric pH and may facilitate recovery.

Avoid smoking, aspirin and NSAIDS should be avoided. Stop ETOH if causal relationship of symptoms exist

Anti-diarrheal o Which one contradicted in children during or after chickenpox

Bismuth subsalicylate (Pepto Bismol) increase risk of Reye's syndrome

Patient teaching for ciprofloxacin for traveler's diarrhea

generally caused by Escherichia coli; treatment is usually unnecessary because the disease runs its course in a few days. If symptoms are severe or prolonged, an antibiotic, such as ciprofloxacin, may be helpful only in nonpregnant women

. This agent should be taken only if needed as antidiarrheal medications may slow the export of the organism and prolong the course of the disease. Prophylactic treatment with antibiotics is not recommended. Ciprofloxacin is taken twice daily, avoiding meals.

Which Anti-diarrheal is associated with gray/black stools and black tongue

Bismuth

Constipation o Lifestyle modifications to suggest prior to treatment

•Increasing fiber and fluid in diet

*Mild exercise, especially after meals

Risks of laxatives during pregnancy

oGI stimulation might induce labor

Preferred Constipation treatment during breastfeeding

oSenna is safe for use during breastfeeding.

Psyllium How it works and what to assess for if it doesn't produce a bowel movement

oAbsorb water in the small intestine and colon, thereby softening and enlarging the fecal mass; fecal swelling promotes peristalsis.

If bowel movement does not occur assess for intestinal obstruction or impaction.

Irritable Bowel Syndrome (IBS) o A diary can be helpful to aid in diagnosis and treatment

•

Vomiting o How to treat gastroparesis

•Metoclopramide (Reglan) = increases upper GI motility

Black box warning associated with gastroparesis treatment

long-term high-dose therapy can cause irreversible tardive dyskinesia, characterized by repetitive, involuntary movements of the arms, legs, and facial muscles.

Contraindicated in patients with GI obstruction, perforation, or hemorrhage.

Metronidazole (Flagyl)

o Patient teaching needed

Side effects - Nausea and vomiting

Alcohol must be avoided

Should not be taken during pregnancy

DTaP or Tdap

Who should receive the Tdap vaccine?

Tdap vaccine is given to adolescents >10 years old and adults.

Vaccine Contraindications. Varicella

Pregnant patients, individuals with certain cancers (leukemia, lymphomas), and individuals with hypersensitivity to neomycin or gelatin, both of which are in the vaccine. The vaccine should be avoided by immunocompromised individuals including HIV infection or congenital immunodeficiency, and those taking immunosuppressant

True contraindication for DTaP or Tdap vaccine.

if a prior vaccination with DTap produced an immediate anaphylactic reaction or encephalopathy within 7 days of vaccination

Vaccine Contraindications - Hepatitis B virus (HBV) vaccine

prior anaphylactic reaction to Hep B itself or baker's yeast.

Examples of vaccine types - Attenuated

Influenza (Live Attenuated)

Examples of vaccine types - Live virus

MMR

MMRV

Varicella

Rotavirus

Influenza

Examples of vaccine types - Toxoid

DTaP

Diphtheria and tetanus and acellular pertussis adsorbed, hepatitis B (recombinant), and inactivated poliovirus vaccine

Examples of vaccine types - Inactive viral antigen

Hep A

Hep B

Influenza (inactivated)

Poliovirus

o Herd Immunity

What are they and how is each one achieved?

The resistance to an infectious organism because a large group of people is immune to the infectious organism through immunization/vaccine. Herd or Community immunity is contingent on the likelihood individuals are prone to the infection will encounter the infected person. For example, most of the people in the community are immune to an infectious disease, which means everyone does not need immunity to prevent the spread of the infection.

Definition of vaccine

a preparation containing whole or fractionated microorganisms. Administration causes the recipient's immune system to manufacture antibodies directed against the microbe.

Post exposure prophylaxis for suspected rabies bite

dose of human rabies immune globulin (HRIG) and rabies vaccine given on the day of the rabies exposure, and then a dose of vaccine given again on days 3, 7, and 14.

For people who have never been vaccinated against rabies previously, post exposure prophylaxis (PEP) should always include administration of both HRIG and rabies vaccine. The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment

Patient teaching and assessments for post vaccine side effects

Many children experience local reactions (discomfort, swelling, and erythema at the injection site.) Fever is also common. Very rare but severe effects include anaphylaxis; acute encephalopathy, and vaccine-associated paralytic poliomyelitis

Who can receive attenuated influenza vaccine (FluMist)?

approved after age 2 years

Signs and symptoms of hyperthyroidism

Heartbeat is rapid and strong - dysrhythmias and angina possible

Nervousness, insomnia, rapid thought flow, and speech

Skeletal muscles may weaken and atrophy

Metabolic rate is raised - increased heat production increased body temp

Intolerance to heat, skin warm and moist

Appetite ↑'d but patient experiences weight loss

All the symptoms are called thyrotoxicosis

If the patient has Graves Disease - exophthalmos

Drug/Food/Supplement interactions with levothyroxine Metabolism ACCELERATED by:

Phenytoin (Dilantin)

Carbamazepine (Tegratol, Caratrol)

Rifampin (Rifadin)

Sertraline (Zoloft)

Phenobarbital

Patients taking these medications will need to have dose of levothyroxine increased

Warfarin and Levothyroxine Interaction

Levothyroxine accelerates degradation of vitamin k dependant clotting factors

May need to reduce the dose of warfarin

Catecholamines and Levothyroxine Interaction

↑'d cardiac responsiveness - at an increased risk of catecholamine - induced dysrhythmias

Digoxin and insulin

May need to have ↑'d dosages of these if patient is taking levothyroxine

Mechanism of Action o TZD

Decrease insulin resistance

Mechanism of Action o DPP-4

inhibit DPP-4 activity and ↑ active incretin concentration which results in ↑'d insulin secretion and ↓'d glucagon

Mechanism of Action o SGLT2

Blocks glucose reabsorption by the kidneys and the proximal nephron and increases the release of glucose in the urine. SGLT2i" Limits reabsorption of glucose in the renal tubules

Mechanism of Action o Sulfonylureas

Act primarily by stimulating the release of insulin from pancreatic islets. They promote insulin release by binding with and thereby blocking adenosine triphosphate (ATP)-sensitive potassium channels in the cell membrane. As a result, the membrane depolarizes, thereby permitting influx of calcium, which in turn causes insulin release. The extent of release is glucose dependent and diminishes when plasma glucose declines.

Symptoms associated with Mild-Persistent classification of asthma

*Symptoms

*Nighttime Awakening

*SABA USE

*More than 2 d/wk but

Symptoms associated with Moderate-Persistent classification of asthma

*Symptoms

*Nighttime Awakening

*SABA USE

*Daily

*More than once/week but

Symptoms associated with Severe-Persistent classification of asthma

*Symptoms

*Nighttime Awakening

*SABA USE

*Several times daily

*Often nightly

*Several times a day

Know examples of drug classes (LABA)

Formoterol (Foradil), Salmeterol (Serevent)

Know examples of drug classes (ICS)

Beclomethasone dipropionate (QVAR), Budesonide (Pulmicort Flexhaler)

SABA Patient instructions

SABA is for acute asthma attacks -NOT LONG TERM use.

Proper use of inhaler and spacer.

Advise pt's w/asthma to assess peak expiratory flow daily, and record data, along with symptom frequency and symptom intensity, nighttime awakenings, effect on normal activity, and SABA use.

Patient education needed for various types • Gum •

*chew the gum slowly and intermittently for approximately 30 minutes. (Rapid chewing can release too much nicotine at one time), resulting in effects similar to those of excessive smoking (e.g., nausea, throat irritation, hiccups).

*Do not eat or drink while chewing or for 15 minutes before chewing (Decrease absorption).

*D/C after 3 mos. nicotine use.

*Withdrawal should be done gradually.

* not recommended > 6 mom.

Patient education needed for various types • Nasal spray

Not for L/T use Nicotine nasal spray (Nicotrol NS) nicotine levels rise rapidly, the spray provides some of the subjective pleasure associated with cigarettes.

*Avoid with sinus problems, allergies, asthma

o Active Immunity

What are they and how is each one achieved?

When the immune system produces antibodies in response to an antigen by the vaccine, or by the infection itself. For example, if a person who has never had hepatitis B contracts hepatitis B and recovers from it, that person becomes immune to hepatitis B because of the immune system's antibody response to the hepatitis B virus

o Passive Immunity

What are they and how is each one achieved?

The immunity that occurs naturally. This type of immunity is passed on when an antibody is produced in another host. For example, immunity is passed on from a mother to her infant or by artificial administration of antibody-containing formulations.