Hospital Lab II Final

Computerized provider order entry (CPOE)

A digital system that allows healthcare providers, such as physicians or prescribers, to directly input medical orders for prescriptions, treatments, and tests into an electronic system instead of using paper-based methods

2

How many sources do you need for a best possible medication reconciliation (BPMR)?

Name, dosage, frequency, route

What 4 things about the about the medications do you need to confirm in med rec?

Verification, clarification, reconciliation

What are the 3 steps to medication reconciliation?

History

Medication (history/reconciliation) is the process of gathering information about a patient's medications.

Reconciliation

Medication (history/reconciliation) is the process of comparing a patient's current medication list to new medication orders.

Medication history, appropriateness, document, communicate

Med rec steps:

1. Collect a ____ ____

2. Assess ____

3. ____ and ____

Open-ended, probing, adherence, 2, patient, loose, discrepancies, educate

Med rec high performance behaviors include:

1. Asking ____-____ questions

2. Use ____ questions to elicit additional info and meds

3. Asks about ____

4. Uses at least ____ sources, ideally one provided by ____ and one from objective source

5. Knows when to get/stop getting additional sources

6. Identify ____ medications using drugs.com or others

7. Return to patient to review new info and resolve any ____

8. ____ patient or caregiver on carrying up to date med list

Home infusion

IV medication therapy, monitor therapy, draw labs, dressing changes, TPN services, pain management and hospice care, chemotherapy, and ambulatory infusion center are all types of services provided by what?

Stability, access, support

To be eligible for home infusion, patients need clinical ____, reliable ____, therapy needs to be appropriate, and adequate ____.

5

Peripheral access is in the forearm or arm and is used for ____ days or less.

Shoulder, 5, 4, osmolarity

Midline catheter is in cephalic or basilica vein inferior to the ____ and is used ____ days to ____ weeks (short-term). It requires low ____.

12

PICC is in basilic or cephalic vein in the superior or inferior vena cava. It is used up to ____ weeks.

Long, more

A port is surgically placed and has special needle access to superior vena cava or subclavian vein. It is (short/long)-term use at 12 or (less/more) weeks.

PICC, midline, port

What 3 vascular access are used for home infusion?

Fluid transfer

Repeater pumps are used for ____ ____ and are very efficient. It allows for automation.

On call, troubleshooting, train, TPN

In addition to normal pharmacist duties, home infusion pharmacists also are ____ ____ to answer medication-related questions, ____ devices, ____ caregivers and patients, and help with ____ formulations.

ABX, pain management, chemo, hydration, bisphosphonate, iron replacement, immunotherapy

What are some examples of meds/therapies that are provided via home infusion (7)?

Programmable, battery

Ambulatory infusion pumps are ____ and typically needs ____ charge. They are used for PCA, chemo, TPN, and enteral nutrition.

Elastomeric devices

What is an infusion pump which utilizes the energy in an elastic membrane to provide the force for fluid delivery?

Ambulatory, silent, single, is not

Elastomeric devices have an ____ design with no cords, outlets, batteries, or IV poles required. They are lightweight, discreet, and (silent/loud) operation. They are (single/multi)-use. Programming (is/is not) required.

Same height

Elastomeric device flow rate is most accurate when the balloon reservoir is (lower/higher/same height) as the Leur Lock connector.

Submerge, under pillow, temps

You can bathe with an elastomeric device but do not ____. When sleeping, place where? Can exercise as long as it's not exposed to extreme ____.

Saline, administer, saline, heparin

What is the SASH technique?

Purple, pink

Gram positive stains (pink/purple). Gram negative stains (pink/purple).

Staph aureus, strep pneumo, pseudomonas, E. coli

What are 4 common inpatient pathogens?

ALP, ALT, AST, bilirubin, BUN, SCr, Na, K, CO2, Cl, albumin, total protein, glucose, and Ca

What are the components of CMP (14)?

RBC, WBC, platelets, Hgb, Hct

What are the components of CBC?

WBC and CRP

What are the two lab markers of infection?

2, 2

How many sets of blood cultures do you get? How many sites should you get them from?

Ceftaroline, ceftobiprole, delafloxacin, SMX/TMP, tetracyclines, vancomycin, clindamycin, daptomycin, linezolid

What ABX cover MRSA (9)?

Pip/tazo, 3rd gen cephalosporins and higher (ceftazidime, cefepime, cefiderocol), carbapenem, aztreonam, quinolones, aminoglycosides

What ABX cover Pseudomonas (6)?

Pseudomonas and atypicals

What two organisms are not covered by any penicillins?

Enterococcus and atypicals

What two organisms are not covered by any cephalosporins?

Atypicals

What is the only organism carbapenems do not cover?

mecA, MRSA

What gene encodes PBP2a, which has low affinity for β-lactams causing resistance? What organism is associated with this?

ESBL, penicillins, cephalosporins, aztreonam

What are enzymes that break down extended-spectrum β-lactams? What ABX do ESBLs inactivate?

AmpC

What is an enzyme that hydrolyzes many β-lactams?

Acquired

What type of resistance is gained via mutation or gene transfer?

Intrinsic

What type of resistance is natural, built-in resistance?

Endocarditis

When would an echocardiogram be used in ID diagnostics?

Ribosomal subunits

Out of cell wall, ribosomal subunits, and DNA replication ABX target, which is bacteriostatic most of the time?

Peptidoglycan synthesis

B-lactams and glycopeptides target what?

30S ribosomal subunit

Aminoglycosides and tetracyclines target what?

50S ribosomal subunit

Macrolides, lincosamides, chloraphenicol, and linezolid target what?

DNA replication

Fluoroquinolones and rifampin target what?

4, 9, 4

Enteral nutrition kcal/g:

Carbs = ___ kcal/g

Lipids = ____ kcal/g

Protein = ____ kcal/g

3.4, 10, 4

Parenteral nutrition kcal/g:

Carbs = ___ kcal/g

Lipids = ____ kcal/g

Protein = ____ kcal/g

Gut mucosa, bowel, fluid/electrolyte, harm, expensive

Benefits of EN:

1. Physiologic presentation of nutrients

2. Maintains ____ ____

3. Stimulates ____ function

4. Simplifies ____/____ maintenance

5. More "complete" nutrition than TPN

6. Less risk of ____

7. Less ____

Increased, basic, bypass

Indications of EN:

1. Difficulty meeting ____ nutritional needs

2. Inability to meet ____ nutritional needs

3. Need to ____ part of the GI tract

Intestinal obstruction and peritonitis

What are the two biggest CI to enteral nutrition?

Obstruction, absorb, enteral, hemorrhage, NPO

Indications for PN:

1. Complete bowel ____

2. Inability to ____ adequate nutrients via GI

3. Inability to obtain ____ access

4. Persistent GI ____

5. Trauma, cancer

6. ____ status

Functional, poor

CI to PN:

1. ____ GI tract

2. (Good/poor) prognosis

3. Risks vs. benefit

Short, 900, 12.5%

Peripheral PN is (short/long)-term use and has an osmolarity requirement of

Long, does not, less

Central line PN is (short/long)-term use and (does/does not) have an upper limit on osmolarity. It requires (less/more) fluid and is more common in critical care units.

SWFI

What component of PN can you never infuse directly?

Dextrose, AA, lipids

TPN 2-in-1 is ____ and ____ with fat piggybacked into PN line close to patient. ____ are separate.

Dextrose, AA, lipids

What is in 3-in-1 TPN?

Calcium and phosphorus, cysteine

What must be separated in neonatal TPN so it doesn't precipitate? What increases the compatibility?

70% dextrose and 30% lipids

What is the 70/30 rule?

60% dextrose and 40% lipids

What is the 60/40 rule?

To limit dextrose in hyperglycemia or increased CO2 production

Why would 60/40 rule be used?

FASTHUG MAIDENS

What is the standardized, structured approach to identifying drug-related problems in the ICU?

Critical Care Pain Observation Tool (CPOT)

What tool is used to assess pain level?

Richmond Agitation Sedation Scale (RASS)

What scale is used to assess level of sedation?

Confusion Assessment Method for the ICU (CAM-ICU)

What assessment is used to assess delirium?

Pain

Fentanyl, morphine, and dilaudid are examples of ____ meds.

Sedation

Propofol, precedex, and versed are examples of ____ meds.

Succinylcholine

What is the only depolarizing NMBA?

Rapid sequence intubation, sedative, NMBA

What is a technique used when rapid control of the airway is needed? Process of administering a ____ and ____ in rapid succession to facilitate endotracheal intubation.

Glasgow Coma Scale

What scale is used to assess the extent of impaired consciousness?

Vasculature, vasoconstriction

Alpha 1 adrenergic receptors are found in ____ and stimulation causes (vasodilation/vasoconstriction).

Cardiac, increased

Beta 1 adrenergic receptors are found in ____ muscle. Stimulation causes (increased/decreased) contractility, cardiac index, HR and impulse conduction.

Lungs, relaxation, dilation

Beta 2 adrenergic receptors are found in vasculature and ____. Stimulation causes smooth muscle (relaxation/contraction), vaso(dilation/constriction), and decrease in SVR.

Dose

Dopamine has a ____ dependent response. Receptors are found in renal, splanchnic / mesenteric, coronary, and cerebral vasculature.

Renal, contraction, reabsorption

Vasopressin receptors are found in vasculature and ____ system. Stimulation causes smooth muscle (relaxation/contraction) and water and Na (excretion/reabsorption) within the kidneys.

Alpha, beta 1

Phenylephrine only acts on what receptor? Where does dobutamine have the strongest effect?

Therapy, alongside, education, ABX

Consultant pharmacist's role across the continuum:

1. Conduct comprehensive monthly reviews

2. Optimize ____

3. Ensure adherence to federal and state regulations

4. Work (alongside/independently of) members of the team

5. Provide in-service ____

6. Help reduce ____ overuse

7. Assist in managing conditions

Clearance and timing

Dialysis affects what two things related to medication administration?

Low, low, small, hydrophilic

(Low/high) MW, (low/high) protein binding, (small/large) Vd, and (hydrophobic/hydrophilic) drugs will increase dialysis removal.

Regular

What insulin is in insulin IV drips?

Institution

The first line approach for insulin IV drips is to use your ____ standard insulin infusion protocol whenever available.

0.1, 0.05

If your institution has no standard insulin infusion protocol, the starting rate for most patients is ____ units/kg/hr. For elderly, renal impairment, or insulin-sensitive the starting rate is ____ units/kg/hr.

Hour, 50-75

For IV insulin drips, check blood glucose every ____.

Goal: ↓ glucose by ____-____ mg/dL per hour

Before, 200, K

When giving IV insulin drip, give basal insulin 2-4 hours (before/after) stopping drip. Add dextrose (D5) when BG approaches ~____ mg/dL (especially in DKA). Monitor ____ closely (watch for lower levels).

0.8-1, 0.5-0.7

Insulin TDD (not based on usage of insulin drip):

Pediatrics: ____-____ unit/kg/day (use current weight)

Adults: ____-____ units/kg/day (using total body weight)

2, before, 80, hypoglycemia

When transitioning IV to SQ insulin, administer basal insulin at least ____ hours (before/after) discontinuing the insulin drip to prevent rebound hyperglycemia. Many clinicians use ____% of TDD when transitioning. Monitor closely for ____ first 24 hours.