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44 Cards in this Set
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monitoring frequency for warfarin (starting-2, when stable, if doses are changed)
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1. START 2-3 days after initiation to give warfarin time to work-->then twice weekly at initiation of therapy, until 2 consecutive therapeutic INRs (rate that INRs increase should be 0.1-0.2/day in first week)
2. Weekly x one month 3. Monthly once stable 4. When weekly doses are changed, boluses are given, or doses held, the INR will be drawn in 1-2 weeks. Monthly INRs will then resume |
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steady state of warfarin reached when?
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10-14 days
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altering dose for INR goal 2-3:
if INR < 2 if INR 3-3.5 if INR 3.6-4 if INR > 4 |
INR < 2: increase weekly dose by 5-20%
INR 3-3.5: decrease weekly dose by 5-15% INR 3.6-4: hold 0-1 doses and/or decrease weekly dose by 10-15% INR > 4: hold 0-2 doses and/or decrease weekly dose by 10-20% |
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altering dose for INR goal 2.5-3.5:
if INR < 2 if INR 2-2.4 if INR 3.6-4.6 if INR > 4.7-5.2 INR > 5.2 |
INR <2 reload x1 or increase weekly dose by 10-20%
INR 2-2.4 -->increase weekly dose by 5-15% INR 3.6-4.6 --> decrease weekly dose by 5-15% INR 4.7-5.2-->hold 0-1 doses and/or decrease weekly dose by 10-20% INR > 5.2 hold 0-2 doses and/or decrease weekly dose by 10-20% |
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medications on the Beers list that are highly anticholinergic (4)
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First generation antihistamines: particularly diphenhydramine, doxylamine, hydroxyzine, promethazine,
(Brompheniramine, carbinoxamine, Chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, Triprolidine) |
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Beers list what is it (and age)
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a list of meds for geriatrics (65+) where the potential risks outweigh the benefits
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CV drugs to avoid (beers list)- 1 (3 subcategories) category, 1 other category, 4 specific drugs
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Antiarrhythmic drugs class ia, ic, III (Amiodarone, Dofetilide, Dronedatone, flecainide, ibutilide, procainamide, propafenone, quinidine, sotalol).
Digoxin >0.125 mg/d unless for afib no alpha blockers for htn (higher dose) spironolactone > 25 mg/d (increased K+) dronederone disopyradine |
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diabetes drugs to avoid (beers list) - 2
why? what do we use instead? |
Insulin (sliding scale- meaning the version where you base how much insulin to give on your drawn blood lvls, not all insulin) , long acting sulfonylureas (Chlorpropamide, glyburide).
increased risk of hypoglycemia. just use metformin if SCr is ok, and glipizide 5 mg QD |
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extrinsic risk factors for elderly falls (3)
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environmental hazards (poor lighting, slippery floors, uneven surfaces, etc.)
• footwear and clothing • inappropriate walking aids or assistive devices |
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exposure to risks...risk factors for falls in elderly (3)
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exposure to risky environmental
conditions (slippery or uneven floors, cluttered areas, degraded pavements), acute fatigue unsafe practice in exercise sessions |
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7 meds that can increase risk of falls
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benzodiazepines
psychotropics (...any psych med i guess...SSRIs, hypnotics, etc) class 1a anti-arrhythmic medications (Disopyramide, Quinidine, Procainamide- DOUBLE QUARTER POUNDER) digoxin diuretics sedatives. 4+ meds |
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diabetes drugs NOT to use in beers criteria for pt with a certain preexisting disease
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thiazolidinediones in CHF
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5 patient demographics type characteristics that intrinsically increase risk of falls in elderly
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hx of falls
age-->increasing falls with age gender: older old-->women > men living alone WHITE PEOPLE FALL MORE THAN MINORITIES |
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3 activity/nutrition related characteristics that increase risk of falls in elderly
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sedentary (atrophy)
nutritional deficiency (low BMI, vitamin D deficiency) impaired mobility/gait |
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6 disease/condition related characteristics that increase risk of falls in elderly
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meds, esp BDZ
medical conditions psychological status (fear of falling) impaired cognition foot problems visual impairments |
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6 medical conditions that case increased risk of falls in elderly
1 that is associated |
circulatory disease
chronic obstructive pulmonary disease depression arthritis Thyroid dysfunction leading to excess circulating thyroid hormone diabetes (if loss of peripheral sensation) incontinence also frequently present |
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3 types of urinary incontinence
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urge, overflow and stress
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urge incontinence- may occur when?
pathophys |
Bladder overactivity may occur during bladder filling and urine storage due to involuntary bladder (detrusor) contractions.
Symptoms of bladder overactivity occur because the detrusor muscle is overactive and contracts inappropriately during the filling phase which, in the neurologically normal individual, results in a sense of urinary urgency. |
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overflow incontinence- result of what? (2)
common? |
result of urethral overactivity and/or bladder underactivity
uncommon type |
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overflow incontinence pathophys
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Overflow incontinence results when the bladder is filled to capacity at all times but is unable to empty, causing urine to leak from a distended bladder past a normal or even overactive outlet and sphincter
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Stress incontinence- due to what (sum it up in 2 words)
pathophys |
urethral underactivity
the compromised urethral sphincter is no longer able to resist the flow of urine from the bladder during periods of physical activity. basically, increases in intraabdominal pressure during physical activity are transmitted to the bladder compressing it and forcing urine through the weakened sphincter |
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stress incontinence usually noticed when? (5)
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exertional activities such as exercise, running, lifting, coughing, and sneezing
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5 disease related reversible factors for incontinence (ignore other one...)
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Psychological
Pregnancy, vaginal delivery, episiotomy (cutting shit in the vagina) Endocrine disorders (Diabetes, Hypercalcemia, Diabetes insipidus) Restricted mobility- get rid of aggravating or precipitating cause Stool impaction |
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6 drugs that are potential reversible factors in incontinence
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Diuretics
Caffeine Anticholinergic drugs- retention Narcotics/sedative hypnotics/alcohol (confusion, sedation, subsequent peeing of pants) Alpha-adrenergic agents (both agonists like decongestants which can produce retention, and antagonists- may worsen stress incontinence) Calcium channel blockers |
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DIA of...potential reversible factors
mnemonic? |
Delirium
Infection (Urinary tract) atrophic urethritis or vaginits DIAPPPERS |
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urge incontinence: post void residual
causes (3) |
normal
Usually neurologic cause like interruption of CNS inhibitory pathways Age-related changes Bladder irritation by infection, stones, neoplasms |
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2 main causes for overflow incontinence
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Diminution or loss of detrusor contraction
OR obstruction of bladder outlet |
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4 types of drugs that cause overflow incontinence
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Anticholinergics
Narcotics Anti-depressants Smooth muscle relaxants |
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3 causes of bladder obstruction in overflow incontinence
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Prostatic hyperplasia or carcinoma
Urethral stricture Genital prolapse in women |
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4 things that cause diminution or loss of detrusor contraction (which leads to overflow)
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(due to drugs, fecal impaction, diabetes, or lower spine injury)
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2 main causes of sphincter/stress incontinence
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Damage to urethra due to surgery or trauma
Decreased pelvic floor compliance as a result of normal aging, multiparity or surgery reversible usually |
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4 behavioral things a patient can do for incontinence
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Kegel exercise
vaginal weight training Bladder training Biofeedback |
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2 behavioral things a caregiver can do for incontinence
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Habit training
Prompted voiding |
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treatments for overactive bladder (3 drug categories)
explain rationale for each |
Anticholinergics
-Inhibit detrusor contraction -May increase bladder capacity Bladder relaxants -Inhibit involuntary bladder contractions -Highly anticholinergic Estrogen-Mechanisms unknown |
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2 anticholinergics (not bladder specific) that can be used for urge
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imiprimine, amitriptyline
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4 treatment categories for overflow
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Correct any outflow obstruction (the -zosins: doxazosin, tamsulosin)
Cholinergic agonists (bethanecol) alpha-adrenergic blockers Surgery |
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stress incontinence therapies (4) give MoA for drugs (2 are non drug)
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Nonpharmacologic (kegals)
Alpha-adrenergic agonists (sudafed)- increases smooth muscle tone increasing urethral resistance Estrogen- Stimulate squamous epithelium Surgery |
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generally, when are catheters used (and for what type of incontinence)
4 indications for it |
short-term use in overflow incontinent patients when wounds need to be protected
Persistent overflow causing infection or renal dysfunction Not correctable surgically Contaminated wounds Terminally ill |
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when might you use TCAs (anticholinergic activity too) for incontinence?
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for urge incontinence (or mixed- combo of urge and stress) if other co-existing indications like depression or neuropathic pain
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bladder relaxants for urge (2)
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oxybutinin- cheapest
tolterodine (detrol)- LA is qd so easier |
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4 alpha antagonists used for overflow incontinence and MoA
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alpha adrenergic antagonists:
prazosin, terazosin, doxazosin, tamsulosin (flomax) MoA: When alpha 1 receptors in the bladder neck and the prostate are blocked, this causes a relaxation in smooth muscle and therefore less resistance to urinary flow. usually alpha 1 receptors cause contraction of smooth muscle (i.e. of the sphincter) |
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cholinergic used for overflow incontinence (if atonic bladder)
dose... |
Bethanechol 25-50 mg TID
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when is estrogen used for incontinence
MoA route |
if vagina atrophy is going on (atrophic urethritis/vaginitis)- stimulates squamous epithelium
topical- oral may worsen |
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First line (check this...) therapy for stress incontinence
optional first line therapy |
duloxetine???
imipramine... |