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T-Level - A1.1 - Policies and procedures
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T-Level: A1.1 - Safeguarding Policies | Employment Contracts | Performance Reviews | Disciplinary Policy | Grievance PolicyT-Level - A1.1 - Equality, diversity and inclusion policyIn this video we take a look at the 0:02 fetch to code 0:03 execute cycle including its effect on 0:06 the various registers we've previously 0:12 [Music] 0:14 discussed a computer is defined Definition 0:17 as an electronic device that takes an 0:20 input 0:22 processes data 0:25 and delivers output 0:29 in this simple example you can see we're 0:31 taking the input 5 0:35 we're multiplying it by 2 that's our 0:37 process 0:39 and we're outputting 10. 0:44 but this could be way more complex for 0:46 example of a game console 0:48 the input could be the buttons you press 0:50 on a controller 0:53 the processes would then be carried out 0:55 by the console itself 0:59 and the output would be some form of 1:01 update to a monitor 1:02 and sound out for a speaker possibly 1:04 vibration feedback through the 1:06 controller 1:10 to process data a computer follows a set 1:13 of instructions 1:14 known as a computer program 1:18 if we take the lid off a typical desktop 1:20 computer we can identify 1:22 two critical components the memory 1:26 that stores the program and the central 1:29 processing unit or processor 1:31 which is under this large fan and 1:33 carries out the instructions 1:37 a computer carries out its function by 1:40 fetching 1:41 instructions decoding them and then 1:43 executing them 1:44 in a continuous repetitive cycle 1:46 billions of times a second 1:48 let's look at each of these stages in a 1:50 little more detail Fetch 1:53 so let's start with the fetch stage the 1:55 very first thing that happens 1:57 is the program counter is checked as it 2:00 holds the address 2:01 of the next instruction to be executed 2:07 the address stored is then copied into 2:09 the memory address register 2:14 the address is then sent along the 2:16 address bus to main memory 2:18 where it waits to receive a signal from 2:21 the control 2:22 bus so it knows what to do 2:27 as we want to read the data that's 2:29 stored in memory address 2:30 0 0 0 0 the control unit sends 2:34 a read signal along the control bus to 2:36 main memory 2:41 now main memory knows the data needs to 2:44 be read 2:45 the content stored in memory address 000 2:49 can be sent along the data bus to the 2:51 memory data register 2:56 now as we're currently in the process of 2:58 fetching an instruction 3:00 the data received by the memory data 3:03 register gets copied 3:04 into the current instruction register 3:11 the instruction effectively has now been 3:14 fetched from memory 3:16 just before we proceed to the decode 3:18 phase we now 3:19 increment the program counter so that 3:22 the address it contains 3:24 points to the address of the next 3:26 instruction which will need to be 3:30 executed 3:32 the instruction now being held in the 3:33 current instruction register 3:35 is ready to be decoded 3:39 now as we mentioned in the previous 3:41 video the instruction is made up of two 3:43 parts 3:44 we have the op code that's what it is we 3:47 need to do 3:50 and we have the operand what are we 3:53 going to do it to 3:55 now the operand could contain the actual 3:57 data 3:58 or indeed it could contain an address of 4:01 where the data is to be found 4:06 by decoding this instruction we can see 4:08 the operation we need 4:10 is a load operation so we need to load 4:14 the contents of memory location0101 4:18 into the cpus accumulator 4:25 in the exam a simple model will be used 4:27 to describe the 4:29 structure of any given instruction 4:32 you're not going to be expected to 4:34 define how an opcode is made up 4:36 but simply to interpret opcodes in the 4:39 given context of an exam 4:40 question in the example here 4:44 you can see there's a total of 16 4:46 different opcodes available 4:48 and this is because we're using four 4:50 bits for our representation 4:56 so now we've fetched the instruction and 4:59 we've decoded it so we know what we need 5:00 to do 5:01 we're finally ready to execute it 5:05 so we now send address 0101 5:08 to the memory dress register 5:13 now we're in the memory address register 5:15 we can finally send the address 5:18 down the address bus to main memory 5:24 this time we want to read the data 5:26 that's stored in memory 5:28 and so the control unit again sends a 5:30 read signal along the control bus 5:36 so main memories now receive an address 5:38 and a read signal 5:40 so the content stored at memory location 5:43 0101 5:44 can now be sent along the data bus back 5:46 to the cpu 5:47 and into the memory data register 5:54 finally the contents of the memory data 5:56 register are copied to the accumulator 5:59 and this is one of a number of general 6:00 purpose registers found in the cpu 6:04 this first instruction is now complete Branching 6:11 so what does this program actually do 6:14 you should be able to work it through 6:16 carefully and figure it out 6:19 we're now pointing instructions zero 6:21 zero zero one in the program counter 6:23 and we're ready to fetch the second 6:25 instruction 6:27 at the end of this video we're gonna 6:29 provide you with the answer 6:34 so let's talk a second about programs 6:37 that branch 6:40 on the left here we have a very simple 6:42 piece of pseudo code 6:44 line zero says first execute this line 6:46 of code 6:47 line 1 now execute this line and then 6:50 line 2 says 6:52 if the age is greater than 18 then 6:56 we're going to execute lines 3 and 4 6:58 otherwise 6:59 we're going to execute lines six and 7:02 seven 7:03 so this program doesn't necessarily 7:05 follow strictly in sequence from line 7:07 zero through to seven there's a chance 7:10 here the program may branch and jump 7:14 around 7:16 so we're going to pretend that this 7:17 program has been loaded into memory 7:20 each line of code on the left here has 7:23 ended up 7:24 as a location in memory now this is not 7:27 strictly how this would happen in this 7:28 one-to-one way 7:29 but for the purpose of example it's 7:31 absolutely fine 7:35 so the program counter starts by 7:37 pointing to memory address zero 7:39 and we fetch the first instruction 7:41 decode it and execute it 7:44 it then updates and tells us the next 7:47 instruction 7:48 is zero zero zero one because remember 7:50 the program counter is being incremented 7:52 so we fetch it decode it and we execute 7:55 line one of our program 7:59 we then fetch line two which in binary 8:01 is one 8:02 zero 8:06 now at this point depending on what 8:10 happens during the execution 8:11 of line two the program may be required 8:15 to fetch line three from memory or 8:18 line five from memory 8:25 so let's look at how this actually works 8:27 because we've said the program counter 8:28 simply gets incremented 8:31 well in the current instruction register 8:33 we have an instruction with the op code 8:36 0 1 1 0. 8:41 now when we look this up in the decode 8:43 unit we discover that this 8:45 code means branch always 8:51 this replaces the value held in the 8:54 program counter 8:56 with the contents of the operand that's 8:58 the second part of the instruction 9:01 from the current instruction register so 9:03 this case 9:04 one zero zero one 9:09 now when the next fetch cycle begins the 9:12 program counter is obviously checked 9:14 and as its contents have been previously 9:16 updated to a new memory location 9:19 and not simply incremented the program 9:22 effectively is able to jump 9:24 around memory 9:28 so having watched this video you should 9:30 be able to answer the following key 9:32 question 9:33 how does a cpu work 9:39 okay so let's um answer the question we 9:41 posed 9:42 earlier what did that program actually 9:48 do 9:50 so this is the first fetch to code 9:53 execute cycle 9:55 and this is the one that we ran through 9:57 in detail earlier 9:58 it effectively loaded the contents of 10:01 the memory 10:02 stored at location location0101 10:05 into the accumulator in other words 10:08 the dna number 3 is moved 10:11 from memory into the cpu 10:18 we then proceed onto the second fetch 10:20 decode execute cycle 10:23 now this one adds the contents of memory 10:27 located at 0 1 1 0 10:30 to the current contents of the 10:32 accumulator 10:34 so in other words the dna number one 10:38 because that's what's stored at address 10:40 zero one one zero 10:43 is added to the number three that was in 10:45 the accumulator 10:46 the results are stored back over the 10:48 accumulator 10:49 so effectively we've done three plus one 10:53 equals four 10:58 the third fetch to code execute cycle 11:00 stores the contents which are in the 11:02 accumulator 11:03 into memory location zero one one one 11:07 and that's because the op code the first 11:09 part of this current instruction 11:10 zero zero one one is the command to 11:13 store when we look it up in the decoder 11:15 unit 11:16 so in other words the result of the 11:17 previous calculation three plus one 11:19 equals four 11:20 is now written back into main memory 11:28 the fourth fetch decode execute cycle 11:30 outputs the contents of the accumulator 11:33 remember they were copied into main 11:34 memory but they're still held in the 11:35 accumulator 11:37 so in this simple abstraction the number 11:40 four is now 11:41 output to the user so they can see the 11:43 result of the calculation 11:49 the fifth and final fetch code execute 11:51 cycle 11:52 brings a halt to the current program 11:58 so this very simple program which has 12:01 five 12:02 fetch decode execute cycles has 12:04 performed the calculation 12:06 three plus one is then stored the result 12:09 in main memory 12:10 and displayed the result four to the 12:12 user 12:13 and in a high-level language this may 12:15 look something very similar to the 12:17 following two lines of code 12:20 sum variable equals num1 plus num2 12:24 print sum to the user 12:27 so you can start to get an appreciation 12:29 here of how the high level code you 12:32 write actually ends up being fetched 12:34 decoded 12:35 and executed inside a processor 12:38 of course your processor is doing 12:40 billions and billions of these 12:42 operations a second 12:43 which when you think about it is really 12:45 very impressive 12:52 [Music] 13:03 you. make 10 questions for a standerd of a levelChapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we wonât talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined Îą and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic Drug Alpha1 Blockers (weâve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an Îą1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic Drugs Alpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels â lowers peripheral resistance â Results in decreased BP So âŚ.Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs Îą1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs Îą1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesnât everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitors aka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion ď¨ less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patientâs chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-lifeď¨ Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers (ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect ď Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia⌠Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTN Treatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)T-level: A1.3 - Autonomy in health and social careT-level: A1.3 - Nonmaleficence in health and social careT-level: A1.3 - Beneficence in health and social careT-level accounting Revision