Exam 1
Acetylcholinesterase Inhibitor Drugs have what common suffix
"Stigmine"
What medications are Inhibitors?
"azole" AcE "mycins" amiodarone diltiazem verapamil
a-1 specific antagonist adverse effects
"first dose" hypotension reflex tachycardia rebound hypertension (if stopped suddenly) Orthostatic/postural hypotension Sexual dysfunction
Neuro-muscular Blocker uses
"paralyzing" Suppress gag reflex Paralyze all muscles including diaphragm Will receive before intubation.
Alpha 1 blocker drugs ends in
"sin"
Alpha 1 Antagonist drugs have what common suffix?
"sin" Tamsulosin Prazosin
Anticholinergic agent common suffix
"tropine"
Adverse Effects of B1 Antagonists
(Metoprolol tartrate) Orthostatic Hypotension (Dizziness/ Fall Risk) Bradycardia Precipitation of heart failure exacerpation (Fluid build up in lungs) Masks S/S of hypoglycemia
Total bilirubin normal range
0.3-1.0 mg/dL (liver)
When should you administer pyridostigmine?
1 hour before a meal OR 2 hours after
When do you administer a direct acting cholinergic agent
1 hour before meals OR 2 hours after a meal.
What are the nine "rights"?
1) right drug 2) right dose 3) right time 4) right route of administration 5) right patient 6) right documentation 7) right reason 8) right response 9) right of patient to refuse
Albumin normal range
3.5-5 g/dL (liver)
Normal Urine Output
30 mL/hr
normal range of alkaline phosphatase (ALP) and in what organ?
30-120 units/L (liver)
Normal range alanine aminotransferase (ALT) and in what organ?
4-36 units/L (Liver)
Consider a drug removed after how many half lives?
4-5
A nurse is caring for a 1-month-old infant who weighs 3500 g and is prescribed a dose of cephazolin 50 mg/kg by intermittent IV bolus three times daily. How many mg should the nurse administer per day? (Numeric value only. Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ________ mg/day
525 mg/day
blood urea nitrogen (BUN) normal range organ?
8-20 mg/dL Kidneys
Estimated Glomerular Filtration Rate (eGFR) normal range and organ
90-120 ml/min Kidneys (Glomerular)
What is malignant hyperthermia?
A side effect of general anesthesia - tachycardia, hypertension, acid-base and electrolyte abnormalities, muscle rigidity, hyperthermia
A client is to receive oral guaifenesin twice a day. Today, the nurse was busy and gave the medication 2 hours after the scheduled dose was due. Which right did the not adhere to? A. Right time B. Right dose C. Right route D. Right medication
A.
What lab values can be used to test for liver impairment?
AST ALT ALP{ albumin total bilirubin
Which of the following values would suggest impaired liver function? BUN of 12 mg/dL SCr of 2.5 mg/dL GFR of 120 ml/min AST of 86 units/L ALT of 200 units/L Potassium of 4.2 mEq/L ALT of 12 units/L
AST of 86 units/L ALT of 200 units/L Potassium of 4.2 mEq/L
What do you expect to find in liver impairment tests?
AST- Elevated (above 35 units/L) ALT-Elevated (above 26 units/L) ALP- Elevated (>120 units/L) Bilirubin- Elevated (>1 mg/dL) Albumin- DECREASED (<3.5 g/dL)
Controlled Substances are ranked by
Abuse/Misuse Potential Medical Use Dependency Potential
Indirect Acting Cholinergic Agents are also called
Acetycholinesterase Inhibitors
Parasympathetic/ Cholinergic Division Key
Acetylcholine (ACh)
Direct acting cholinergic agonists produce effects that mimic
Acetylcholine (Ach)
Pyridostigmine is a
Acetylcholinesterase inhibitor
Whatis Isotretinoin used to treat?
Acne
Sympathetic/ Adrenergic Division Key
Adrenaine (Epinephrine)
Category C drugs and pregnancy
Adverse effects reported in the animal fetus; information on humans not available
assessment/recognizing cues
Age Medications Polypharmacy Lab test results History of smoking and alcohol Dietary habits Deficits ETC
Older Adult Considerations: Metabolism
Aging liver produces fewer enzymes, affecting drug metabolism Reduced blood flow to the liver
Pyridostigmine (Indirect Acting Cholinergic Agents) is used to treat
Alzheimer's REverse Anticholinergic Effects Myasthenia Gravis Reverse Effecs of Neuromuscular Blocking Agents
Atropine (Anticholinergic Agent) MOA
Antagonist at various muscarinic receptors in parasympathetic division particularly in the heart allowing sympathetic to take control.
Atropine is what kind of drug?
Anticholinergic Agent
Warfarin is an
Anticoagulant
What is a contraindication?
Any condition that renders a particular form of treatment improper or undesirable
How is someone relaxing after a meal illistrated?
BP low HR low RR low GI activity high Skin=warm Pupils constricted Miosis
SOFT drugs contraindication
BPH Glaucoma Urinary retention/hesitation
Tamsulosin (Flomax) has two main uses. What are they?
Benign prostatic Hyperplasia (BPH) Bladder Outlet Obstruction (Kidney Stones)
What are the 7 inducers?
CSPRSPO- Carbamazepine Smoking Phenytoin Rifampin St John's Wart Phenobarbital Oxcarbazepine
Adverse Effects of Atropine (Anticholinergic Agents)
Cant See Cant Pee Cant Spit Cant Shit Canot Schvitz (Sweat)
Adverse effects of SOFT drugs
Cant see Cant Pee Cant Spit Cant Shit Cant Schvitz
Adverse effects of Epinephrine on the heart(Vasopressors)
Cardiac complications Tachycardia Dysrhythmia ischemia- MI
What are the different pregnancy safety categories?
Category A Category B Category C Category D Category X
What defines Nephrotoxicity?
Certain drugs may be harmful to the kidneys and the resulting damage is named Nephrotoxicity.
Muscarinic receptors are what kind of receptor?
Cholinergic
What are potentials complications of Highly Protein Bound Drugs?
Deficiency in protein/Albumin Competition (Two drugs can result in toxicity)
direct acting cholinergic agent Bethanechol MOA
Directly stimulates the parasympathetic division mainly located in the bladder
Which part of Pharmacokinetics is primarily influenced by liver function?
Distribution Metabolism
What is Phase IV of a clinical trial?
Drug reaches the market (gen pop) Post marketing surveillance
Which part of Pharmacokinetics is influenced by kidney function?
Elimination
What is the therapeutic index/range?
Enough drug is present to produve therapeutic response, but not enough to be toxic
In which step of the nursing process does the nurse determine the outcome of medication administration?
Evaluation
Category X drugs and pregnancy
Fetal abnormalities have been reported and positive evidence of fetal risk in humans; not to be used during pregnancy
How many schedules of controlled substances are there?
Five
What happens if you give Warfarin with Fluconazole?
Fluconazole is an inhibitor so higher levels of the Other drug
The nurse knows that which factors will affect the absorption of orally administered medications? (Select all that apply.) Form of drug preparation Time of day pH of stomach Patient in high-Fowler's position Presence of food in the stomach
Form of drug preparation Time of Day pH pf stomach Presence of food in stomach
Most cholinergic drugs target
GI Tract Bladder Eyes Heart
Pediatric Considerations : Absorption
Gastric pH less acidic Gastric emptying is slowed Topical absorption faster through the skin Intramuscular absorption faster and irregular First-Pass elimination by liver is reduced
Pediatric Considerations: Distribution
Greater total body water means lower fat content Decreased level of protein binding Immature blood-brain barrier—more drugs enter the brain
How is someone who is threatened illistrated?
HR increase RR rapid and deep Skin= cold/ sweaty Pupils dilate
LABetalol is used to treat
HTN management in pregnant pts. so LABor and delivery
Epinephrine Beta 1 activation
Heart + /chronotropic (HR) + Inotropic (CO)
Beta 1 receptors
Heart kidneys eyes
What is Symptomatic Bradycardia? What is one of the first drugs given?
Heart is in constant battle between Sympathetic and Parasympathetic nercous system Atropine blocks the Vagus Nerve's influence on the heart
Metoprolol tartrate is used to treat
Heart- current or hx of MI Hypertension Angina Dysthymias Heart failure Hyperthyroidism Migraine prophylaxis Glaucoma (drops)
Explain "Can't Shit" for Anticholinergic Adverse Effects
Increase Fiber and fluid intake Exercise
"Stigmine" or Pyridostigmine MOA
Inhibits acetylcholinesterase not at the receptors, which increases acetylcholine's activity in the parasympathetic system.
What is an AKI (acute kidney injury)?
Injury to the kidney which results in SUDDEN elevated SCr/BUN and decreased eGFR/CrCl
What are ways to avoid the "First Pass Effect"?
Intravenous, intramuscular, and sublingual
Pediatric Considerations; Excretion
Kidney immaturity affects glomerular filtration rate and tubular secretion Decreased perfusion rate of the kidneys may reduce excretion of drugs
Primary site of elimination
Kidneys
What organ does CYP450 target?
Liver enzymes
Primary organ of Metabolism
Liverpool
Older Adult Consideration: Distribution
Lower total body water percentages Increased fat content Decreased production of proteins by the liver, resulting in decreased protein binding of drugs Increased circulation of free drugs
Epinephrine Beta 2 activation
Lungs- Bronchdialation
Intended outcome taking pyridostigmine for Alzheimer's disease?
Maintain cognition
Serum Creatinine (SCr) normal range. What organ?
Male- 0.6-1.2 mg/dL Female- 0.5-1.1 mg/dL Kidnets
Pyridostigmine "stigmine" adverse Effects
Minor DUMBBBELS Drop in BP Drop in HR Cholinergic Crisis
Evaluation of "Sin" drugs (Nursing Process)
Monitor BP 2-6 hours after initiation Monitor Urine Output Monitor Urinary retention symptoms
Parasympathetic (Cholnergeic) Autonomic receptors (Locks)
Muscarinic (M) Nicotinic (N)
Direct Acting Cholinergic agent lock
Muscarinic Receptor
Explain "Can't See" for Anticholinergic Adverse Effects
Mydriasis (too much light, even at night) Blurred vision Dry eyes increased IOP
Direct Acting Cholinergic Agents Key
Natural AcetylCHOLINE
What drug type would cross into breastmilk?
Non-Polar Lipid-Soluble
What type of drug would reach the brain?
Non-Polar Lipid-Soluble
Which type of drug would reach a developing fetus?
Non-Polar Lipid-Soluble
Asthma/COPD is a contraindication for what blocker drugs
Non-selective Beta Blockers
Plan/Implementation for "sin" drugs
Often given at night educate about "First Dose Phenomenon" Never Stop suddenly Educate about sexual dysfunction
First Pass Effect only effects what kind of drugs?
Orally given
Oxybutynin, solifenacin, tolterodine are all used to treat
Overactive Bladder (OAB) Urinary Incontinence
What is a mnemonic used for remembering drug inhibitors?
PACMAN loves Grapefruit Juice?
What are seven main drug inhibitors?
PACMAN loves Grapefuit juice Protease inhibitor (HIV) Antifungals (that end in 'azole) Cimetidine (H2RAs) Macrolides (ACE, ends in'mycin) Non-DHP Calcium Channel Blockers (diltiazem, verapamil) Grapefruit Juice
PROpanolol is used to treat
PROfessions (Hypertension)
Adverse effects of Neuro-Muscular Blockers
Paralysis Malignant Hyperthermia
Muscarinic receptors are part of what division?
Parasympathetic
nicotinic receptors are part of what division
Parasympathetic
Parasympathetic = P for
Peace
What is Clozapine's REMS program?
Prescriber enrolls pt into Clozapine registry.
Which of the following factors primarily influence Distribution? -Protein Binding -Alzheimer's Disease -Lipid Soluble Drugs -Hepatic Necrosis -Drug Interaction with Liver Enzyme Inducers -Acute Kidney Injury
Protein Binding Lipid Soluble Drugs
Seven Key Elements of Medication orders
Pt Name + 2nd identifier Date drug order was written Name of drug drug dosage amount drug dosage frequency route of administration Prescribers signature
Explain "Can't Schvitz" for Anticholinergic Adverse Effects
Pts may overheat and develop hyperthermia Be careful in hot heat
Indirect-Acting Cholinergic/ Parasympathetic Drugs
Pyridostigmine
What is the intended outcome when taking pyridostigmine for Myasthenia Gravis
REcovery of muscle strangth
The nurse is interpreting data from a client's laboratory blood draw. Which step does this illustrate in the clinical judgement measurement model? Prioritize hypothesis Recognize cues Analyze cues Take-action
Recognize cues
What is the REMS program?
Risk Evaluation and Mitigation Strategy (REMS) - FDA requirement for drug manufacturers to develop strategies to assure safe use of a specific drug Benefits>Risk
Which of the following factors influence Absorption? -Hepatic Necrosis -Protein Binding -Drug Interaction with Liver Enzyme Inducers -Route -Heart Failure -Acute Kidney Injury -Gut Malabsorption Issue
Route Gut Malabsorption Issue
A pt has been prescribed Vancomycin, an antibiotic that is renally eliminated and known to cause kidney damage. The prescriber incorrectly orders a dose that is too high. What will lab numbers look like?
SCr- Elevated BUN- Elevated CrCl- Decreased eGFR- Decreased Urine Output- Decreased
What are you expected to find within lab values to determine renal impairment?
SCr- Elevated (Male- >.2. Female- >1.1) BUN- Elevated >20 mg/dL) CrCl- Decreased (<120 ml/min) eGFR- Decreased (<120 ml/min) Urine output- <30 ml/hr
Anticholinergic agents for OAB
SOFT Bladder Solifenacin Oxybutynin Finally Tolterodine
Remember Meds for Overactive Bladder using the Mnemonic
SOFT Bladder "Too much urination, need to dry up" Solifenacin Oxybutynin Finally Tolterodine
Metoprolol is a ___________ blocker
Selective Beta 1 blocker
What lab values can be used to determine renal function?
Serum Creatinine (SCr) Blood Urea Nitrogen (BUN) Creatinine Clearance (CrCl) Estimated Glomerular Filtration Rate (eGFR) Urine Output
What factors affect pediatric drug dosages?
Skin- think and permeable Stomach- lacks acid to kill bacteria Body temp- less well regulated Dehydration occurs more easily Liver and Kidneys- immature, impairing drug metabolism and excretion
First step to treating malignant Hyperthermia.
Stop the drug
Sympathetic = S for
Stress
Category B drugs and pregnancy
Studies indicate no risk to the animal fetus; information on humans not available
Two kinds of Neuromuscular Blockers
SuccinylCHOline Vercuronium
Depolarizing NMB Drug
Succinylcholine
Metoprolol tartrate boxed warning
Sudden stoppage can increase risk for Heart Attack
Assessment rules for suffix "sin" drugs
Take BP before you administer Hold if <90/60
What is onset of a drug?
The amount of time it takes a drug to elicit a therapeutic response.
What is the duration of a drug?
The time a drug concentration is sufficient to elicit a therapeutic response.
Schedule I drugs
These drugs have NO accepted medical use in the united states. These drugs have the highest abuse and dependency potential.
Schedule V drugs
These drugs have less potential for abuse than schedule II, III, and IV drugs.
Schedule IV drugs
These drugs may be refilled 5 times in a 6 month period. These drugs have less potential for abuse/dependence than schedule II/III drugs. Limited physical or psychological dependency potential
Schedule III drugs
These drugs may be refilled 5 times in a six month period. These drugs have less potential for abuse/dependence than schedule I or schedule II drugs Moderate to low physical or high psychological dependency potential
_____is an eye drop that helps treat Glaucoma
Timolol
Pilocarpine/ carbaCHOL/ BethaneCHOL are used to treat
Urinary retention Neurogenic bladder
Explain "Can't Pee" for Anticholinergic Adverse Effects
Urinary retention/hesitation Report a distended bladder Do not give to pts with enlarged prostate (BPH)
What is the intended use for BethaneCHOL
Urination- specifically after a procedure/surgery)
Which of the following values would suggest impaired kidney function? AST of 86 Potassium of 4.2 mEq/L Urine Output of 40 ml over 2 hours SCr of 2.5 mg/dL BUN of 12 mg/dL CrCl of 30 ml/min GFR of 120 ml/min
Urine Output of 40 ml over 2 hours SCr of 2.5 mg/dL CrCl of 30 ml/min
Epinephrine Alpha 1 activation
Vascular Smooth Muscle- Vasoconstriction (Increased BP)
Non-Depolarizing NMB drug
Vecuronium
Polar Drugs are ___ soluble
Water
What is toxicity?
When plasma drug levels climb too high, toxicity occurs
Isotretinoin is in what pregnancy category?
X
Explain "Can't Sput" for Anticholinergic Adverse Effects
Xerostomia Avoid alcohol based mouthwash Avoid Sugar gum/candy if possible to reduce risk of cavities.
PilocarPine is used to treat
Xerostomia (caused by radiation or Sjogrens Syndrome) Glaucoma (Eye Drops)
dopamine receptor locations
blood vessels to kidneys
Alpha 1 receptor locations
blood vessels, eyes, bladder, prostate, nose
Alpha 2 receptor locations
brain (pre-synaptic receptor) Nose
Glycogenolysis
breakdown of glycogen to glucose
Agonist synonyms
cholinergic parasympathetic parasympathomimetic
What defines Chronic Kidney Disease?
chronically elevated SCr/BUN and decreased eGFR/CrCl
Vasopressors include the drugs
epinephrine/adrenaline
Pyridostigmine can be used as a pre-treatment for
exposure to nerve gas
sympathetic catch phrase
fight or flight
How many clinical trial phases are there?
four
most pharmacokinetic experts agree that steady state is achieved after
four half lives
Timolol is used to treat
glaucoma (eye drops)
What is the "filter" of the kidneys?
glomerulus
What is Peak Level?
highest blood level of a drug
Water Soluble drugs typically remain in
highly vascularized spaces and can easily leave the body via elimination.
Before giving a neuro-muscular blocker you must
hook the pt up to oxygen
Prazosin's main use is to treat
hypertension
Adverse effects of vasopressors on the vasculature systeme
hypertension- can lead to MI/stroke.
There are subtype A1 receptors found in the...
peripheral vascular smooth muscles (arteries) Bladder/Urethra/Prostate
Atropine is used to treat
poisoning by Cholinergic drugs/agents Reduce salivation/secretions Symptomatic Bradycardia
To help prevent vasodilator-induced reflex tachycardia pts can be...
pretreated with a beta blocker, which blocks sympathetic stimulation of the heart
A1 Antagonists MOA
prevents activation of A1 receptors and some subtype A1 receptors) Some A1 blockers are selective or non-selective
Non selctive beta blocker drugs
propranolol carvedilol labetalol
Myasthenia Gravis medication
pyridostigmine
What are adverse effects of all BP medications?
rebound hypertension if stopped suddenly Orthostatic/postural hypotension sexual dysfunction
_______ _______ is commonly seen with anti-hypertensive drugs that do no work directly on the heart
reflex tachycardia
Parasympathetic is illistrated in a person who ______
relaxes after a meal
if a pt refuses to take a medication that has been prescribed, you should
report to the pt;s physician and charge nurse
Parasympathetic catch phrase
rest and digest
Metoprolol MOA
selective beta 1 antagonist (heart) Eyes- miosis (lowers IOP)
Minor Metabolism roles
skeletal muscle kidneys lungs plasma intestinal mucosa
Direct Acting Cholinergic Agent Agonists
stimulates a response
Malignant Hyperthermia is associated with
surgery drugs
Two reasons reflex tachycardia is undesirable
tachycardia can put an unacceptable burden on the heart If a vasodilator were given to reduce BP, the tachycardia would raise the BP and negate the desired effect
What is a drug substrate?
target drug
What is Minimum Effective Concentration (MEC)
the plasma drug level below which therapeutic effects will not occu
Bethanechol is used to treat
urinary retention (The goal is to reverse the retention and allow someone to void)
Anti-adrenergic drugs are also called
• Also called adrenergic-blocking anyagonists
Older Adult Considerations: Excretion
•GFR decreased •The number of working nephrons decreased Drugs are cleared less effectively because of decreased excretion
Goal of Cytochrome P-450
convert drugs to become hydrophilic and polar
S/S of impaired liver function
dark urine Jaundice Swelling of abdomen bruising/bleeding fatigue Ammonia can concentrate
If pupil constriction occurs, then IOP ________
decreases
Reflex tachycardia is caused by
dilation of arteries/veins causing a sudden drop in BP
What is mydriasis?
dilation of the pupil
Pilocarpine is a
direct acting cholinergic agonist
What is Steady State?
drug in=drug out When the amount of drug removed equals the amount of drug absorbed
Lipid soluble drugs
easily distribute into fatty tissues where they may store or concentrate.
Isotretinoin REMS program is called
iPLEDGE
What are "pro-drugs"?
inactive drugs which become active after being metabolized
What is Phase III of a clinical trial?
includes a large number of volunteers to establish a drug's clinical effectiveness, safety, and dosage range SAFETY and EFFECTIVENESS
What is Phase I of a clinical trial?
includes a small number of people (10-80) to evaluate the drug's safety, TESTS SAFETY
What is Phase II of a Clinical trial?
includes a small number of pts who have the intended disease trying to treat. Determines EFFECTIVENESS and adverse effects (Optimal Dosage) (drug interactions)
Goal of bethanechol
increase urine outcome (>30ml/hr)
Pilocarpine intended outcomes.
increased Saliva Decreased IOP
If pupil dialtion occurs this _____ IOP
increases
The Sympathetic system is illistrated by a person who
is threatened
All "sin" drugs (Alpha 1 Antagonist blockers) have what adverse effect?
lightheadedness/dizzy Orthostatic Hypotension
Non-polar drugs are ____ soluble
lipid
B1 antagonists are ___phillic
lipo
Cytochrome P-450 typically target
lipophilic and nonpolar
Beta blocker drugs end in ____
lol
Some A1 blockers are selective or non-selective. This means that a drug that targets the bladder may also
lower someone's blood pressure
Beta 2 receptors
lungs skeletal muscle uterine smooth muscle liver
CARvedilol is used to treat
mainly CARdiac conditions
Selective Beta 1 Blocker drug
metoprolol
Never stop taking _______ suddenly
metoprolol tartrate/ Selective B1 Blockers
Parasympathetic Direct Acting Agents are typically agonists at
muscarinic receptors in various organs (not skeletal muscle)
Bethanechol works by binding to what receptors?
musclarinic
Parasympathetic Indirect Acting Agents are typically agonists at
nicotinic receptors (skeletal muscles)
Schedule II drugs have
no refills
Category A drugs and pregnancy
no risk to fetus
The "LOL"s that are NOT metoprolol tartrate are considered
non-selective B Blockers
Epinephrine binds ____ to _____
nonselectively to alpha and beta receptors
Adrenergic drugs produce effects that mimic
norepinephrine or epinephrine
Potential Alterations of metaboism
other drugs Certain foods (Grapefruit) Smoking Alcohol Diseases Genetics Age
Lipid soluble drugs have the potential to cross the
Blood brain Barrier Placenta
Adverse effects of Non-selective B Blockers. B1
Bradycardia leading to decreased CO Hypotension Precipitation of Heart failure (fluid retention) Masks the S/S of diabetes (tremors. palpitations)
Epinephron Alpha 2 activation
Brain- No sig. results
Adverse effects of non-selective Beta Blockers B2
Bronchoconstriction (bad for asthma) Prevent glycogenolysis in liver (complicates hypoglycemia)
The nurse is performing an assessment of a newly admitted client. Which is an example of objective data? (Select all that apply) -Weight 255 pounds -The client states, "I'm really dizzy." -Client is alert and oriented to name, place, and time -The client reports that he uses the herbal product St. John's Wart -Blood pressure 158/96 mmHg
-Blood pressure 158/96 mmHg -Client is alert and oriented to name, place, and time -Weight 255 pounds
Client is a 56-year-old man with a past medical history of hypertension, hyperlipidemia, and gout. Client arrived at the emergency department at 1730. Client states, "my stomach has been hurting for the past week." RN asked client to rate pain 1-10 on numeric pain scale. Client rated his pain a 7 out for 10. RN auscultated client's abdomen; bowel sounds were absent in all quadrants. MD ordered abdominal X-ray. Xray suggestive of severe constipation. RN discussed findings with the client. Client states, "I have not had a bowel movement in 10 days." -Client states, "my stomach has been hurting for the past week." RN asked client to rate pain 1-10 on numeric pain scale. -Client is a 56-year-old man with a past medical history of hypertension, hyperlipidemia, and gout. -Client states, "I have not had a bowel movement in 10 days." -Xray suggestive of severe constipation -RN auscultated client's abdomen; bowel sounds were absent in all quadrants. -RN asked client to rate pain 1-10 on numeric pain scale. Client rated his pain a 7 out for 10.
-Client states, "my stomach has been hurting for the past week." RN asked client to rate pain 1-10 on numeric pain scale. -Client states, "I have not had a bowel movement in 10 days."
Considerations for Older Adults
-Decline in organ function occurs with advancing age. -Drug therapy in older adults is most likely to result in adverse effects and toxicity.
Bethanechol is a
-Direct cholinergic agonist
Older Adult Considerations: Absorption
-Gastric pH less acidic -Gastric emptying slowed -Movement through GI tract slowed because of decreased muscle tone and activity -Blood flow to GI tract reduced -Absorptive surface of GI tract reduced
high alert drugs
-anticoagulants (Warfarin, Heparin) -insulin -opioids and narcotics (Morphine) -potassium -Antibiotics (penicillin) -Cardiac Medications (Epi, metoprolol)
Normal Range Aspartate aminotransferase (AST) and in what organ?
0 to 35 units/ L (Liver)
The prescriber as order that a client receive an antibiotic every 6 hours to treat their pneumonia. If the last medication was administered at 0700, what time is the next dose due? 1200 1300 1500 1600
1300
Creatinine Clearance (CrCl) normal range and organ
90-120 ml/min Kidneys, but more specifically in the Glomerular
What is a partial drug agonist?
A drug that binds to a receptor and the results are diminished compared to an agonist.
What is a drug antagonist?
A drug that binds to the receptor, there is no response.
What is a drug agonist?
A drug that binds to the receptor. There is a response.
What is a noncompetitive antagonist?
A drug that combines with different parts of the receptor and inactivates it. The agonist then has no response.
What is a competitive antatgonist?
A drug that competes with the agonist for binding to the receptor. If it binds, there is no response.
When a patient has impaired kidney function, what are some potential different medical terms? ototoxicity acute kidney injury anuria hepatotoxicity akathesia paresthesia oliguria declined renal function nephrotoxicity tardive dyskinesia chronic kidney disease
AKI Anuria oliguria declined renal function nephrotoxicity chronic kidney disease
Which of the following factors influence Elimination? -Acute Kidney Injury -Chronic Kidney Disease -Heart Failure -Gut Malabsorption Issue -Hepatic Necrosis -Alzheimer's Disease -Grapefruit Juice -Drug Interaction with Liver Enzyme Inducers -Hypertension
AKI Chronic Kidney Disease
Contolled substances are
ANY drug that are found to have any dependency or abuse potential
A pt is taking Tylenol (acetaminophen) but has exceeded the maximum dosage. Exceeding the maximum dosage is known to harm the liver.. What are some lab values to observe?
AST ALT
Types of liver function tests
AST ALT ALP Albumin Total bilirubin
Sympathetic (Adrenergic) Autonomic Receptors (Locks)
Alpha 1 (a1) Alpha 2 (a2) Beta 1 (B1) Beta 2 (Beta 2) Dopamine (DA)- Rare
What is a dug interaction?
Alteration in the pharmacologic or kinetic activity of a given drug caused by the presence of one or more additional drugs. Usually related to the effects on the enzymes required for metabolism of the involved drugs.
a1 antagonists focus on what three areas?
Arteries Prostate Bladder
What are potential lab values that can be used to assess liver function?
Aspartate AminoTransferase (AST) Alanine Aminotransferase (ALT) Alkaline Phosphatase (ALP) Albumin Bilirubin Potassium
The nurse monitors the fulfillment of goals, and may revise them, during which phase of the nursing process?
Assessment
5 steps of the nursing process
Assessment Diagnosis Planning Implementation Evaluation
Five phases of the nursing process
Assessment Diagnosis Planning Implementation Evaluation
Contra-indication of bethaneCHOL
Asthma
Contra-indication of carbaCHOL
Asthma
Contra-indication of pilocarpine
Asthma
Contraindications of "lol" drugs
Asthma/COPD
When do we draw a Trough?
At the lowest point. Check 30 minutes to 1 hour prior to the next dosing interval
Antidote to "Stigmine" overdose
Atropine
antidote to cholinergic crisis
Atropine
Treatment for a Cholinergic Crisis
Atropine (cholinergic antagonist)
A nurse makes an error when administering a medication to a client. Which action by the nurse would require immediate intervention by the charge nurse? A. The nurse completes an incident report B. The nurse informs the health care provider (HCP) of the error C. The nurse documents adverse effects to the medication error D. The nurse records the completion of an incident report in the client's electronic health record (EHR)
B
The day shift charge nurse is making rounds. A client tells the nurse that the night shift nurse never administered the medication he normally takes for his high cholesterol. Which action should the nurse perform first to determine whether the medication was given? A. Call the night nurse at home B. Check the medication administration record (MAR) C. Call the pharmacy D. Review the night nurse's end of shift note that is documented in the electronic health record (EHR)
B
When giving epinephrine, regardless of route, what would you monitor? Why?
BP and HR drug increases the O2 demand on the heart and may lead to angina or dysrhythmia. Improves the gas exchange in the lungs.
Why does orthostatic/postural hypotension occur when given an anti-hypertensive medication?
Because of venous relation, gravity causes blood to pool in the veins decreasing venous return to the heart which in turn causes a decrease in cardiac output and a decrease in BP
Direct Acting Cholinergic Agent Drug
BethaneCHOL
Three Direct Acting Cholinergic Agents
BethaneCHOL Pilocapine carbachol
Direct ACting Parasympathetic. Cholinergic Drugs
Bethanechol Pilocarpine
Succinylcholine MOA
Binds to receptors at the neuromuscular Junction (NMJ). Once bound it depolarizes the cells and stays in place causing them to be stuck.
Muscarinic Receptors are mainly located in the
Bladder
Non-selective B blockers MOA
Block Beta 1 receptors on heart May block Beta 2 receptors in lungs. May block alpha 1 receptors in arteries.
Vecuronium MOA
Blocks acetylcholine from binding to nicotinic receptors at the neuromuscular Junction If acetylcholine cannot work normally on muscles they become paralyzed
What are potential lab values that can be used to assess kidney function?
Blood Urea Nitrogen (BUN) Urine Output Creatine Clearance (CrCl) Serum Creatine (SCr)
The nurse answers a client's call light and finds the client sitting up in bed and requesting pain medication. Which action should the nurse perform first? A. Check the prescriber order and give the client the requested pain medication B. Provide non-pharmacological comfort measures to the client C. Assess the client's pain and pain level D. Evaluate the effectiveness of previous pain medications
C
Nicotinic receptors are what kind of receptor
Cholinergic
What is a Mnemonic for remembering drug inducers?
Clumsy Sally's Palm Releases and Shatters Priceless Objects (Used to remember that inducers DROP levels of other drugs)
What is the extra adverse effect of an Anticholinergic Agent
Confusion- can potentially hallucinate
Which of the following would suggest renal impairment? SELECT ALL THAT APPLY CrCl of 120 ml/min Urine Output of 200 ml over 2 hours CrCl of 30 ml/min BUN of 40 mg/dL SCr of 1 mg/dL BUN of 10 mg/dL SCr of 2 mg/dL Urine Output of 40 ml over 2 hours
CrCl of 30 ml/min BUN of 40 mg/dL SCr of 2 mg/dL Urine Output of 40 ml over 2 hours
How can we estimate Glomerular Foltration Rate (GFR)?
Creatinine Clearance (CRCL) Estimated Glomerular Filtration Rate (eGFR)
The "lol"s are used to treat
Current or hx of MI Hypertension Angina Dysthymias Heart Failure Symptoms of Hyperthyroidism Anxiety
The client's medication administration record (MAR) lists the client's antiepileptic medication that is due at 0900 as an oral tablet, but the client is NPO (nothing to eat or drink) pending a barium swallow evaluation. Which action should the nurse perform next? A. Give the tablet with a small sip of water B. Override the medication dispensing system and administer the same medication in intravenous (IV) form C. Hold the medication until the client has returned from the procedure D. Call the health care provider (HCP) to clarify the order
D
Parasympathetic involves the ___ activities
D (Digestion, Defecation, Diuresis)
If overdosed on a Cholinergic Drug what do you expect to see?
DUMBBBELS Defecation/ Diarrhea Urination Miosis (Pupil Constriction) Bradycardia Bronchspasm Bronchorrhea (Mucus w/in lungs) Emesis (vomiting) Lacrimation Salivation/Secretions
Signs of Muscarinic Overactivation
DUMBBBELS Defecation/Diarrhea Urination Miosis Bradycardia Bronchospasm Bronchorrhea Emesis Lacrimation Salivation/Secretions
Adverse Effects of BethaneCHOL (rare at normal doses)
DUMBBBELS Increased salivation, Gastric Acid secretion Abdominal cramps Diarrhea Exacerbation of asthma- (in rest and digest state the lungs are now constricted)
Atropine can be considered and anti-
DUMBBBELS drug
What drug counters malignant hyperthermia?
Dantrolene
A pt is taking Tylenol (acetaminophen) but has exceeded the maximum dosage. Exceeding the maximum dosage is known to harm the liver. What is a medical term for this?
Drug Induced Liver Injuruy Acetaminophen Toxicity
What is a protein-bound drug?
Drugs that attach to protein and stays in the bloodstream. Cannot get to extravascular space to its target.
B1 Antagonists (metoprolol tartrate) are used to treat what heart related issues?
Dysrhythmias MI Heart Failure Hypertension Symptoms of Hyperthyroidism
The sympathetic nervous system involves _____ activities
E (Exercise, Excitement, Emergency, Embarrassment)
A pt is taking Tylenol (acetaminophen) but has exceeded the maximum dosage. Exceeding the maximum dosage is known to harm the liver. What will the lab numbers look like?
Elevated
"sin" (a1 blockers) are commonly given when and why?
Generally given at bedtime to reduce the risk for postural/orthostatic hypotension
Lifespan considerations of SOFT drugs
Geriatric Pts are very susceptible to developing adverse effects of anticholinergics
Lifespan considerations of Atropine
Geriatric pts are susceptible to developing adverse effects of anticholinergics
B1 Antagonists (metoprolol tartrate) are used to treat what non-heart related issues?
Glaucoma Anxiety Hyperthyroidism
Atropine Contraindications
Glaucoma Benign Prostatic Hyperplasia (BPH) Urinary retention/hesitancy
Which of the following factors influence Metabolism? -Grapefruit Juice -acute kidney injury -Gut Malabsorption Issue -Hepatic Necrosis -Drug Interaction with Liver Enzyme Inducers -Heart Failure -Alzheimer's Disease -Hypertension -Chronic Kidney Disease
Grapefruit Juice Hepatic Necrosis Drug Interactions w/ Liver Enzyme Inducers
Extremely Rare adverse effects of BethaneCHOL (Cholinergic agent)
Hypotension Bradycardia This drug enhances PARAsympathetic- Decreased BP or HR
Pediatric Considerations: Metabolism
Immature liver, does not produce enough enzymes Older children may have increased metabolism, requiring higher doses than infants
Vasopressor infiltration drug (antidote)
Phentolamine
Most common highly protein bound drug
Phenytoin
What happens if you give Warfarin with Phenytoin
Phenytoin is in inDucer so it Drops levels of the other drug
Category D drugs and pregnancy
Possible fetal risk in humans has been reported; in selected cases consideration of potential benefit vs. risk may warrant use
When a patient has impaired liver function, what are some potential different medical terms? cirrhosis anuria nephrotoxicity paresthesia declined renal function hepatic necrosis hepatotoxicity oliguria drug induced liver injury tardive dyskinesia
cirrhosis hepatic necrosis hepatotoxicity drug induced liver injury
Examples if some drug classes that we do not change manufacturers for
Thyroid Epilepsy Transplant
What is a Free Drug?
Unbound; it can leave capillaries when it wants. It is not bound to a protein. (Active)
Intended outcome for Acetylcholinesterase Inhibitors
Urinary Retention Relief
Adrenergic drugs are generally agonists at ____ receptors
a or B
Schedule II drugs
a type of drug with medicinal uses that is highly addictive and have a high abuse potential and only available with a prescription
Tamsulosin (Flomax) is what kind of drug?
a1 blocker
When do we draw a Peak?
about 30 mins after a dose
Indirect Cholinergic Acting Agents inhibit
acetylcholinesterase (An enzyme that breaks down acetylcholine)
Beta Blocker eye drops block ______
adrenaline in the eye.
Pilocarpine MOA
agonist at cholinergic (muscarinic) receptors which causes secretions (sweating, salivation, GI tract) EYE= causes Miosis, decrease intra-ocular pressure
Adrenergic drugs are
agonists
Prazosin is what type of drug?
alpha 1 blocker
Nicotinic Division Receptors are important for _____
anesthesia/paralyzing agent drugs. Important for ED,ICU, OR, Anesthesia
Orthostatic/postural hypotension is commonly seen with _____ medications
anti-hypertensive
What is clozapine?
antipsychotic that lowers Absolute Neutrophil Count (ANC) which increases the risk for infection
4 Anti-Cholinergic Drugs
atropine, oxybutynin, solifenacin, tolterodine
When administering Pilocarpine
avoid taking with high fat meal and stay hydrated
Indirecting Acting Cholinergic Agents do no
bind to receptors
Alpha 1 Antagonists address ______ and _____ conerns
bladder and prostate
If patient is allergic to morphine, this is considered a _______ of morphine.
contraindication