Pharm Final
what should pts do when on codeine
should increase fluids to liquefy secretions and minimize constipation
Benzodiapiens (lorazepam and clonazepam) CI
sleep apnea/respiratory depression
k+ sparing diuretics for htn
spironolactone
serotonin syndrome action
stop drug, call physician, supportive care
serotonin syndrome action
strop drug, call physician, supportive care (IV, antipyretics, cooling blankets)
Neuromuscular blocking agents
succinylcholine-rapid intubation, resp depression, malignancy hyperthermia. Nursing: remain at bedside, keep emergency equip near, teaching about muscle pain, temp paralysis
Clonazepam SE
suicidal thoughts, behavioral changes, drowsiness, ataxia, incr. secretions, palpitations, dependence and tolerance, slurred speech, dizzy, lethargy, n/v, dry mouth, blurred vision, hypotension, tolerance, paradoxical excitation
which information would the nurse include when teaching a client with parkinsons disease about carbidopa-levodopa
the medication should be taken with meals
low CO symptoms
tired, dizzy, light headed
What happens if GABA is not present
epilepsy -seizure and anxietydoesnt have GABA to settle the brain down
heparin uses
evolving stroke, pulmonary embolism, massive DVT;; treatment of DIC
AE: NSAIDs
gi upset, should not take if h/o ulcers!! increased bp, renal failure (rare) CNS Dermatologic hematologic Wt gain/edema age
If vitamin K does not work give what ?
give fresh frozen plasma or whole blood to replace needed clotting factors
spironolactone se
hyperkalemia, gynecomastia
heparin CI
hypersensitivity, bleeding disorders, severe low PLT; during labor or post-partum, recent, surgery/trauma
low MCV
iron deficiency hemoglobinopathy chronic disease lead poisoning
How is parkinsons disease related to dopamine
its a loss of dopamine secreting neurons
Benzodiazepines
lorazepam and clonazepam
what is something you always need to be prepared for when giving succinylcholine
loss of airway NEED TO BE PREPARED
beta blockers for HTN
lower CO, lower renin secretion due to beta1-receptor blockade on JGA cells
NSAIDS
medication that exerts analgesic and anti-inflammatory actions -ibuprogen (motrin, advil), indomethacin (indocin); naproxen (naprosyn); ketorolac (Toradol) -Inhibit cyclooxygenase and prevent synthesis of prostaglandins and thromboxane -reduce inflammatory process and pain
Benzodiazepines MOA
Faciliate GABAa action by increasing frequency of chloride channel opening Decrease REM sleep Long half-lives and active metabolites (except: triazolam, oxazepam, and midazolam are short acting--> higher addictive potential)
iron deficiency anemia manifestations
Fatigue, lethargy, pallor of nail beds, intolerance to cold, headache, tachycardia
SSRIs
Fluoxetine, paroxetine, sertraline, citalopram.
SE of lithium
GI distress- N/Diarrhea, abdominal pain -Bradycardia, hypotension, electrolyte imbalances -Fine hand tremors -polyuria; mild thirst weight gain -renal toxicity -goiter and hypothyroidism
Iron toxicity symptoms
GI distress; iron overload: infections, fatigue, joint pain, skin pigmentation, organ damage
carbidopa-levodopa adverse effects
GI: N/V most common Orthostatic hypotension (most common after first starting drug) Ataxia, dyskinetic movements(blepharospasm, twitching, head bobbing, tics) Especially during initiation of therapyamantadine (Symmetrel) may help with this Psychosis, hallucinations, paranoia (b/cof activation of dopamine receptors)may need antipsychotics Depression, SI Cardiac dysrhythmias Hepatoxicity Darkening of sweat and urine
adverse effects of phenytoin
Gingival hyperplasia, nystagmus, diplopia and ataxia
Cholinesterase inhibitors interventions
Give w/food (decreases GI s/s) :Wt loss GI bleeding CNS effects (insomnia, dizziness) Assist w/ambulation Notify Md if CNS effects interfere w/comfort Monitor HR, BP,RR
Fluoxetine (prozac) Sertraline MOA
SSRIs Selectively inhibits serotonin reuptake resulting in more serotonin at neuronal junction Long half-life
Serotonin Syndrome
Similar to NMS but caused by serotonin medications, and has HYPERreflexive muscle activity
SSRI interaction
St. John's Wort
Lupus triggers
Sunlight Smoking Infectious agents Stress Drugs Pregnancy
Heparin aPTT therapeutic range
Usually 60-80 seconds is therapeutic level but it would be 1.5-2.0x whatever the lab control is May vary based on reason for therapy and other pt conditions
Treating iron toxicity
Usually starts with GI sx then pt seems to improve Do not be fooled........systemic damage is occurring (metabolic acidosis, bleeding, shock, etc.) Gastric lavage and bowel irrigations are used to try to rid any iron left in gut Chelating (binding) agent deferoxamine (Desferal)binds with iron and promotes excretion through kidneys
Warfarin antagonist
Vitamin K
IV heparin infusion
Will follow agency specific protocol Always check baseline Aptt before starting infusion Confirm dosage/rate in the order received Check aPTT every 4-6 hours for the first 24 hours Once stable, then it may go to checking aPTT once daily Monitor for occult or obvious bleeding at all times when on heparin drip Have protamine sulfate available incase it is needed Heparin may have to be stopped for PLT count of less than 100,000
warfarin action
Interferes with synthesis of Vitamin K-dependent clotting factors No effects on PLTs Does not "thin the blood" Drug prevents liver from producing key clotting proteins thus blood will not clot as easily
characteristics of parkinson disease
Involutary tremors of limbs Rigidity of muscles Bradykinesia (slow movement) Postural changes Head and chest thrown forward Shuffling walk Lack of facial expression Pill-rolling motion of hands
succinylcholine MOA
mimic acetylcholine bind with cholinergic receptors at NM junction Causes muscle fasciculations then paralysis
fentanyl uses
moderate to severe pain, used pre and postoperatively for analgesic effect
Lorazepam SE
drowsiness, dizziness, weakness, ataxia, lightheadedness, withdrawal symptoms when DC
Dantrolene (baclofen)
drug that acts directly on muscles Used for M.S., Cerebral palsy; spinal cord injury, Malignant hyperthermia
which instruction will the nurse include when teaching a client with Parkinson's disease who is prescribed carbidopa- levodopa
"you may experience dizziness when moving form sitting to standing"
types of anemia
- Aplastic - Iron Deficiency - Folic Acid Deficiency - Vitamin B12 Deficiency - Sickle Cell
Clonidine nursing interventions
- Monitor B/P - Monitor I & OWeigh daily - Change positions slowly due to orthostatic hypotension - Do not take OTC meds, alcohol or CNS depressants until discuss w/HCP - Avoid overheated or dehydration
interventions for lupus
- assess BUN and creatinine for kidney function - assess the temperature of hands and feet: Raynaud's phenomenon - avoid prolonged sun exposure: increases inflammation in the body
lupus patient education
- sun exposure -smoking -stress -sepsis
fluoxetine + sertraline DI
- use of MAOIs or TCA antidepressant can cause serotonin syndrome -st johns wort
Lupus s/s
-A butterfly rash over the cheeks and nose -Fever higher than 100 (report to HCP) -Joints are painful and swollen
carbidopa added to reduce A.E
-Also slows breakdown of levodopa (=more dopamine) -Carbidopa is the "car" that drops off levodopa in the brain
Dopamine replacement contraindications
-Angle-closure glaucoma -Hypersensitivity -Do not use with MAO inhibitors -Do not use in pregnancy or lactation -Psychosis, suicidal
heparin patient education
-Avoid OTC preparations that may cause serious product interactions unless directed by prescriber; to notify all health care persons of heparin use -That product may be held during active bleeding (menstruation), depending on condition -To use soft-bristle toothbrush to avoid bleeding gums; to avoid contact sports; to use an electric razor; to avoid IM injection -To carry emergency ID identifying product taken -Bleeding: report any signs of bleeding (gums, under skin, urine, stools) -Report signs of hypersensitivity: rash, chills, fever, itching
heparin adverse effects
-Bleeding! also bruising and rash, low platelets-Thrombocytopenia is b/c of autoimmune rxn to proteins in heparin
Acetylcholine
-Cholinergic fibers-Causes parasympathetic effects-e.g., slows HR
precautions of phenytoin (dilantin)
-DM -Resp dysfunction -liver, renal d/o -monitor carefully in those whose are older -alcoholism, increased risk of toxicity
Common benzodiazepines for anesthesia and sedative-hyponotics
-Diazepam (high doses for IV anesthesia) -Midazolam (high doses for IV anesthesia) -Iorazepam
buspirone SE/AE
-Dizziness, lighteheadedness, HA, agitation -Nausea
Clonidine patient teaching
-Do NOT stop abruptly -Safety concerns.... .-Take own BP -Dry mouth
education about morphine
-Educate pt about orthostatis hypotension -Caution in elders of those with increased ICP, hepatic or renal disease, or pulm disease -Caution with other CNS depressants (e.g. other pain meds, sedative, alcohol, antihistamines) -Dependence can become an issue-safety issues; falls
who it at risk for toxicity with ferrous sulfate
-Elderly at risk of toxicity; usually require lower dosages of iron -Iron poisoning particularly common in children 6 years old and younger. Leading cause of poisoning fatalities
lithium DI
-Encourage diet adequate in sodium -kidneys process lithium and Na in the same way so there must be adequate Na levels -increase fluids (2,000-3,000) -Avoid NSAIDs (increase renal absorption of lithium) -Avoid anticholinergics (urinary retention)
ferrous sulfate AE
-GI upset: anorexia, nausea, constipation, diarrhea -Dark or black stools -Skin rash or urticaria -If liquid form, stains teeth
TCA nursing education
-Get up slowly, monitor P &BP before administration, 1 hr after (notify provider prn) -minimize, notify provider if persistent -less over time, avoid hazardous activities, take @ hs
dopamine replacement patient education
-Give with food-Moderate protein diet -Avoid excessive pyroxidine (vitamin B6) -High fiber diet; increased fluid intake -Never stop drug abruptly -can cause neuroleptic malignant syndrome
nursing management NSAIDs
-Good PO absorption; some also in IM form -Higher incidence of anaphylaxis with ASA allergy -Pts with ASA allergy, nasal polyps, and bronchospastic disease may experience bronchospasm and respiratory failure -Use caution in elderly or those with hepatic or renal impairment, ulcerative GI disease
spironolactone nursing interventions
-I&O -daily weights -electrolytes -VS -report palpitations
AD severe or stage 3
-Incapacitated; bedridden -Agnosia (cannot recognize faces) -No independent ADLs -Cannot communicate -Loss of mobility
Bupropion MI
-MAOIs increase toxicity -d/c MAOIs 2 weeks before starting bupropion
acetaminophen toxicity
-Monitor for abd discomfort, nausea, vomiting, sweating, diarrhea -Liver damage results in 48-72 hours after overdose ◦ Look for jaundice, scleral icterus -Prepare to administer acetylcysteine (Mucomyst) oral or IV to counteract overdose and reduce liver damage -DO NOT exceed 4 grams per day (adults) ◦ May be some variation of this by source; some products state to use less than that; or with certain medical conditions use less -Younger kids, no more than 2600 mg/day
Dopamine replacement interventions
-Monitor for dyskinesia before and after therapy -What would be a sign of toxicity? -Monitor mental status, GI SE -Help w/ambulation (orthostatic hypotension)
Teaching about beta blockers
-Never stop drug abruptly -never double up -report dizziness, decreased pulse, weakness or fatigue -If pt has diabetes, be more careful b/c beta blockers mask hypoglycemia
ibuprofen
-Non-aspirin 1st generation NSAID -Like aspirin, inhibits cyclooxygenase -analgesic, anti-inflammatory and antipyretic actions -usually well tolerated in safe doses -less gastric bleeding than aspirin -less PLT aggregation -Safer than aspirin with anticoagulation's (thought still not a great idea!)
ibuprofen ae
-PUD-Increased Gastric Acid -Irritate gastric mucosa -Inhibit prostaglandin synthesis -Liver & renal impairment (monitor renal function(BUN, Scr) & liver function (AST, ALT) -Non-severe AE by opioids -MI/Stroke (not the case with aspirin) -Does not inhibit PLT aggregation (leads to thrombosis) -Inhibits COX-2: increased vasoconstriction, which makes it worse once thrombosis begins
Dopamine
-Precursor in synthesis of ego and norepinephrine -Found in substantial nigra, midbrain, hypothalamus, and basal ganglia -Also found outside the brain -May be inhibitory or excitatory -Important role in smooth movements
diagnostic lab studies for RBC abnormalities
-Red blood cell - norm: 4-6 million-Hemoglobin (HGB)- Norm: 12-16.5g/dl-Hematocrit (HCT) - Norm- 37-50%
With heparin and warfarin clients should
-Report any bleeding (gums, GU, GI, bruising, nosebleeds) -Report GI distress -Avoid injury -Be consistent about vit K intake while on warfarin -Have PT/INR every 2-4 weeks (at least) once dose of warfarin is stable -Nurses: avoid IM injection or other invasive procedures (If possible)
AE of midazolam
-Resp depression, apnea -Hypotension -Cardiac arrest -Prolonged sleepiness, amnesia
Vitamin K
-Reverses anticoagulant effects of warfarin
Alzheimers early/mild or stage 1
-Still independent with ADLs-Denies anything is wrong -S.T., memory loss; forgets names, misplaces things -Dec. spontanity, dec. social interactions -Subtle personality changes, mild impaired cognition which is worsened by stress -Dec. sense of smell in some pts -Cant travel to new places alone -phase lasts up to 4 years
patient education about cholinesterase inhibitors
-Take at HS (helps GI SE) -Report any AE from previous Slides -NSAIDS increase risk of GI bleed -Anticholinergic drugs dec effectiveness
Fluoxetine + sertraline education
-Take with food to decrease Gi distress -Take in AM to decrease sleep problems -take on daily basis -therapeutic effects seen in 1-3 weeks
what may atropine sulfate be used for
-antidote for cholinergic toxicity-inhibits action of Act-Inhibits action of acetylcholine-blocks vagus nerve = increased HR and CO-Used to treat bradycardia-Also used to dry up secretion and treat PD tremor-Antidote is physotigmine
fentanyl
-approximately 100 times stronger than morphine -parenteral, transdermal, transmucosal, intranasal
Nursing interventions of midazolem
-be sure pt has a good airway -VS -Antiemetics as ordered -Give ordered oxygen -Give slowly over 2 or more minutes -wait for 2 or more minutes to assess effect, then repeat if necessary
warfarin AE
-bleeding is main AE, especially if INR is greater than 3.5 and in elderly patients
side effects of phenytoin (dilantin
-blunted -more sedated -Gingival hyperplasia (excessive gums, need good oral health) -Rash the may turn into SJS or toxic epidermal necrolysis -Purple glove syndrome -hirsutism -numerous interactions with other meds -pregnancy category D (fetal deformitites)
AE of beta blockers
-bradycardia, decreased CO -orthostatic hypotension -AV block -Masks s/s of hypoglycemia -sometimes sexual dysfunction -depression in some pts -bronchoconstriction in some pts -Bronchoconstriction (seen with propranolol b/c of beta-2 blocking)
Drugs that decrease effectiveness of warfarin
-chronic alcohol use (not binge drinking) -Carbamazepine, pheobarbital, phenytoin -estrogens, oral contraceptives -Rifampin -Vitamin K
SLE labs
-creatinine over 1.3 - Bad kidney -Decreased WBC (norm. 5,000-10,000) -inflammation (increased ESR and CRP)
Typical monitoring of INR
-daily x 5 days when warfarin is started -Twice a week for next 1-2 weeks -Once a week next 1-2 months -Every 2-4 weeks thereafter -If dose is changed, requires careful INR monitoring
Effects of beta blockers
-decrease HR and RR -Decreases Blood pressure -Decrease contractility -Decrease cardiac output -Slowed AV conduction/AV heart block -Decreased automaticity -Bronchial Constriction (beta 2 only) -decrease glycogenolysis (may lead to hypoglycemia)
Anemia manifestations
-decreased HGB, HCT, and RBC -manifestations caused by decreased oxygen -carrying capacity
dopamine replacement precautions
-depression, bipolar-renal, liver, resp, endocrine d/o-PUD-older adults
Clonidine SE/AE
-dry mouth (xerostomia) -drowsiness -Rebound HTN
SE/AE of SSRIs
-early on: nausea, headache, CNS stimulation (nervousness, insomnia, anxiety) should subside with time -later: sexual dysfunction -report to MD; may need to decrease dose, change med or "med holiday" -weight gain-withdrawal syndrome (nausea, anxiety, malaise) -Taper drug, dont d/c abruptly -also a problem for fetus later in pregnancy -hyponatremia (older clients on diuretics) -serotonin syndrome -less common: --EPS SE --GI bleeding --Bruxism --Dizziness, fatigue
who is at risk for toxicity with ferrous sulfate
-elderly at risk of toxicity; usually require lower dosages of iron -common in children years old and younger.
early features of clinical manifestations of parkinsons disease
-fatigue-depression -slight tremor -loss of smell -softer speech or handwriting change -loss of facial expression
Anti anemics for Fe deficiency
-ferrous sulfate: oral -Iron dextran: parenteral
therapeutic effects of cholinesterase inhibitors
-help increase ACh which may improve cognitive ability/function -Prevents acetylcholinesterase from inactivating acetylcholine in the brain -Makes more acetylcholine available in brain=more cognitive function -Drugs to NOT cure Alzheimers -Currently no therapy to target the underlying pathology of the disease -Drugs only benefit 1 in 12 pts
Neurolpetic Malignant Syndrome (NMS) manifestations
-hyperthermia -Rigidity -Tachycardia, unstable BP -life-threatening -ANS is unstable -Early s/s: muscle cramp, tremors, fever, BP changes, altered LOC
Alzheimers disease moderate or stage 2
-impaired cognition with all functions -Speech/language issues; sometimes aphasic -Money/finance issues -Disoriented; time, place, event -not independent with ADLs; incontinent -Can be restless, depressed, agitated, may wander, sleep issues -"sundown syndrome" -Inappropriate behavior/repetitive behavior -Can get lost; trouble with driving -phase lasts 2-3yrs
physical s/s of pain
-increased HR, BP, and RR -Dilated pupils, respiration, pallor
general signs and symptoms of anemia
-increased heart rate -increased respiration -fatigue -decreased activity tolerance -pallor -white palmar creases and pale conjunctiva
Contraindications of cholinesterase inhibitors
-kids -active or H/O GI bleed -Jaundice
Common manifestations Alzheimers disease
-loss of short-term memory -Disorientation -Communication issues: apraxia(unfamiliar with objects), aphasia (cant speak), agnosia (loss of sensory comprehension), anomia (can't find words) -Impaired ability to think abstractly or use judgment -Changes in affect and personality
Foods with highest amount of vitamin K
-mayonnaise -egg yolks -canola and soybean oil -Green leafy veggies -Asparagus, broccoli, brussels sprouts, Tuna fish in oil -Kiwi fruit
Tramadol (Ultram)
-miscellaneous analgesic; schedule IV controlled substance -bind to selected opioid
Buspirone interventions
-most side effects are self-limiting -take with food
mean corpuscular concentration
-norm 31-35-indicated concentration of HGB (color)-Normochromic, hypochromic
patch form of fentanyl
-onset slow but lasts about 3 days -Patches should not be used in patients who are opioid tolerant and NOT used for acute pain -Always avoid heat over patch, will increase diffusion into patient -Flush patch down toilet at home, at hospital, check policy
Hydantoins: phenytoin (dilatin) CI
-preg cat: D -Skin rash -bradycardia, heart block -seizures caused by low blood sugar
Nursing interventions re: hydantoins -phenytoin (dilantin)
-pregnancy -blood levels -Skin (rash) -gums -circulation -compliancy
warfarin contraindications/precautions
-pregnancy/lactation; Vit K def., bleeding, liver and kidney disease, PUD, thrombocytopenia, severe HTN, certain surgical procedures
Later (cardinal) features of parkinsons disease
-rigidity -bradykinesia -tremor -mask-like facies -stopped posture and shuffling gait -orthostatic hypotension -speech difficulties
tramadol se/ae
-sedation, dizziness, HA; rare seizures -N/V, constipation, dry mouth -Urinary retention Low potential for abuse, dependence but avoid in addicted
contraindications of beta blockers
-severe bradycardia, cardiogenic shock, complete heart block, severe airway disease, clinical depression
Oxycodone
-similar structure to morphine -Comparable analgesia compared to morphine -When combined with acetaminophen, brand name is percocet -Has immediate release form: OxyIR -Has sustained release form: OxyContin -New formulation makes crushing tab for misuse harder to do
education about SSRI
-take with food to decrease GI distress -take in AM to decrease sleep problems -take on daily basis -therapeutic effects seen in 1-3 wees
Precautions of beta blockers
-use cautiously in patients with peripheral vascular disease as it may increase symptoms of PVD
treating iron toxicity
-usually starts with GI sx then pt seems to improve -do not be fooled....systemic damage is occurring (metabolic acidosis, bleeding, shock, etc.) -Gastric lavage and bowel irrigations are used to try to rid any iron left in gut -Chelating (binding) agent deferoxamine (desferal) binds with iron and promotes excretion through kidneys
Hydrocodone
-weaker than oxycodone -very common used -only in tablet form -when combined with acetaminophen: Vicodin, Noro -also a schedule II drug, like the other opioids discussed
Lithium therapeutic range
0.4-1.0 mEq/L
Lithium ideal range
0.6-0.8
Beta blocker effects in treating HTN
1- decrease heart rate and contractility 2-decrease reflex tachycardia 3-Decrease renin response 4-
Bupropion SE/AE
1. HA, dry mouth, increased heart rate. nausea, restlessness, insomnia 2. constipation, wt. loss 3. Seizures
Buproprion Nurisng interventions
1. Monitor/report if intolerable;analgesic for HA, 2. Fiber/fluids; monitor weight& intake 3. Avoid for those at risk for seizures (head injury);monitor & treat for seizures
Anti-seizure drugs: general facts
1. Most anti-epileptic drugs (AEDs) alter NA channels and neurotransmitters (NTs) -increases GABA, restores NT balance -Makes neurons less excitable -Increases seizure threshold -blocks abnormal nerve stimulus 2. AED depends on pt variables and seizure type 3. AEDs are CNS depressants(people are more blunt) 4. sudden withdrawal may precipitate seizures 5. Nursing Implications (take drugs regularly, drug levels, avoid other CNS depressants (alcohol)
Benzodiazepines (lorazepam and Clonazepam) education
1. Take as prescribed 2. avoid abrupt d/c to prevent withdrawal symptoms 3. GI upset= give with food 4. Dont crush/chew SR tabs 5. possibility of dependency
Levels must be kept under what with lithium or serious toxicity can occur
1.5 monitor levels every 2-3 days in early therapy, every 3-6 months in maintenance therapy
Advanced lithium toxicity
1.5-2.0 mEq/L; manifestations: mental confusion, sedation, poor, coordination, coarse tremors, ongoing GI distress (nausea, vomiting, diarrhea) Stop med, notify provider New dosage based on level
Lithium nursing education
1.Monitor lithium levels (12 hrs. after last dose) 2.Teach client s/s lithium toxicity, when to call provider (stop med, seek medical help: diarrhea, vomiting, excessive sweating) 3.Toxic lithium levels = hospitalization 4. Narrow therapeutic range: keep lab appts. 5. Lag period (7-14 days) 6. Take as prescribed, divided doses, with food 7. Nutritional counseling (fluids, sodium)
Antidepressant general education points
1.Take as prescribed daily 2.Educate about lag period 3.Continue therapy (6-12 months) to prevent relapse 4.Suicide prevention (TCAs) 5.SSRIs: AM, with food, baselinesodium 6.MAOIs: give list of tyramine-richfoods
therapeutic level of phenytoin
10-20 mcg/mL
hemoglobin norm
12-16 g/dL
severe lithium toxicity
2 to 2.5 mEq/L -Ataxia -Serious EEG changes -Blurred vision -Clonic movements -Large output of dilute urine -Tinnitus -Seizures -Stupor -Severe hypotension -Coma -Death is usually secondary to pulmonary complications Interventions: There is no known antidote for lithium poisoning. The drug is stopped, and excretion is hastened. If patient is alert, an emetic is administered. Otherwise, gastric lavage and treatment with urea, mannitol, and aminophylline hasten lithium excretion.
hematocrit norm
37-50%
carbamazepine drug level
4-12 mcg/mL
When given hydantoins: phenytoin (Dilantin) IV what should the nurse do
50 mg/min cardiac monitor
anemia
A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume.
Glutamate
A major excitatory neurotransmitter; involved in memory Glutamate Normally= learning and memory Too much glutamate in patients with Alzheimers Excess glutamate is excitatory
Parksinsons disease
A progressive, degenerative change in the basal nuclei. Associated with lack of dopamine in the substantia nigra, and results in a loss off controlled movement and coordination
ARB patient teaching
Advise patients to: Have blood pressure checked regularly Rise slowly from sitting Avoid situations that reduce blood pressure such as dehydration, excessive sweating Continue the medication even though you feel well Refrain from taking potassium supplements unless ordered by your provider
serotonin syndrome s/s
Agitation, confusion, disorientation, difficulty concentrating, anxiety, hallucinations, hyperreflexia, fever, diaphoresis, incoordination, tremors Usually begins 2 to 72 hr after initiation of treatment Resolves when the medication is discontinued
MOA of phenytoin
Alters the movement of sodium, potassium, calcium, and magnesium ions which decreases the discharge of neurons
causes and risks for SLE
Asian and native American hormones
antidote for taking too much donepezil
Atropine
Nurisng interventions for diuretics for HTN treatment
Baseline VS, RR Monitor daily weights, I/O, serumlytes Would expect increase in U/Oand lower BP Teaching: How and when to take meds SE/AE Lifestyle changes How/when to check BP F/U with HCP What to report to HC
Atypical anxiolytic/nonbarbiturate anxiolytic
Buspirone (Buspar) Utilized to decrease anxiety without causing sedation or CNS depression
spironolactone use
CHF, hypertension
MAOIs (Phenelzine) SE/AE
CNS stimulation (anxiety, agitation, mania ,hypomania) Orthostatic hypotension Hypertensive crisis (intake of tyramine) IV phentolamine (Regitine), nitroprusside Local rash with selegiline patch
Celecoxib (Celebrex)
COX-2 inhibitor -FDA recommends only being used if other NSAIDs are effective -Safety concerns.....may cause MI or CVA resulting in death!!! -May have less chance of GI side effects than other NSAIDs (research unclear) -Still has risk of renal injury
iminostilbenes
Carbamazepine (Tegretol) -AEDs -Also work for bipolar d/o and tigeminal nerve pain -work similarly to hydantoins -inhibit Na influx, decreasing discharge of neuron in high activity areas
Drugs to treat Alzheimer's
Cholinesterase inhibitors(increase ACh) -inhibits the enzyme that produces acetylcholine -donepezil (Aricept) -Rivastigmine (echelon) -Galantamine (reminds) NMDA Antagonist SSRIs Antianxiety (lorazepam and oxazepam) Antipsychotics-->used with extreme caution Anticonvulsants
Centrally acting alpha agonists
Clonidine Methyldopa - Knocks down sympathetic nervous system (lower BP) -Not first line drug for HTN -PO or transdermal -Other uses: hot flashes (menopause), ADHD, ETOH W/D, severe CA or neuropathic pain
Spironolactone MOA
Competitive inhibition for aldosterone receptors in distal tubules, leading to increased excretion of fluid and sodium with increased potassium retention
Warfarin dosing
Dosage is determined by associated lab values Pts usually maintained by dose somewhere between 2-10 mg/day Drug action peaks in 1-9 hours Maximum effect takes 3-4 days Effects last 4-5 days after drug is stopped
SSRIs: Fluoxetine, Paroxetine, Sertraline, Citalopram SE/AE
Early on: nausea, headache, CNS stimulation [nervousness,insomnia, anxiety]........Should subside with time Later: sexual dysfunction Report to MD; may need to decrease dose, change med or "medholiday" Weight gain Withdrawal syndrome (nausea, anxiety, malaise) Taper drug; don't d/c abruptly Also a problem for fetus later in pregnancy Hyponatremia (older clients on diuretics) Get baseline Na; Monitor labs Serotonin Syndrome (more to come....) Less common: EPS SE GI bleeding Bruxism Dizziness, fatigue
Buproprion CI
Hx of epilepsy or seizures MAOIs Does not cause sexual dysfunction or weight gain
Furosemide CI
Hypersensitivity to furosemide; anuria
Losartan ci
Hypersensitivity to losartan or other angiotensin II receptor antagonists, pregnancy
fluoxetine + sertraline CI
Hypersensitivity; concomitant pimozide, thioridazine, or MAOIs
naloxone (Narcan) can be given
IV (onset 1-2min), IM (onset 2-5), SC (onset 2-5) -usual IV dose 0.4 to 2.0mg may be repeated every 2-3min up to 10 mg, if necessary
IV heparin monitoring
If APTT is higher than 80 or 90 seconds, MAY NEEDTO lower dose (depends on current protocol) If APTT is lower than 60 seconds, will likely need to increase dose Newer practice: measure Anti-Xa heparin assay level instead of aPTT If above 0.7 units/mL, may need to decrease dose If less than 0.3 units/mL may need to increase dose
Mean Corpuscular Volume (MCV)
Indicates the oxygen-carrying capacity of blood, indicates volume/size and maturity 85-100
spironolactone drug interactions
LIFE THREATENING WITH ACE INHIBITOR (they both spare potassium)
early lithium toxicity
Less than 1.5 mEq/L; manifestations: diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy Stop med, notify provider New dosage based on levels
precautions of cholinesterase inhibitors
Liver, renal, cardiac, GI, or pulmonary disorders Hyperthyroidism Seizures
iron deficiency anemia labs
Low: rbc, hgb, hct, MCV, MCH, ferritin, Fe High: TBIC Normal: Vit B12, folate
Angiotensin II Receptor Blockers (ARBs)
Lower blood pressure by blocking the angiotensin II enzyme from causing vasoconstriction. aldosterone secretion -Leads to vasodilation, excretion of NA and H20, and retention of k
TCA (amitriptyline) DI
MAOIs St johns wort Antihistamines sympathomimetics, ephedrine Alcohol, benzodiazepines, opioids, CNS depressants SSRIs
Lithium MOA and Use
MOA: Not established; possibly related to inhibition of phosphoinositol cascade. Use: Mood stabilizer for bipolar disorder; treats acute manic episodes and prevents relapse.
caution with acetaminophen
May cause liver damage and even liver necrosis
Therapeutic response of carbidopa - levodopa
May take up to 6 months time for full effect of these drugs Times of day when muscle rigidity and tremors recur "Wearing-off" Develops near the end of the dosing interval Too little dopamine in blood stream Need to be sure to regulate time and dose of drugs in these patients to prevent or minimize this "On-Off "EpisodesCan happen despite correct dosing, etc.
Nursing interventions for beta blockers
Measure Blood Pressure and Apical Pulse --les than 60 or look at trends Monitor for Hypotension Shortness of BreathMonitor for I/O
DI Phenelzine
Medications: cold medication, TCAs, SSRIs, antihypertensives NO meperidine (Demerol) Caution with vasopressors (caffeine, chocolate) Tyramine rich foods can lead to hypertensive crisis (aged or smoked cheese, meats, & fish; beers, red wine; soy sauce)
Furosemide patient teaching
Monitor BP and weight .Avoid sudden changes in position. Eat foods rich in K+ Report S&S associated with electrolyte imbalance.
monitor what with naloxone
Monitor VS, airway, RR, for ventricular/atrial dysrhythmias ◦ Expect adverse effects if giving naloxone to an opioid addict; withdrawal symptoms can be very severe ◦ Have oxygen, suction, and resuscitative equipment ready ◦ THE NURSE MUST BE PREPARED TO MANAGE THE PATIENT'SAIRWAY AS A FIRST PRIORITY!
naloxone (Narcan) ae
N/V/, dizziness, HTN, tachycardia, sweating, abd.cramps, confusion, mood change
lupus medications
NSAIDs Corticosteroids -Immunosuppressants (stops the body from attacking itself) -Hydroxychloroquine -methotrexate -infliximab -azathioprine Antimalarials
clonidine drug interactions
NSAIDs TCAs Beta-blockers Calcium channel blockers Cyclosporine
warfarin therapeutic level Pt/INR
Normal INR is around 0.8-1.2 for those NOT on anticoagulants Therapeutic ranges :1.5 = low level anticoagulation 2.0-3.0 = medium level anticoagulation (most patients are here) 2.5-3.5 = high level anticoagulation (e.g. prosthetic valves)
TCA (amitriptyline) contraindications
Not with seizure disorders No alcohol
Furosemide SE
OTOTOXICITY HYPOKALEMIA ->DYSRHYTHMIA DEHYDRATIONALLERGY-SULFA DRUG NEPHRITIS GOUT
MAOIs phenelzine MOA
Older class, usually 2nd or 3rd choice for pts Work well but are more hazardous than newer classes These medications block MAO in the brain Increasing the amount of norepinephrine, dopamine, and serotonin available for transmission of impulses Increased amount of these neurotransmitters at nerve endings relieves depression
warfarin
Oral anticoagulant prototype: causes synthesis of nonfunctional versions of the vitamin K− dependent clotting factors (II, VII, IX, X). Tox: bleeding, teratogenic. Antidote: vitamin K, fresh plasma
Benzodiazepines acute toxicity
Oral overdose: Drowsiness, lethargy, and confusion Intravenous toxicity: Life-threatening reactions, profound hypotension, respiratory arrest, and cardiac arrest General treatment measures Oral: Gastric lavage, activated charcoal, saline cathartic, and dialysis
Side effects of TCAs
Orthostatic hypotension Anticholinergic effects--dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia Sedation Toxicity Decreased seizure threshold Excessive sweating
TCA SE
Orthostatic hypotension is common (alpha1 effects) Anticholinergic (dry mouth, constipation, difficulty urinating, blurry vision) Nortriptyline is the least anticholinergic and least likely to cause hypotension (TCA of choice in elderly) Cardiac- arrhythmogenic and very dangerous in overdose (need and EKG prior to starting on TCAs) Therapeutic window is small
route of morphine
PO, IM, IV, SC, PR, epidural, intrathecal
heparin labs
PTT + aPTT think H has two T's
ferrous sulfate CI
PUD, severe liver disease, Inflammatory intestinal disorders
SJS
Prodrome of fever, malaise followed by rapid onset of erythematous/pruritic macules [Oral, ocular, genital]. Skin lesions progress to epidermal necrosis and sloughing
How do I know if my lithium is working for my bipolar
Relief of acute manic symptoms (flight of ideas, obsessive talking, agitation) or depressive symptoms Verbalizing improvement in mood Ability to perform ADLs Improved sleep & appetite Improved interaction with peers
morphine adverse effects
Respiratory depression, hypotension, nausea, vomiting, somnolence, constipation, diaphoresis, urinary retention, cough suppression, biliary colic, N/V, elecation of ICP, euphoria/dysphoria, sedation,
Nursing interventions for TCAs
Teach patient to report blurred vision, excessive drowsiness, sleepiness, urinary retention, constipation, and cognitive impairment. *Fatal if OD. Can be used after SSRI's fail.
warfarin uses
To prevent thrombosis associated with PE, MI, unstable angina, prosthetic heart valves, DVT. To treat atrial fibrillation
Benzo withdrawal symptoms
Tremors, Agitation, Anxiety, Abdominal Cramps, N/V, seizures, Dizziness, diasphoresis Assist with ADL's
TCA toxicity
Tri-C's: convulsion, coma, cardiotoxicity (arrhythmias), - resp depression, hyperpyrexia,
which nursing priority is the priority when caring for a patient treated with warfarin who received a new medication prescription for cimetidine? a. monitor the patient for increased action of the anticoagulant b. monitor the patient for decreased action the anticoagulant c. monitor the patient for increased action of cimetidine d. Monitor the patient for decreased action of cimetidine
a
GABA
a major inhibitory neurotransmitter-synthesized in cerebellum, basal ganglia, cerebral cortex, and spinal cord
normal MCV
acute bleeding aplastic hemolytic low erythropoietin malignancy
vitamin K administration
administer 0.5-1mg itno vastus lateralis during first 24hrs of life IV Oral form: usually 2.5 mg dosage
Clonidine
alpha 2 agonist stimulates alpha 2 receptors opposes SNS- blower HR Vasodilates
Tricyclic Antidepressants (TCAs)
amitriptyline, imipramine, clomipramine
codeine use
analgesic and antitusive effects, antidiarrheal effects weaker effects than morphine, often given with acetaminophen
iron deficiency anemia
anemia resulting when there is not enough iron to build hemoglobin for red blood cells
Midazolam is used for what
anesthesia induction agent, pre-op sedation, for intubated pts, and for conscious sedation
Clonidine CI
angina. MI, CRF, pregnancy, lactation
Angiotensin II receptor blockers (losartan) SE/AE
angioedema hyperkalemia Renal failure and fetal harm
spironolactone CI
anuria, acute renal insufficiency, hyperkalemia
selective beta blockers
atenolol (Tenormin) metoprolol (Lopressor) bisoprolol (sebeta) esmolol (brevibloc)
The nurse is caring for a patient who is being treated with warfarin and who is scheduled to be place on phenytoin. The nurse anticipates which effect will occur when the phenytoin is administered? a. increased effect of the warfarin b. decreased effect of the warfarin c. therapeutic effect of the warfarin d. anaphylactic reaction to the warfarin
b
a patient with deep vein thrombosis receiving an intravenous heparin infusion asks the nurse how this medication works. Which response would the nurse make? a. "heparin converts plasminogen to plasma, which in turn dissolves the clot matrix" b. "Heparin suppresses coagulation by helping antithrombin perform its natural functions" c. "heparin prevents activation of vitamin k and thus blocks synthesis of some clotting factors" d. "heparin inhibits the enzyme responsible for platelet activation and aggregation within vessels"
b
which substance will the nurse administer to reverse the effect of warfarin in a patient who has received too high of a warfarin dosage? a. aspriin b. calcium c. potassium d. phytonadione
b
clonidine DI
beta blockers, tricylics
heparin action
binds with antithrombin which inactivated clotting factors thrombin and factor Xa, so fibrin is not formed
Acetaminophen (Tylenol) action
blocks prostaglandin synthesis to reduce pain and fever but it is NOT an NSAIDs
causes of anemia
blood loss, low RBC production, high RBC destruction
Beta blocker CI
bradycardia, cardiogenic shock
codeine isnt good for who
breastfeeding moms
What may you find in the brain of a patient with Alzheimer's
build-up of amyloid plaques and neurofibrillary tangles
ferrous sulfate toxicity
early -diarrhea that may contain blood -severe abdominal cramping or pain -nausea or vomiting -elevated temperature -shock Later -acidosis -Hepatic failure -pulmonary edema -gastric necrosis -pulmonary edema, vasomotor collpase -coma/death
the nurse assess the patients activated partial thromboplastin time (aPTT) to determine the effectiveness of the heparin regimen and noted that is is 30 second. which interpretation by the nurse of this finding is accurate? a. The aPTT is within normal limits b. The aPTT is significantly elevated c. The aPTT is significantly decreased d. The aPTT is inadequate to evaluate treatment
c
Which antihypertensive requires a patient with diabetes to increase the frequency of blood glucose monitoring? select all that applya. enalapril b. diltiazem c. metoprolol d. furosemide e. hydrochlorothiazide
c,d,e
which medication is prescribed to improve the physical manifestations of parkinsons disease
carbidopa-levopdopa
Cholinesterase inhibitor (donepezil) adverse effects
cardiac: low BP, bradycardia, fainting CNS: convulsions, headaches, seizures, sweating GI: increased salvation and secretions, vomiting/diarrhea, abdominal cramps Respiratory: bronchospasm and increased secretions Urinary: urinary incontinence Have atropine ready as antidote
epidermal necrolysis
cell death causes detachment of top layer of skin from the dermis; potentially life-threatening
Donepezil (Aricept)
cholinesterase inhibitor -For mild, moderate, and severe disease -Increases acetylcholine in the brain -Oral drug only
systemic lupus erythematosus
chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs
carbidopa/levodopa (Sinemet)
class: Antiparkinson agent, Dopamine Agonist Indication: Parkinson's disease Action: levodopa is converted to dopamine and works as a neurotransmitter and carbidopa prevents the destruction of levodopa Nursing Considerations: - may cause orthostatic hypotension - may cause dark urine - weeks to months to take effect - do not use with MAOIs - don't use with glaucoma, melanoma - assess for parkinsonian symptoms - instruct patient to take as directed
ferrous sulfate (Feosol)
class: iron supplements Indication prevention and treatment of iron-deficiency anemia Action: Iron is essential for hemoglobin, myoglobin and enzymes, it is transported to organs where it becomes part of iron stores Nursing Considerations: - may cause seizures, hypotension, constipation, epigastric pain, diarrhea, skin staining, anaphylaxis - assess nutritional status, bowel function- monitor hemoglobin, hematocrit, iron levels - may cause elevated liver enzymes - take on an empty stomach to increase absorption/vitamin c helps with absorption - use z-track for IM injections
Hydromorphone (Dilaudid)
class: opioid agonist Indication moderate to severe pain Action: alters the perception and reaction to pain by binding to opiate receptors in the CNS, also suppresses the cough reflex Nursing Considerations: -Assess BP, respirations, and pulse before and during administration - medication causes general CNS depression - Narcan is the antidote for overdose - use caution with concurrent use of MAOI - avoid use within 14 days of each other - may be used as an antitussive - advised to dilute with NS prior to administration and to administer slowly to decrease CNS depression
SE/AE of donepezil
consequence of overstimulation of PNS -sweating -diarrhea -bradycardia, hypotension, fainting -increased bronchial secretions, bronchoconstriction -dizziness
The nurse teaches a clients family about the administration of donepezil for treatment of dementia of the alzheimer type. which side effect identified by the caregiver indicates to the nurse that further teaching is needed
constipation
The nurse is ready to begin aheparin infusion for a patient with evolving stroke. The baseline activated partial thromboplastin time is 4- seconds. which apTT value indicates a therapeutic dose has been achieved a. 50 sec b. 70 sec c. 9 sec d. 110 sec
d
Which medication would the nurse expect to be administered to a pregnant patient with severe preeclampsia and blood pressure averaging 160/95mm Hg? a. captopril b. labetalol c. verapamil d. Spironolactone
d
which statement reflects a patients accurate understanding of green, leafy vegetables while taking warfarin ? a. "i will avoid all green, leafy vegetables in my diet" b. I will increase green, leafy vegetables in my diet c. I will reduce my intake of green, leafy vegetables d. I will jeep my intake of green, leafy vegetables consistent
d
which statement will the nurse make when teaching a patient about essential hypertension? a. "once you have surgery, this will go away" b. "this type of hypertension has a definitive cause" c. "this type of hypertension is not able to be treated" d. "this cause of hypertension is known but treatable
d
Alzheimers disease pathophysiology
deficiency in cholinergic function in the cortex and basal forebrain
what is too low and too high in parkinsons disease
dopamine is too low and ACh is too high
what is frequently used to treat parkinsons disease?
dopaminergic and anticholinergic drugs
heparin dose
dose adjusted according to PTT or aPTT-1.5-2.0 times control (60-80)
What can happen when an IV dose of is given too quickly hydantoins: phenytoin (Dilantin)
hypotension and dysrhythmias
levadopa converted to dopamine in CNS
increase in EPS areas of brain reduces involuntary motion; crosses blood brain barrier
Buproprion MOA
inhibits reuptake of NE and dopamine nicotinic antagonist
other symptoms of lupus
mouth ulcers, anemia, vasculitis,
AE of succinylcholine
muscle fasciculation, muscle pain, bradycardia, apnea, resp depression, bronchoconstriction, malignant hyperthermia
what drug would reverse the opioids effect
nalaxone
morphine Nursing interventions
naloxone is antidote, monitor VS esp. resp effort, encourage cough & deep breathing, monitor for urinary retention, orthostatic hypotension, pt education: no alcohol or CNS depressants, avoid driving, constipation: >fluid, increase fiber if use is longer than 3 days
morphine
narcotic drug derived from opium, used to treat severe pain, as well as in acute pulmonary edema and with MIs
Busprione CI
not for nursing mothers Niot with MAOIs, 14 day wash out
codeine
opiate with relatively low potency often prescribed for minor pain
Furosemide DI
oral hypoglycemics, warfarin, aminoglycosides, NSAIDs, digoxin
SLE can lead to what
organ failure
Acetylcholine and alzheimers disease are related how?
patients with Alzheimer's disease lack acetylcholine which is associated with memory, speech, arousal.
carbidopa-levodopa is met____ and excreted________
periphery kidney
which drug is the drug of choice for seizures
phenytoin
SSRIs: serotonin syndrome
possible adverse effect of SSRIs- may begin 2-72 hrs after starting treat., may be lethal -mental confusion,difficulty concentrating -fever -agitation, anxiety, hallucinations -decreased coordination, tremors Do NOT use SSRIs and migraine (serotonin agonist drug) together
loop diuretics for htn
powerful, for pts with reduced renal NA excretion, furosemide is short acting- given 2-3x/day
lithium CI
pregnancy, severe renal disease, cardiac disease
heparin agonist
protamine sulfate
Cholinergic excess
relaxation of sphincters, constriction of the pupil (mitosis), increased saliva and bronchial secretions, decrease in BP, bradycardia, Increase in GI tone, diarrhea, salivation, lacrimation, urination, diarrhea, emesis (slude), miosis (ie. AChE inh.)
which symptom of levopda toxicity will a client taking levodopa be taught as a reason to contact the primary health care provide
twitching
heparin caution
uncontrolled HTN, recent surgery, GI ulcers
Can warfarin be taken with heparin
yes they both work in different ways so if warfarin isnt working heparin can be added
carbamazeine (tegretol): Iminostilbenes interventions
• Give most of dose at bedtime to avoid CNS effects • Monitor CBC, WBC and for skin rash • Monitor drug level• ____4-12___________ mcg/mL
education about beta blockers
• How to take pulse • May mask signs of hypoglycemia (for ptsw/DM) • Do NOT stop abruptly • Take heart rate before taking med;monitor BPTeaching:
patient education: hydantoins, phenytoin (oral )
• NEVER stop taking abruptly • Avoid ETOH (protect liver) • Monitor for toxicities • Soft bristle toothbrush • Regular dental check-ups • Notify provider if rash occurs • Give w/ meals • If drowsy, do not drive, etc.
Carbamazepine se/ae
• Unlike phenytoin, has min. effects on cognitive fx • Nystagmus, ataxia, H/A, blurred vision: usually getbetter with time • Fluid retention......watch who for this - HF, kidney failure? • Hyponatremia: drug promotes secretion of ADH • Skin rash (SJS, epidermal necrolysis) • Bone marrow suppression
Phenelzine CI
•Pregnancy Category C; don't use with SSRIs; heart failure, cerebral vascular disease, severe renal insufficiency •Caution with seizure disorders, DM, TCAs •No selegiline with Tegretol or Trileptal