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