PHARM FINAL!!!!!

Carbapenems (Drugs that weaken bacterial cell wall) (Beta-lactam family)

"Gorilla-cillin" "Holy water" Extremely broad spectrum Low toxicity -not active against MRSA Imipenem (Most effective beta-lactam antibiotic for use against anaerobic bacteria), meropenem, ertapenem, doripenem Adverse effects: Neurotoxicity, seizures, superinfection, Hepatotoxicity, acute renal failure

A patient with angina pectoris is prescribed sublingual nitroglycerin. Which statement made by the patient indicates understanding of the medication teaching?

"I may experience a headache as a side effect"

Prevention of Drug Resistance

-Adherence to appropriate prescribing guidelines and regimens -Reduce demand for antibiotics among healthy adults and parents of young children -Only prescribe antibiotics to bacterial infections, NOT viral.

Prophylactic Use of antimicrobials

-Agents given to prevent infection rather than to treat an established infection Ex; Surgery, bacterial endocarditis, neutropenia, other indications

Treatment Modalities

-Calorie restriction -Exercise -Behavior modification -Drug therapy -Bariatric therapy

Prediabetes

-Increased risk for developing T2DM Impaired fasting plasma glucose -100 - 125 mg/dL Impaired glucose tolerance test -140 - 199 mg/dL Reducing risk -Diet changes -Exercise (weight loss) -Certain oral anti-diabetic drugs Many people who meet criteria for prediabetes never develop diabetes, even if they do not take precautions against diabetes

Clindamycin [Cleocin] (bacteriostatic inhibition of protein synthesis)

-Inhibits protein synthesis -active against Anaerobic bacteria Use: Alternative to penicillin AE: Diarrhea, C. diff-associated diarrhea, hepatotoxicity, blood dyscrasias, hypersensitivity reactions

Hyperthyroidism Agents

-Methimazole ** -Propylthiouracil ** -Radioactive Iodine-131 -Nonradioactive Iodine -Potassium iodide -Beta blockers

Fosfomycin (Disrupts synthesis of peptidoglycan polymer strands that compose cell wall)

-Single dose therapy of uncomplicated UTI. caused by E.coli or E. faecalis. AE; Diarrhea, headache, vaginitis, nausea.

Beta-Adrenergic Blocking Agents

5 approved glaucoma agents MOA: Reduces production of aqueous humor Uses: -Initial therapy and maintenance therapy for POAG -Combined with other drugs for emergency management of acute angle-closure glaucoma Adverse effects: Local -Usually minimal; transient stinging Systemic -If absorbed in sufficient amounts --> heart and lungs (bradycardia, bronchospasm) -Cardioselective agents (betaxolol and levobetaxolol recommended for asthma patients What patients are we going to be most worried about? Asthma and COPD.

The perioperative nurse is caring for a patient receiving Isoflurane [Forane]. The nurse understands that this medication will be excreted by the body through which organ system? A. Kidneys B. Liver C. Lungs D. Circulation

C. Lungs Isoflurane [Forane] is an inhaled anesthetic. These drugs are taken in by the lungs, distributed to areas with high blood flow by the circulation, and eliminated by the lungs.

Centrally Acting Muscle Relaxants

Diazepam and Tizanidine Therapeutic use: -Relief of localized spasm caused by muscle injury -Can decrease local pain and tenderness -Can increase range of motion -Sedation Adverse effects: -Generalized CNS depression -Hepatic toxicity (liver damage): diazepam and tizanidine -Hepatitis & Necrosis: Chlorzoxazone -Physical dependence (Abstinence syndrome) ---Withdrawal should be done slowly and tapered

Vasodilator Pharmacology

Dilation of arterioles = Hydralazine Dilation of venous circulation = Nitroglycerin Dilation of arterioles = Prazosin

Primary Hyperaldosteronism

Excessive secretion of aldosterone Potential causes: -Aldosterone-producing adrenal adenoma -Bilateral adrenal hyperplasia Presentation: -Hypokalemia -Metabolic alkalosis -Hypertension -Increased HF risk Treatment- directed at cause: -Adrenal mass --> surgery -Bilateral adrenal hyperplasia --> aldosterone antagonist (spironolactone)

Pantothenic Acid (B5)

No reason to take supplements Actions: -Essential component of two biologically important molecules (coenzyme A and acyl carrier protein) Sources: -Present in all foods Toxicity: None Deficiency: None

Dihydropyridines

Prototype: Nifedipine Works directly on vascular smooth muscle in the arterials, blocking calcium channels themselves, blood vessels (significant), and heart (minimal)

Beta Blockers

Therapeutic uses -Treat angina and dysrhythmias * -Given post MI to help circulation of vessels * -Help reduce perioperative mortality * -Help with migraines * -hypertension -heart failure -Hyperthyroidism -stage fright -Pheochromocytoma (A hormone-secreting tumor that can occur in the adrenal glands) -Glaucoma (A group of eye conditions that can cause blindness)

Alpha1 Adrenergic Antagonists

Selective agents (-"sin") -Prazosin -Terazosin -Doxazosin -Tamsulosin -Alfuzosin Nonselective agents (-"mine") -Phentolamine -Phenoxybenzamine

Serotonin 5-HT 2c Receptor Agonist: Lorcaserin

Selective serotonin antagonist; binds to serotonin receptors. It makes you feel full and eat less -Chronic weight-loss therapy -Activates the hypothalamic and mesolimbic pathways that control appetite

Morphine (Strong Opioid agonist)

Source: -Seedpod of the poppy plant Therapeutic use: Relief of pain -No loss of consciousness -Relieve pain by mimicking actions of endogenous opioid peptides, primarily at mu receptors Pharmacokinetics: Route: PO, IM, IV, SC, epidural, and intrathecal -Not very lipid soluble -Doe not cross BBB easily (it can cross it, just not easily) Adverse effects: Respiratory depression -Most serious adverse effect -Infants and elderly are especially sensitive Onset: IV = 7 minutes IM = 30 minutes SC = Up to 30 minutes; may persist 4-5 hours Spinal injection: response may be delayed by hours -Tolerance to respiratory depression can develop -Increased depression with concurrent use of other drugs that have CNS depressant actions (alcohol, barbiturates, and benzodiazepines) -Can compromise patients with impaired pulmonary function (asthma, emphysema, kyphoscoliosis, extreme obesity) Constipation Causes: suppressed propulsive intestinal contractions, intensified nonpropulsive contractions, increased tone of the anal sphincter, inhibited secretions of fluids into intestinal lumen Complications: Fecal impaction, bowel perforation, rectal tearing, hemorrhoids Treatment: Physical activity, increased intake of fiber and fluids, stimulant laxatives (bisacodyl), stool softeners (docusate), and osmotic laxatives (polyethylene glycol) Orthostatic hypotension -Lowers blood pressure by blunting baroreceptor reflex and by dilating peripheral arterioles and veins Urinary retention and hesitancy -May interfere with voiding by suppressing awareness of bladder stimuli Cough suppression -Codeine and hydrocodone-based cough remedies -Acts on receptors in medulla to suppress cough -Suppression may lead to accumulation of secretions in airway -Teach patients to actively cough at regular intervals Emesis -Promotes N/V through direct stimulation of chemoreceptor trigger zone of the medulla -Reactions are greatest with initial dose, then diminish with time -Occur in 15% to 40% of ambulatory patients -Can be reduced by pretreatment with an antiemetic and by having the patient remain still Euphoria/dysphoria -Euphoria: exaggerated sense of well-being caused by activation of mu receptors -Dysphoria: a sense of anxiety and unease -Dysphoria is uncommon among patients in pain, but it may occur when morphine is taken in absence of pain Sedation -Drowsiness and mental clouding -Can't get up and move around, avoid hazardous activities Sedation can be minimized -Take smaller doses -Use opioids that have short half-lives -Give small doses of a CNS stimulant (methylphenidate or dextroamphetamine) -Nonamphetamine stimulants such as modafinil or armodafinil may also be tried Miosis Pin point pupils Bright lights Neurotoxicity -Delirium, agitation, myoclonus, hyperalgesia, and other symptoms -Risk factors: renal impairment, pre-existing cognitive impairment, and prolonged high-dose opioid use -Manage: hydration and reducing dose Drug interactions -CNS depressants (increased respiratory depression and sedation) -Anticholinergic drugs (increased constipation and urinary retention) -Hypotensive drugs (increased hypotension) -MAOIs (Hyperpyrexic coma) -Agonist-antagonist opioids (Precipitation of a withdrawal reaction) +Opioid antagonists (Suppression of symptoms of opioid overdose) Toxicity Common signs of overdose: Coma, respiratory depression, pinpoint pupils Treatment: Ventilator support, Antagonist: Naloxone Guidelines: monitor VS before giving, give on fixed schedule Tolerance -Increased doses needed to obtain the same response -Develops with analgesia, euphoria, sedation, and respiratory depression -Cross-tolerance to other opioid agonists Physical dependence -Abstinence syndrome with abrupt discontinuation -About 10 hours after last dose: initial reaction occurs (yawning, rhinorrhea which is Excess drainage ranging from a clear fluid to thick mucus from the nose and nasal passages, and sweating) -Progresses to violent sneezing, weakness, N/V/D, abdominal cramps, bone and muscle pain, muscle spasms, kicking movements -Lasts 7 to 10 days if untreated

Sodium bicarbonate [antacid]

-Useful for treating acidosis and elevating urinary pH to promote excretion of acidic drugs after overdose -Inappropriate for treating PUD: Brief duration, high sodium content, can cause alkalosis -Eructation and flatulence -Can exacerbate hypertension and heart failure -Can cause systemic alkalosis in patients with renal impairment

Who can give anesthesia?

Anesthesiologist MD or Certified Registered Nurse Anesthetists (CRNA)

COMT Inhibitors

Catechol-O-methyltransferase (COMT) = enzyme that degrades catecholamines such as dopamine, epinephrine, norepinephrine. MOA: -Inhibit metabolism of levodopa in the periphery -Indirect drugs No direct therapeutic effects of their own 2 COMT Inhibitors are available: 1. Entacapone (safer and more effective) 2. Tolcapone

A nurse assesses a patient who takes a maintenance dose of lithium carbonate [Lithobid] for bipolar disorder. The patient complains of hand tremor, nausea, vomiting, and diarrhea. The patient's gait is unsteady. The patient most likely has done what? A. Consumed some foods high in tyramine B. Not taken the lithium as directed C. Developed tolerance to the lithium D. Developed lithium toxicity

D. Developed lithium toxicity Early lithium toxicity is evidenced by diarrhea, anorexia, muscle weakness, nausea, vomiting, tremors, slurred speech, and drowsiness. Later signs include blurred vision, seizures, trembling, confusion, and ataxia.

The nursing instructor asks a student nurse which bacterial pathogen is most commonly found in the middle ear of children with AOM. The nursing student demonstrates understanding by giving which answer? A. Escherichia coli B. Moraxella catarrhalis C. Haemophilus influenzae D. Streptococcus pneumoniae

D. Streptococcus pneumoniae S. pneumoniae accounts for 40% to 50% of bacterial pathogens found in the middle ear during an episode of AOM. H. influenzae accounts for 20% to 24%, and M. catarrhalis accounts for 10% to 15%. E. coli typically is not found.

A patient who has diabetes insipidus is receiving desmopressin [DDAVP]. Which laboratory test should a nurse obtain to evaluate the effectiveness of the medication? A. Urine ketones B. Blood urea nitrogen (BUN) C. Creatinine D. Urine specific gravity

D. Urine specific gravity Diabetes insipidus is characterized by a decrease in the urine specific gravity because of the excretion of large volumes of dilute urine. Desmopressin acts to prevent fluid loss through the renal tubules and increases the urine specific gravity. Urine ketones are present in type 1 diabetes mellitus. The BUN and creatinine are indicators of renal function but not of the effectiveness of treatment of hypothalamic diabetes insipidus.

Lifestyle Modifications

Helps control weight, blood pressure, joint pain, etc. DASH diet Sodium restriction Alcohol restriction Aerobic exercise Smoking and vaping cessation Maintenance of potassium and calcium intake

Gabapentin (Newer AED)

Therapeutic use: -Adjunctive therapy of partial seizures -Work by enhancing GABA release Off-label use: -Neuropathic pain -Prophylaxis of migraine -Treatment of fibromyalgia -Relief of postmenopausal hot flashes Adverse reactions: -Very well tolerated -Most common: Somnolence, dizziness, ataxia, fatigue, nystagmus, peripheral edema

Dorzolamide

Topical carbonic anhydrase inhibitor Well tolerated MOA: Decreases production of aqueous humor Adverse effects: -Ocular stinging -Bitter taste -Allergic reaction (conjunctivitis, eyelid reactions, if occur; stop immediately and notify prescriber) -Others: blurred vision, tearing, eye dryness, photophobia

Proton Pump Inhibitors (PPIs)

Well tolerated Selection is based on cost and prescriber's preference Compared to H2 blockers: -Faster onset -Greater reduction in acid secretion (90% vs 65%) MOA: Block hydrogen potassium ATPase pump enzyme that makes acid Therapeutic uses: -Short term -Variety of conditions (GI conditions) Increase risk of serious adverse events: -Fracture -Pneumonia -Acid rebound -Possible clostridium difficile infection

Metabolic Acidosis

Low pH, Normal CO2, Low HCO3 Causes: -Chronic renal failure -Loss of bicarbonate during severe diarrhea -Metabolic disorders that result in overproduction of lactic acid or keto acids -Methanol poisoning -Aspirin poisoning Treatment: -Treating original problem -Give alkaline salt

Serotonin Receptor Antagonists: Ondansetron

MOA: Blocks type 3 serotonin receptors on afferent vagal nerve Uses: -Chemotherapy-induced nausea/vomiting (CINV) -Nausea/vomiting associated with radiotherapy and anesthesia -Morning sickness (off label) Adverse effects: Most common = headache, diarrhea, dizziness Most concerning = Prolonged QT interval (can lead to dysrhythmias), risk of torsades de pointes Administration: -PO -IM -IV

Hydrochlorothiazide "HCTZ" THIAZIDE DIURETIC

MOA: Promotes urine production by blocking reabsorption of sodium and chloride in the early segment of distal convoluted tubule -Diuresis usually begins in 2 hours and peaks at 4-6 hours Uses: Hypertension, edema Adverse effects: Identical to that of loop diuretics, except no ototoxicity Drug interactions: Similar to loop diuretics. -Often combine with other classes of antihypertensives (usually make it in a combination pill)

Selegiline

Monotherapy or used with levodopa for Parkinson's disease MOA: -Selective and irreversible inhibition of MAO-B (keeps dopamine around) -Suppresses destruction of dopamine derived from levodopa and prolong the effects of levodopa -Improvement in motor function -Benefits decline dramatically within 12 to 24 months When used alone -Insomnia (tip scales toward excitatory mechanism) -Give last dose no later than noon

Estrogens

Physiologic actions -Female reproductive tract and secondary sex characteristics -Physiologic processes related to reproduction Metabolic actions -Positive effect on bone mass -Favorable effects on cholesterol levels -Blood coagulation (alter levels by increasing or decreasing levels of coagulation factors in blood) Adverse effects -Endometrial hyperplasia and carcinoma (cells are growing rapidly) -Promotes growth of existing breast cancer -Ovarian cancer -Cardiovascular events -Nausea Therapeutic uses -Menopausal HRT -Female hypogonadism (used to promote puberty) -Acne Administration routes -Oral -Transdermal -Intravaginal -Parenteral

Androgens

Produced by testes, ovaries, and adrenal cortex Major endogenous androgen = Testosterone most noted for expression of male sex characteristics Primary clinical application: -Androgen deficiency in males -Hypogonadism Principal adverse effects: -Virilization -Hepatotoxicity -Cardiac risks (due to lower HDL and increase LDL)

General Anesthetics

Produces unconsciousness and a lack of responsiveness to all painful stimuli Analgesia -Loss of sensibility to pain -Provides pain relief like ibuprofen Anesthesia -Loss of pain and loss of all other sensations like touch, temperature, taste 2 main groups: 1. Inhalation anesthetics 2. Intravenous anesthetics Neuromuscular Blocking Agents -Reduce amount of anesthesia needed

Heart Failure

Progressive, fatal disorder Characterized by: -Left ventricular dysfunction -Reduced cardiac output -Insufficient tissue perfusion -Signs of fluid retention/overload 2 major forms: 1. Heart failure with left ventricular systolic dysfunction 2. Diastolic heart failure (heart failure with preserved LV ejection fraction) -Ejection fraction = amount of blood that is ejected with each contraction. Then there is a little bit left, clots occur. **Focus primarily on treatment of #1, heart failure with LV systolic dysfunction

A nurse administers quinidine sulfate to a patient with atrial fibrillation. The nurse should assess the ECG tracing knowing that quinidine sulfate has what effect on the ECG?

Prolongation of the QT interval. Two things that are concerned about Quinidine is widening of QRS and prolongation of QT.

Active vs Passive immunity

Active- acquired -Infection or vaccine -Antibodies -Long-term -Remembers antibodies Passive- Performed antibodies -Placenta to fetus, breast milk, antibody infusion -Short-term

Schizophrenia

Acute episodes -Delusions (fixed false beliefs) --Religious, grandiose, persecutory -Hallucinations are frequently prominent --Auditory > Visual Residual Symptoms -After florid symptoms of acute episode -Suspiciousness; poor anxiety management; and diminished judgement, insight, motivation, and capacity for self care

ANS Regulation of AP

All of this is controlled by ANS. Brain is what controls everything -Baroreceptor reflex in brain stem, if it gets stimulated too full, then its going to try to drop blood pressure If it's thinned out or stimulated not enough, it's going to bring pressure up.

Which treatment would not be used for the management of wet (neovascular) ARMD? A. Laser therapy B. Prostaglandin analogs C. Photodynamic therapy D. Angiogenesis inhibitors

B. Prostaglandin analogs Prostaglandin analogs are considered first-line medications for the treatment of glaucoma, not ARMD. The remaining options are appropriate interventions for wet ARMD.

The healthcare provider ordered lamotrigine [Lamictal] for long-term maintenance therapy of BPD. The nurse anticipates which dosing schedule? A. Starting at a high dose to quickly control mania B. Starting at a low dose and titrating up C. Starting at a high dose and titrating down D. Starting with a loading dose and then a low maintenance dose

B. Starting at a low dose and titrating up Lamotrigine [Lamictal] is indicated for long-term maintenance therapy of BPD. The goal is to prevent affective relapses into mania or depression. To minimize the risk of serious rash, dosage should be low initially (25 to 50 mg/day) and then gradually increased.

A nurse assesses a patient who is taking pramlintide [Symlin] with mealtime insulin. Which finding requires immediate follow-up by the nurse? A. Skin rash B. Sweating C. Itching D. Pedal edema

B. Sweating Pramlintide is a new type of antidiabetic medication used as a supplement to mealtime insulin in patients with type 1 and 2 diabetes. Hypoglycemia, which is manifested by sweating, tremors, and tachycardia, is the adverse reaction of most concern. Skin rash, itching, and edema are not adverse effects of pramlintide.

The nurse is caring for a patient receiving glatiramer acetate [Copaxone] for MS. Which finding, if present in this patient, could be considered a potential adverse effect of this drug? A. Flu-like symptoms with fever B. Decreased neutrophil count C. Jaundice and elevated bilirubin D. Injection site pain and redness

D. Injection site pain and redness Injection site reactions, such as pain, erythema, pruritus, and induration, are the most common adverse effects of glatiramer. Unlike interferon, glatiramer does not cause flu-like symptoms, myelosuppression, or hepatotoxicity, which would be indicated in the other responses.

Differentiate among the U.S. Food and Drug Administration pregnancy risk categories

FDA pregnancy risk factors A: Safest B C D X: Most dangerous; known to cause fetal harms.

H. pylori Antibiotic Regimens

Goal: Minimize emergence of resistance Guidelines recommend: -At least 2 antibiotics (preferably three), PLUS an Anti-secretory agent -PPI, or Histamine 2 receptor antagonist (H2RA) Course duration and eradication: 10-day course = good 14-day course = better

What is Epilepsy?

Group of disorders characterized by excessive excitability of neurons in CNS Variety of symptoms; from brief periods of unconsciousness to violent convulsions May also cause problems with learning, memory, and mood

Five classes of antibodies

IgA- GI tract and lungs, breast milk IgD- antigen recognition on B cells IgE- allergies (release of histamine) and parasitic worms; on mast cells IgG- major antibody in blood; target-cell lysis; phagocytosis; transferred across placenta; passive immunity IgM- target-cell lysis; antigen recognition on B cells

A patient with depression has been prescribed fluoxetine. Which statement made by the patient indicates an understanding of the medication teaching? A. "Disorientation and hallucinations are common" B. "The drug may enhance my interest in sex" C. "It may take 3 to 4 weeks before my mood is elevated" D. "I can stop this medication when I feel less depressed"

C. "It may take 3 to 4 weeks before my mood is elevated"

Other Beta-Adrenergic Blockers

Labetalol*used for pregnancy* Carvedilol Nebivolol MOA: Differ in that they block alpha- and beta- adrenergic receptors Uses: -Hypertension -Angina pectoris -Cardiac dysrhythmias -Prophylaxis of migraine headache -Myocardial infarction -Situational anxiety -Heart failure

Tamsulosin (Selective alpha1 antagonist)

MOA: -Selective blockage of the smooth muscle of bladder neck (trigone and sphincter), prostatic capsule and prostatic urethra -Blockade of vascular alpha1 receptors is weak Use: -Approved only for BPH Adverse effects: -Headache -Dizziness -Abnormal ejaculation -Rhinitis Drug interactions: -Cimetidine --> increase tamsulosin toxicity -Hypotensive drugs and PDE5 inhibitors [Viagra] --> significant reduction in blood pressure

Diazepam (Drug for spasticity)

Only approved benzodiazepine for spasticity MOA: -Acts in the CNS -Mimics action of GABA Adverse effect: -Sedation -Dependence -Tolerance

A patient is receiving a drug that blocks alpha 1- adrenergic receptors. which adverse effect, if experienced by the patient, is of most concern to the nurse?

Orthostatic hypotension

Neuromuscular Blockers

Prevent Acteylcholine from activating nicotinicM receptors, which results in muscle relaxation or paralysis It is used for muscle relaxation during surgery, endotracheal intubation, mechanical ventilation, and other procedures Can't be absorbed in GI tract, so no oral forms (usually given IV) Cannot cross -Blood brain barrier so no impact on CNS -Placenta, so little effect on fetus

A patient is prescribed cimetidine and aluminum hydroxide for treatment of PUD. What should the nurse teach the patient to do?

Take the Tagamet (cimetidine) 2 hours before the Maalox (aluminum hydroxide)

Acute Complications of Poor Glycemic Control

Uncontrolled diabetes will lead to hyperglycemia... which can turn into.. 1. Diabetic ketoacidosis (DKA) 2. Hyperosmolar hyperglycemic state (HHS) Cardinal features of both conditions: -Hyperglycemic crisis -Associated loss of fluid and electrolytes Differences -Hyperglycemia is more severe in HHS -Ketoacidosis characteristic of DKA and absent in HHS

Contraindications to Laxative Use

Use with caution in pregnancy and lactation (pregnant people are prone to constipation. Need to have very high fiber diet and take stool softeners) History of ulcerative colitis, regional enteritis, diverticulitis, appendicitis -abdominal pain, nausea, cramps Acute surgical abdomen -He doesn't want to have stool because it is going to hurt, tighten up those abdomen muscles to pass the stool, so we give stool softener Fecal impaction or bowel obstruction Habitual use -overuse of laxatives can cause appendicitis

Entacapone (COMT Inhibitor)

Use: -Adjunct for use with carbidopa/levodopa MOA: -Selective and reversible inhibitor of COMT -Increases levodopa availability by inhibiting COMT which results in a decreased production of levodopa metabolites that compete with levodopa for transport Adverse effects: -Managed by decreasing levodopa dosage -Dyskinesias -Orthostatic hypotension -N/V/D -Hallucinations -Sleep disturbances -Impulse control disorders -Yellow-orange discoloration of the urine Drug interactions: Increase levels of drugs metabolized by COMT, dose reduction may be needed if taking these drugs together: -Levodopa -Methyldopa -Dobutamine -Isoproterenol

A patient is prescribed lovastatin. The nurse will teach the patient to take the medication at which time?

With the evening meal The only one that you don't is Rubastatin

Adrenergic Agonists

"Sympathomimetic" Fight or flight -Mimic sympathetic nervous system Produce their effects by activating adrenergic receptors. Broad spectrum of applications: -Congestive heart failure -Asthma -Preterm labor

Chloramphenicol (Bacteriostatic inhibitors of protein synthesis)

Broad spectrum Life threatening infections only where safer drugs aren't working or not effective. Not first line drug

Necrotizing Otitis Externa

"Malignant OE" Rare, potentially fatal complication of AOE High risk groups: -Older adults with diabetes -Immunocompromised patients

Which patient would the nurse expect to have the highest risk for postural hypotension?

A patient who is prescribed a drug that promotes venous vasodilation

Which of these local anesthetic agents is most likely to cause an allergic response? A. Procaine [Novocain] B. Lidocaine [Xylocaine] C. Bupivacaine [Marcaine] D. Ropivacaine [Naropin]

A. Procaine [Novocain] Procaine is an ester-type anesthetic. Ester anesthetics pose a greater risk of allergic reactions than the amide-type anesthetics. All the other choices are amide anesthetics.

Which therapeutic effect is the purpose of a progestin medication in menopausal hormone therapy (HT)? A. To reduce urogenital atrophy B. To suppress endometrial proliferation C. To relieve vasomotor symptoms D. To prevent adverse cardiac events

B. To suppress endometrial proliferation Progestin is prescribed in HT to provide a counterbalance to estrogen-mediated stimulation of the endometrium, which can lead to endometrial hyperplasia and cancer. However, it is omitted in women who do not have a uterus. Progestins appear to increase the risk of adverse cardiac events. Estrogens relieve the vasomotor symptoms of menopause and prevent urogenital atrophy (manifesting as vaginal dryness and itching).

Drugs for Spasticity

Baclofen -Acts in CNS Diazepam -Acts in CNS Dantrolene -Acts directly on skeletal muscle

Sulfonamides and Trimethoprim

Broad spectrum antibiotics Closely related mechanisms -Suppress bacterial growth by inhibiting tetrahydrofolic acid, a derivative of folic acid (folate) Sulfonamides -Silver sulfadiazine (not painful) -Mafenide (painful) -these are used to suppress bacterial colonization in patients with second and 3rd degree burns Use: UTI, chlamydia infections, UC, second and third degree burns High possibility for resistance. Hypersensitivity reactions: Stevens-Johnson Syndrome (SJS) monitoring patients at first sign of rash. Trimethoprim Suppresses bacterial synthesis of DNA, RNA, and proteins Used for acute and complicated UTIs AE: Hematologic effects, hyperkalemia Precaution: Pregnancy, nursing Interacts with sulfamethoxale for UTIs to make it more powerful (TMP/SMZ); Bactrim

The nurse is preparing to administer quetiapine extended-release 400 mg PO every day as ordered. The available medication is quetiapine 200-mg extended-release tablets. How many tablets should the nurse administer? A. 0.5 B. 1 C. 2 D. 4

C. 2 The ordered dose is 400 mg, and the available tablets are 200 mg. 200 mg × 2 tablets equals the 400-mg ordered dose.

Other PO Diabetes Drugs

Colesevelam (bile-acid sequestrant) -Usually used to reduce cholesterol but also reduces blood glucose Bromocriptine (dopamine agonst) -Decreases in A1C

A patient is prescribed amoxicillin and tetracycline to treat PUD. the nurse will instruct the patient that these medications will do what?

Destroy the bacteria in the stomach that are causing ulceration

Polyethylene Glycol - Electrolyte Solutions

GoLYTELY -Volume administered = 4 L -Patients must ingest 250 to 300 mL every 10 minutes for 2 to 3 hours Adverse effects -Nausea -Bloating -Abdominal discomfort

Estrogens and Progestins

Hormones with multiple actions -Promote female maturation -Regulate ongoing activity of female reproductive organs -Affect bone mineralization and lipid metabolism Principal estrogen = estradiol Principal progestin = progesterone

FGAs

Potency -Most clinically relevant with classifications of FGAs -Low potency = Chlorpromazine -High potency = Haloperidol (used as a chemical restraint. if someone is being difficult, use haloperidol to knock them out) Use Primary indication: Schizophrenia -Suppress symptoms during acute psychotic episodes -Continued use reduces the risk of relapse MOA -Block variety of receptors types within and outside CNS -Suppress symptoms by blocking D2 receptors in mesolimbic area of the brain -Adverse effects are a result of blocking dopamine, ACh, histamine, and NE receptors Adverse effects Extrapyramidal Symptoms (EPS) -Extrapyramidal system = same neuronal network --> movement disorders seen in PD Early in therapy (less frequent with low-potency drugs) Acute dystonia (Involuntary muscle contractions that cause repetitive or twisting movements.) -Oculogyric crisis (spasmodic movements of the eyeballs into a fixed position, usually upwards) -Opisthotonus (spasm of the muscles causing backward arching of the head, neck, and spine) -Joint dislocation -Impaired respiration -Treatment = Anticholinergic medication (benztropine, benadryl) -Parkinsonism -Akathisia (A feeling of muscle quivering, restlessness, and inability to sit still) Late in Therapy (risk is equal with all agents) Tardive Dyskinesia **most concerning EPS effect** -Worm like movements of tongue, can interfere with being able to speak, swallow, chew. Involuntary movements of the limbs, toes, fingers, and trunk -Lip-smacking movements -Tongue flicks Neuroleptic malignant syndrome (NMS) -Occurs with more high potency FGAs like haloperidol -Rare but serious reaction -Risk of death without treatment -"Lead pipe" rigidity -Sudden high fever, sweating -Autonomic instability -Dysrhythmias -Fluctuations in blood pressure -Altered level of consciousness -Seizures or coma may develop -Death from respiratory failure, cardiovascular collapse, dysrhythmias -Immediate withdrawal of antipsychotic medication -Drug therapy: dantrolene and bromocriptine Other -Anticholinergic effects -Orthostatic hypotension -Sedation -Neuroendocrine effects -Seizures -Sexual dysfunction -Dermatologic effects -Agranulocytosis -Severe dysrhythmias -TEACH PATIENTS ABOUT S/S for agranulocytosis (severe and dangerous leukopenia (lowered white blood cell count), most commonly of neutrophils) If you develop a fever or sore throat or any mild form of infection, that needs to be reported right away. Drug interactions -Anticholinergic drugs intensify anticholinergic effects -CNS depressants intensify depressant effects -Levodopa and direct DA receptor agonists may counteract antipsychotic effects of neuroleptics Toxicity -Conventional antipsychotic drugs are safe -Death by overdose is extremely rare -Overdose --> hypotension, CNS depression, EPS -Treatment = IV fluids, alpha-adrenergic agonists, Gastric lavage

Bone/Joint Disorders

Rheumatoid Arthritis (RA) Autoimmune inflammatory disorder -Treatment to relieve symptoms, maintain function, delay progression; not curative Glucocorticoids Prednisone/prednisolone NSAIDs ASA Celecoxib Disease-modifying antirheumatic drugs (DMARDs) Methotrexate -Add folic acid to minimize toxicity risk -Contraindications: Pregnancy (fetal death, congenital abnormalities) -Etanercept Gout Recurrent inflammatory disorder Hyperuricemia -Uric acid crystals deposited in joints, especially big toe -Excessive production or impaired excretion of uric acid -Severe joint pain (episodic) Short term treatment -NSAIDs, glucocorticoids, colchicine -Relieve symptoms of attack Long term treatment -Lower uric acid level -Urate-lowering therapy ---Allopurinal; inhibits xanthine oxidase to reduce uric acid level in blood AE: Hypersensitivity, N/V/D, HA, drowsiness Interactions: CYP450 (warfarin, theophylline), ampicillin febuxostat, probenecid, pegloticase Calcium -skeletal, nervous, muscular, cardiovascular system function -Stored in bones -Serum calcium level: 8.5-10.5 Absorbed in small intestine (increased by PTH, vitamin D. Decreased by glucocorticoids) -Excreted by kidneys Resorption -Osteoclasts break down bone tissue, calcium deposited in blood -Calcitonin decreases resorption Hypocalcemia -Increases neuromuscular excitability -Tetany, convulsions Osteoporosis -Low bone mass, increased fragility -Calcium, Vitamin d, lifestyle changes -Biphosphonates --Alendronate --Uses: Postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, Paget's disease, hypercalcemia ---Inhibit bone resorption by decreasing activity of osteoclasts --AE: esophageal ulceration, ocular inflammation, osteonecrosis of jaw, atypical femur Selective Estrogen Receptor Modulator -Raloxifene -Preserves bone density, reduces cholesterol Teriparatide -Form of PTH -increases bone formation BBW: osteosarcoma -Denosumab

Beta1 Antagonists

Therapeutic Applications: -Due almost entirely to the blockade of beta1 receptors Think heart -Dysrhythmias and glaucoma Angina pectoris -Beta blockers are mainstay of antianginal therapy -Blocking beta1 receptors in the heart -> decreased cardiac workload -Reduce oxygen demand by balancing it with oxygen supply -Prevention of ischemia and pain Hypertension -Once considered drugs of choice for hypertension -Decrease AV node conduction -Decreased cardiac workload -Long term: beta blockers reduce peripheral vascular resistance --> anti-hypertension effects Cardiac dysrhythmias Blockage of cardiac beta1 receptors result in: -Decrease in the rate of sinus nodal discharge -Suppression of the conduction of atrial impulses through AV node --> prevents ventricles from being driven at excessive rate Glaucoma -Elevated intraocular pressure (IOP) with subsequent injury to the optic nerve -Specific group of beta blockers are used for the treatment of glaucoma to lower intraocular pressure Myocardial Infarction (MI) -Treatment with beta blocker can reduce pain infarct size, mortality, and risk of reinfarction -Therapy must begin soon after MI occurs -Standard of care for treatment of MI Heart failure -Considered standard therapy for heart failure Hyperthyroidism -Associated with increase in sensitivity of the heart to catecholamines -Beta 1 blockades will suppress that response Migraine prophylaxis -MOA is not known -Taken prophylactically, beta-adrenergic blocking agents can reduce frequency and intensity of migraine attacks -Not able to abort a migraine Stage fright -Symptoms: tachycardia, tremors, sweating -Brought on by generalized discharge of the sympathetic nervous system -Beta blockers can help by preventing beta1-mediated tachycardia Pheochromocytoma -Pheochromocytomas secrete large amounts of catecholamines --> excessive cardiac stimulation -Cardiac stimulation can be prevented by beta1 blockers Adverse Effects: Involve both beta1 and beta2 blockade Nonselective agents produce broader spectrum of adverse effects In neonates (newborns) -Use during pregnancy can have residual effects on newborn infant Remain in circulation for several days after birth and put baby at risk for -Bradycardia -Respiratory distress -Hypoglycemia Bradycardia -Blockade of cardiac beta1 receptors can produce bradycardia Reduced cardiac output -Beta1 blockade --> decreased heart rate and myocardial contraction --> reduced cardiac output -Use with caution in patients with Heart failure or reduced cardiac reserve -Further decrease in cardiac output could result in insufficient tissue perfusion Precipitation of heart failure -Suppression of cardiac function --> heart failure -Teach about early signs of heart failure (shortness of breath, night coughs, swelling of extremities, notify the prescriber if these occur) -They also are used to treat heart failure AV heart block -Blockade of cardiac beta1 receptors --> suppressed AV conduction -Production of AV block is a potential complication of therapy -Contraindicated for patients with pre-existing AV block Rebound cardiac excitation -Long term use of beta blockers can sensitize heart to catecholamines. -If withdrawn/discontinued abruptly --> development of anginal pain or ventricular dysrhythmias (rebound excitation) -Risk is minimized by gradual tapering off Bronchoconstriction -Blockade of beta2 receptors in the lung --> constriction of the bronchi -Contraindicated for people with asthma -Patients should be given an agent that is beta1 selective (Metoprolol) Hypoglycemia -Inhibits process of glycogen, so it may result in hypoglycemia because you can't use glycogen you stored up. -Diabetic patients are especially dependent on beta2-mediated glycogenolysis as a way to overcome insulin-induced hypoglycemia -If diabetic patient requires beta blocker, a cardioselective agent should be chosen (metoprolol)

A patient is prescribed sustained-release oral nitroglycerin capsules for chronic stable angina. The nurse should include which instruction?

"Sit or lie down if dizziness or lightheadedness occurs"

Respiratory Alkalosis

-High pH -Low PaCO2 -Normal HCO3 Causes: Hyperventilation (decrease in CO2, which is an acid) Symptoms: Swimmy headed, numbness, tingling fingers Treatment: Mild: nothing More severe: Rebreathe CO2-laden expired breath (paper bag trick)

Adrenocortical hormones

3 classes of steroid hormones: 1. Glucocorticoids 2. Mineralocorticoids 3. Adrenal androgens Affect multiple processes -Maintenance of glucose availability -Regulation of water and electrolyte balance -Development of sex characteristics -Life-preserving responses to stress Most familiar forms of adrenocortical dysfunction: -Adrenal hormone excess = Cushing's syndrome -Adrenal hormone deficit = Addison's disease

Cholinergic Categories

6 categories 1. Muscarinic agonists -Bethanechol 2. Muscarinic antagonists - Atropine 3. Ganglionic stimulating agents - Nicotine 4. Ganglionic blocking agents -Mecamylamine 5. Neuromuscular blocking agents - d-Tubocurarine - succinylcholine 6. Cholinesterase inhibitors -Neostigmine -Physostigmine

Drugs Acting on RAAS

ACE (angiotensin-converting enzyme) Inhibitors: -any with suffix "-pril") Prototype: Captopril ARBs (Angiotensin 2 receptor blocker): Prototype: Losartan Direct Renin Inhibitor: Prototype: Aliskiren -Direct vasodilator Aldosterone Antagonist: -Aldosterone runs blood pressure up, so aldosterone antagonist is going to interfere with that. Prototype: Eplerenone -Used to treat congestive heart failure, hypertension after an MI

Other preventive agents

ACE inhibitors and ARBS Calcium channel blockers -Verapamil -Nimodipine Botulinum Toxin A Supplements -Riboflavin (Vitamin B2) -Coenzyme Q-10 -Butterbur & Feverfew (from the daisy family)

Pure Opioid Agonists

Activate mu and kappa receptors -Can produce analgesia, euphoria, sedation, respiratory depression, physical dependence, constipation, and other effects Sub-classifications: -Strong opioid agonists (Morphine) -Moderate to strong opioid agonists (Codeine)

A patient is receiving an intravenous infusion of heparin to treat a pulmonary embolism. What laboratory value will the nurse monitor to evaluate treatment with this medication?

Activated partial thromboplastin time (aPTT)

Direct Renin Inhibitors

Aliskiren Indications: Hypertension MOA: -Causes direct vasodilation -Acts at first step in RAAS, Binds to the renin to stop the RAAS or interfere with the whole RAAS system. Administration -PO Adverse Effects: -Angioedema -Cough -GI effects -Hyperkalemia BLACK BOX WARNING: Fetal Toxicity Drug interactions: Atorvastatin (given for cholesterol) = increase aliskiren levels Ketoconazole = increases aliskiren levels Aliskiren = decrease furosemide levels (get some edema)

What are analgesics and opioids?

Analgesics are drugs that relieve pain without causing the loss of consciousness Opioids are the most effective pain relievers available Opioid = defined as any drug natural or synthetic, that has actions similar to those of morphine Opiate = applies only to compounds present in opium

Lubiprostone (IBS drug)

Approved for IBS-C in women older than 18 years and chronic idiopathic constipation (CIC) in women and men Causes select activation of chloride channels in lumen of intestine Modest benefits of pain reduction

Immunosupressants

Azathioprine and Mercaptopurine -Induce and maintain remission in both ulcerative colitis and Crohn's disease -Onset of effects may be delayed for up to 6 months -Reserved for patients who have not responded to traditional therapy -Adverse effects are pancreatitis and neutropenia

The nurse is caring for a patient with MS who is receiving interferon beta-1a [Rebif] by subcutaneous injection. Which laboratory tests should be performed regularly in this patient to monitor for a potential adverse effect? (Select all that apply.) A. Blood urea nitrogen B. Complete blood count C. Hemoglobin A1c D. Alkaline phosphatase E. Immunoglobulin G levels

B. Complete blood count D. Alkaline phosphatase When monitoring a patient receiving interferon, the nurse should watch for potential adverse reactions of hepatotoxicity (alkaline phosphatase) and myelosuppression (complete blood counts). The blood urea nitrogen value is an indicator of renal function, which is not affected by interferon beta-1a. The hemoglobin A1c test is a weighted average of the glucose level over the past several months. Glucose levels are not affected by interferon beta-1a. Immunoglobulin G levels might be assessed when making the diagnosis, but they are not used to monitor for adverse effects of interferon.

A patient who has Cushing's syndrome is taking ketoconazole [Nizoral] as an adjunct treatment to brain radiation. A nurse should expect the patient to have which of these therapeutic responses? A. Increased resistance to infection B. Enhanced radiation effect to the brain C. Suppressed cortisol synthesis D. Increased ACTH production

B. Enhanced radiation effect to the brain Ketoconazole is an antifungal drug that inhibits glucocorticoid synthesis very effectively. It is used as an adjunct to radiation or surgery in patients with Cushing's syndrome. Increased ACTH production and resistance to infection and suppressed cortisol synthesis are not actions of ketoconazole.

A nurse caring for a patient who is taking the prostaglandin analog latanoprost [Xalatan] documents which finding as an adverse effect? A. Tachycardia and hypertension B. Heightened brown pigment of the iris C. Headache, dry mouth, and altered taste D. Ocular stinging and conjunctivitis

B. Heightened brown pigment of the iris Latanoprost is used to increase aqueous outflow in the treatment of open-angle glaucoma. Heightened brown pigmentation of the iris occurs as an adverse effect. Tachycardia and hypertension are associated with nonselective adrenergic agonists. Headache, dry mouth, and altered taste are associated with alpha-adrenergic agonists. Ocular stinging and conjunctivitis are seen with carbonic anhydrase inhibitors.

A patient with a history of numbness, weakness, and blurred vision recently was diagnosed with multiple sclerosis (MS). What does the nurse understand to be the underlying pathophysiology for these symptoms? A. An imbalance of dopamine and acetylcholine in the central nervous system B. Inflammation and myelin destruction in the central nervous system C. An inability of serotonin to bind to its receptors in the chemoreceptor trigger zone D. High-frequency discharge of neurons from a specific focus area of the brain

B. Inflammation and myelin destruction in the central nervous system The underlying pathophysiology of MS is related to myelin destruction and slowing of axonal conduction related to inflammation within the central nervous system. The demyelination leads to the characteristic neurologic symptoms associated with MS.

An adult patient who has GH deficiency is receiving somatropin [Nutropin]. An increase in which finding would indicate to the nurse that the patient is improving? A. Height (by 3 inches) B. Lean body mass C. Physical strength D. Joint range of motion

B. Lean body mass Nutropin is a form of GH. In adults with GH deficiency, replacement therapy does not cause long bone growth or an increase in height, because the epiphyses are already closed. It does increase lean body mass and reduces adipose tissue. Although it increases muscle mass, Nutropin does not increase strength. Joint range of motion is not affected.

A patient is prescribed metformin. Which statement about metformin does the nurse identify as true? A. Metformin increases absorption of vitamin B12 B. Metformin can delay the development of type 2 diabetes in high-risk individuals C. Metformin causes patients to gain weight D. Metformin use predisposes patients to alkalosis

B. Metformin can delay the development of type 2 diabetes in high-risk individuals

Adrenergic Antagonists

Block adrenergic receptors Majority produce reversible (competitive) blockade Most adrenergic antagonists are more selective than the agonists 2 major groups: Alpha-adrenergic blocking agents Beta-adrenergic blocking agents Summary: Sympathetic on: Adrenergic agonist (fight) Sympathetic off: Adrenergic antagonists/blockers (rest) Parasympathetic on: Cholinergic agonist (sludge) Parasympathetic off: Anticholinergics (dry)

Which statement made by a patient indicates a need for further teaching by the nurse about reducing injection site reactions from interferon beta? A. "I need to rotate my injection sites, so I'll need to keep a record of them." B. "I will apply hydrocortisone ointment to the injection site if it is itchy." C. "Applying a warm compress before giving the injection will reduce the risk of pain at the site." D. "I can take over-the-counter Benadryl if the injection site itches and is red."

C. "Applying a warm compress before giving the injection will reduce the risk of pain at the site." Brief application of ice rather than warm compress application is indicated prior to injection. Warm compresses may be helpful following the injection. Injection sites should be rotated to decrease discomfort. Itching and erythema can be reduced by topical application of hydrocortisone or oral diphenhydramine.

Which ophthalmic solution would be most appropriate for a patient with open-angle glaucoma and a history of chronic obstructive pulmonary disease (COPD)? A. Timolol B. Carteolol C. Betaxolol D. Levobunolol

C. Betaxolol Betaxolol is a beta1-selective blocker and the preferred drug for use in patients with asthma and COPD. Timolol, carteolol, and levobunolol are nonselective beta-adrenergic blockers; that is, they block both beta1 and beta2 receptors. Blockade of beta2 receptors can lead to bronchospasm.

The nurse is caring for a patient receiving buspirone [BuSpar] for the treatment of anxiety. Which symptom is most likely explained as an adverse effect of this drug? A. Diarrhea B. Risk for abuse C. Dizziness D. Weight gain

C. Dizziness Buspirone is an antianxiety medication with few side effects. The most common effects are dizziness, nausea, headache, nervousness, lightheadedness, and excitement. Buspirone does not cause drowsiness, risk for abuse, or weight gain.

When assessing a patient who takes finasteride [Proscar], a nurse should monitor for which adverse effect? A. Hair loss B. Increased libido C. Ejaculatory dysfunction D. Muscle weakness

C. Ejaculatory dysfunction Common adverse effects of finasteride include impotence, decreased libido, and decreased volume of ejaculate. The drug also is used to treat male pattern baldness; therefore, it would cause hair growth, not hair loss. Muscle weakness is unrelated.

The nurse is caring for a patient receiving dantrolene [Dantrium] for spasticity associated with MS. Which laboratory test will be important in monitoring for a potential adverse effect of this drug? A. Blood urea nitrogen (BUN) B. Albumin level C. Gamma-glutamyltransferase (GGTP) D. Complete blood count (CBC)

C. Gamma-glutamyltransferase (GGTP) In large doses dantrolene has been associated with fatal liver failure. Liver function tests, such as gamma-glutamyltransferase (GGTP), should be performed at baseline and periodically thereafter.

Which medication should the nurse anticipate administering to a patient in convulsive status epilepticus to halt seizure activity? A. Phenytoin [Dilantin] 200 mg IV over 4 minutes B. Phenobarbital 30 mg IM C. Lorazepam [Ativan] 0.1 mg/kg IV at a rate of 2 mg/min D. Valproic acid [Depacon] 250 mg in 100 mL of normal saline infused IV over 60 minutes

C. Lorazepam [Ativan] 0.1 mg/kg IV at a rate of 2 mg/min Intravenous benzodiazepines, such as lorazepam or diazepam, are used for abrupt termination of convulsive seizure activity. Lorazepam is preferred over diazepam because of its longer effects. Once seizures have been stopped with a benzodiazepine, phenytoin may be administered for long-term suppression. Phenytoin and valproic acid are not benzodiazepines.

Which statement about memantine [Namenda] is false? A.Memantine is indicated for moderate or severe AD. B. Memantine modulates the effects of glutamate. C. Memantine does not slow the decline in function. D. The most common side effects are dizziness, headache, confusion, and constipation.

C. Memantine does not slow the decline in function For many patients, the drug can slow the decline in function, and, in some cases, it may actually cause symptoms to improve. The other statements are true.

A patient has been diagnosed with performance anxiety. The nurse anticipates use of which drug to treat this psychologic disorder? A. Clonazepam [Klonopin] B. Alprazolam [Xanax] C. Propranolol [Inderal] D. Sertraline [Zoloft]

C. Propranolol [Inderal] Propranolol [Inderal] and other beta blockers can benefit patients with performance anxiety. When taken 1 to 2 hours before a scheduled performance, beta blockers can reduce symptoms caused by autonomic hyperactivity (eg, tremors, sweating, tachycardia, palpitations). Doses are relatively small (eg, only 10 to 80 mg for propranolol).

Enterohepatic Circulation

Drugs absorbed from GI tract must pass through liver before they reach general circulation. Enterohepatic recycling is when Drug in the liver --> into bile --> back into duodenum via bile duct --> reabsorbed back into portal blood -This remains unchanged in system longer. -Drugs keep cycling through GI tract until it's finally gotten rid of.

Drugs for Hypertensive Disorders of Pregnancy

Chronic hypertension with pregnancy -ACE inhibitors, ARBs, and DRIs are contraindicated during pregnancy (avoid these) -Most other antihypertensives can be continued during pregnancy Preeclampsia and eclampsia Multi-system involvement: BP is over 140/90. -Proteinuria after 20th week -Severe peripheral edema Treatment: -Drug of choice to lower BP: labetalol -If eclampsia develops: Magnesium sulfate IV or IM

Laxative Abuse

Causes: -Misconception that daily bowel movement has to happen -Bowel replenishment after evacuation can take 2 to 5 days --> often mistaken for constipation Consequences: Chronic use = diminished defecatory reflexes = further reliance on laxatives Electrolyte imbalance, dehydration, and colitis

Receptor Specificity

Catecholamines Epinephrine -A1, A2, B1, B2 Norepinephrine -A1, A2, B1 Isoproterenol B1, B2 Dobutamine B1 Dopamine A1, B1, dopamine Noncatecholamines Ephedrine A1, A2, B1, B2 phenylephrine A1 Albuterol B2

Social Anxiety Disorder (Social Phobia)

Characteristics -Intense and irrational fear that one will be scrutinized by others (generalized or nongeneralized like a situational specific like public speaking) -Very debilitating -One of the most common psychiatric disorders Treatment Psychotherapy Drug therapy: SSRIs, paroxetine, and sertraline

Obsessive-Compulsive Disorder

Characteristics -Potentially disabling condition -Persistent obsessions and compulsions Treatment Behavioral therapy Drug therapy SSRIs First line drugs for OCD -Citalopram -Escaitalopram -Fluoxetine -Fluvoxamine -Paroxetine -Sertraline TCAs Clomipramine -Less well tolerated -Second line drug

Which statements about zaleplon [Sonata] does the nurse identify as true? (Select all that apply.) A. Zaleplon [Sonata] is a benzodiazepine. B. Zaleplon [Sonata] is indicated for long-term management of insomnia. C. Zaleplon [Sonata] is used to maintain sleep throughout the night. D. Zaleplon [Sonata] should not be administered with cimetidine [Tagamet]. E. Zaleplon [Sonata] interacts with the neurotransmitter GABA.

D. Zaleplon [Sonata] should not be administered with cimetidine [Tagamet]. E. Zaleplon [Sonata] interacts with the neurotransmitter GABA. Zaleplon [Sonata] belongs to a new class of drugs called the pyrazolopyrimidines. It is indicated for short-term management of insomnia. Zaleplon has a rapid onset and short duration of action and therefore is beneficial for initiating sleep but not for maintaining it throughout the night. Zaleplon and cimetidine should not be administered together. Zaleplon interacts with the neurotransmitter GABA.

Anti-epileptic Drugs (AEDs)

Effects: -Suppress discharge of neurons when seizure is happening -Suppress propagation of seizure activity from the focus to other areas of the brain MOA: -Suppression of sodium influx -Suppression of calcium influx (Both affect how nerves work) -Antagonism of glutamate (which is an excitatory transmitter) -Potentiation of gamma-aminobutyric acid (GABA) (GABA is an inhibitory neurotransmitter because it blocks, or inhibits, certain brain signals and decreases activity in your nervous system) Goals of treatment: -Reduce seizures to a level that allows patient to live as normal a life as possible -Balance the desire for complete seizure control with acceptable side effects Two major categories: Traditional AEDs -Phenytoin -Fosphenytoin -Carbamazepine -Valproic acid -Ethosuximate -Phenobarbital -Primidone Newer AEDs -Total of 14

Rivastigmine (Cholinesterase Inhibitors)

Exelon patch has lower side effects than oral preparation Uses: Mild to Moderate AD Mild to moderate Parkinson dementia MOA: Irreversible inhibition of cholinesterase Adverse effects: Causes adverse effects with higher frequency than other 2 drugs -N/V/D -Abdominal pain -Anorexia -Significant weight loss Intensify symptoms in patients with: -Peptic Ulcer disease (PUD) -Bradycardia -Sick sinus syndrome -Urinary obstruction -Lung disease -Fainting, falls, and fall-related fractures

Pyrimidine analog

Flucytosine -Use for serious infection with Candida and Cryptococcus neoformans -Resistance common AE: bone marrow suppression, hepatotoxicity Precaution: Renal impairment, Hematologic disorders

Factors That Can Trigger Migraine Headache

Foods that contain: Tyramine -Aged cheeses or Chianti wine Nitrates -Hot dogs -Cured meat products Phenylethylamine -Chocolate Monosodium glutamine (MSG) - preservative -Asian food -Buffet foods -Canned soups Aspartame - artificial sweetener -Diet sodas -Other artificially sweetened foods Yellow food coloring

Blood pressure goals

General Population (no diabetes or kidney disease) Older than 60: 150/90 Younger than 60: 140/90 Diabetes or kidney disease present: All ages, diabetes, no kidney disease: 140/90 All ages, kidney disease, with/without diabetes: 140/90

Diabetes and Pregnancy

Gestational diabetes (GDM) -Appears during pregnancy and subsides after delivery -Blood glucose should be measured closely -If diabetes persists beyond delivery, it is no longer considered gestational and should be re-diagnosed -Managed just as any other diabetic pregnancy (insulin) Contributing factors during pregnancy -Placenta produces hormones that antagonize insulin actions -Production of cortisol increases threefold (promotes hyperglycemia) -Glucose passes freely from maternal to fetal circulation Glucose should be monitored 6 to 7 times a day and treat with insulin and adjust food intake

The nurse prepares to administer metoprolol to a patient with chronic stable angina. What is a priority assessment to make before the administration of this medication?

Heart rate. If heart rate is less than 60, hold the dose.

Vasodilators

Hydralazine + Isosorbide dinitrate (ISDN) Hydralazine --> select ARTERIAL dilation -Improves Cardiac output and renal blood flow -By itself, not effective for heart failure ISDN --> select dilation of VEINS -Reduces congestive symptoms -Improves exercise capacity -Adverse effect: orthostatic hypotension, reflex tachycardia IV vasodilators for acute care -Nitroglycerin: veins only Given in IV drip Adverse effects: hypotension and resultant reflex tachycardia -Sodium nitroprusside: arteries & veins Adverse effects: profound hypotension -Nesiritide: Adverse effect: symptomatic hypotension

Calcium Channels

It works on the calcium channels in the vascular smooth muscle. The calcium channels open during the contractile process & close when vessels or heart relaxes. If we blocked calcium channels, we are going to get vasodilation. They help dilate the coronary arteries = help promote collateral circulation. Calcium channels help regulate myocardium muscle itself, the SA node, and the AV node. They couple calcium channels with the Beta 1 adrenergic receptors.

Antibiotics

Metronidazole and ciprofloxacin -Crohn's disease: can help control symptoms -Ulcerative colitis: Antibiotics largely ineffective Metronidazole: long term therapy is required; prolonged use of high-dose metronidazole poses risk of peripheral neuropathy Ciprofloxacin: highly effective in patients with mild or moderate Crohn's disease

Aripiprazole (SGA)

New class: -Dopamine system stabilizer (DSSs) MOA: Binds to multiple receptors (Pure agonist) Blocks: H1, 5-HT2, alpha1 receptors Partial agonist: 5-HT1, D2 Uses: -Schizophrenia -Major depressive disorder (MDD) -Bipolar disorder -Irritability associated with autism -Agitation associated with schizophrenia or bipolar mania Adverse effects: -Generally well tolerated Preparations: -PO tabs -Solution -ODT (oral disintegrating tablet) -IM

Tolterodine [Anticholinergic Drug for OAB]

Nonselective muscarinic antagonist Approved only for OAB Fewer anticholinergic side effects QT interval prolongation risk

Chronic stable Angina (Exertional)

Pathophysiology Emotional excitement Large meals Cold exposure Coronary artery disease (CAD) Goal Reduce intensity and severity of angina pain. -Decrease O2 demand (primarily) -Increase cardiac O2 supply Therapeutic agents (symptomatic relief) -Organic nitrates -Beta blockers -Calcium channel blockers -Ranolazine Non-drug therapy -Have person sit down or lay down and rest. -Rest will help stop it if it's angina. After 15 minutes, call 911.

Alosetron (IBS drug)

Potentially hazardous drug; approved for women only -Blockades serotonin receptors GI Toxicities can cause complicated constipation, leading to perforation and ischemic colitis (losing blood flow to colon) Risk management program (it can be so severe, FDA requires it to be monitored) It doesn't directly interact with other drugs

Diabetes Treatment Goals

Primary goal: prevent long-term complications Glycemic treatment targets Hemoglobin A1c -A1C i goal less than 7% is good for most patients -Goal less than 8% may be appropriate Self monitoring of blood glucose Before meals: 70-130 mg/dL Peak postmeal: Less than 180 mg/dL Bedtime: 100-140 mg/dL

Radioactive Iodine-131

Radioactive isotope of stable iodine MOA: -Emits gamma rays and beta particles -Beta particles destroy thyroid tissue Uses: -Graves' disease: remission without complete destruction of the thyroid gland -Thyroid cancer: destroy malignant thyroid cells -Diagnostic use with thyroid scans (not preferred) Pharmacokinetics: -Half life: 8 days -2 to 3 months for full effect Preparations: Capsules and solutions (PO) -Both odorless and tasteless

Solifenacin [Anticholinergic drug for OAB]

Similar to darifenacin, but not as M3 selective Long half life = 50 hours (allows for once daily dosing) Adverse effects: -Dry mouth -Constipation -Blurred vision can prolong QT interval --> fatal dysrhythmias Drug interactions: Same as darifenacin

Other Antiulcer Drugs

Sucralfate Misoprostol Antacids (use carefully for patients who are in renal failure) -Aluminum compounds -Magnesium compounds -Calcium compounds -Sodium compounds

Calcium carbonate [antacid]

Tums The bone is demineralized, if you have bone density and have slight decalcification on bone density, it will help with that. ANC: -High, rapid acting, long duration Acid rebound Adverse effects -Constipation -Eructation (belching) Flatulence Low palatability = low adherence

Drugs for Muscle Spasm and Spasticity

Two groups that cause skeletal muscle relaxation 1. One for Localized muscle spasm 2. One for Spasticity Most drugs (except dantrolene) produce their effects through actions in the CNS Groups are not interchangeable. Drugs for one don't address the other.

Isoniazid

Used for active and latent TB Bactericidal AE: peripheral neuropathy, hepatotoxicity, optic neuritis, anemia

Cocaine (local anesthetic)

Used topically in ear, nose, throat Intense vasoconstriction Happens rapidly and lasts for about 1 hour DO not use with other vasoconstrictors

Dantrolene (Drug for Spasticity)

Uses: -Spasticity associated with MS, CP, and SCI (spinal cord injury) -Malignant hyperthermia (caused by succinylcholine and general anesthetics) MOA: -Acts directly on skeletal muscle -Suppresses release of calcium from the sarcoplasmic reticulum Adverse effects: -Most serious = liver toxicity -Muscle weakness -Drowsiness -Diarrhea -Acne-like rash

Overview of Treatment

Who might want to be treated? -Individuals with a BMI of 30 or higher -Individuals with a BMI of 25 to 25.9 plus two risk factors -Individuals with a waist circumference (WC) greater than 40 inches (men) or greater than 35 inches (women) plus two risk factors Treatment goals: Initial objective: reduce weight by 10% over 6 months After 6 months: prevent lost weight from returning -Combination of diet, physical activity, behavioral therapy

After an intramuscular injection of penicillin, a patient develops severe difficulty breathing and a swollen tongue. Which medication should the nurse prepare to administer?

epinephrine.

A patient with irritable bowel syndrome is prescribed Alosetron. Before this drug is administered, it is most important for the nurse to do what?

-Ask the patient about any problems with constipation

Lidocaine (local anesthetic)

Most widely used local anesthetic Also used for cardiac dysrhythmias Anesthetic effects extended with Epi Preparations Topical -Cream -Ointment -Jelly -Aerosol -Patch Injectable solution

Unstable Angina: Medical Emergency

Pathophysiology Severe coronary artery disease that is complicated by vasospasm Symptoms -Angina at rest, wake up in middle of night with chest pain -New-onset exertional angina -Intensification of existing angina Goal -Reduce pain, prevent progression to MI/death -Increase oxygen supply -Decrease oxygen demand Therapeutic agents for acute management

Verapamil & Diltiazem (NON-DIHYDROPYRIDINES) Hemodynamic Effects

-Act on vascular smooth muscle and heart 5 direct hemodynamic effects of blockade: 1. At peripheral arterioles --> reduces aP 2. At cardiac arteries and arterioles --> increases coronary perfusion 3. At SA node --> reduces heart rate 4. At AV node --> decreases AV node conduction 5. In myocardium --> decreases force of contraction

Class 1C: Flecainide & Propafenone SODIUM CHANNEL BLOCKERS

-Block cardiac sodium channels -Delay ventricular repolarization -For maintenance prescribed of Ventricular dysrhythmias (frequent PVCs) -All class 1C agents can exacerbate existing dysrhythmias and create new ones

Antimicrobials

-Treat infectious disease Antibiotic = anything we make is not antibiotic. Strictly speaking, chemical produced by one microbe that can harm other microbes. Antimicrobial agent = any agent that can kill or suppress microorganisms

Overview of Autonomic Nervous System Functions

3 principal functions: 1. Regulate the heart 2. Regulate the secretory glands (salivary, gastric, sweat, and bronchial) 3. Regulate the smooth muscles (Bronchi, blood vessels, GU system, and GI tract

A patient is receiving dopamine for the treatment of shock. What would indicate to the nurse that the medication is effective?

Increased urine output You have enough perfusion, absorption of kidneys. Your goal is to perfuse to organs, kidney is one of those. Now your patients are making urine, that is indicator of perfusion and that is the goal of therapy.

Acid-Base Disturbances

Acid-Base is maintained by: -Bicarbonate-carbonic acid buffer -Respiratory system (CO2, acid) -Kidneys (HCO3-, base) Respiratory alkalosis Respiratory acidosis Metabolic Alkalosis Metabolic Acidosis

Dobutamine (BETA 1 SPECIFIC)

Actions and uses: -Congestive heart failure Preparations, dosage and administration: -Continuous IV infusion Adverse effects: Tachycardia Drug interactions: -MAOIs -TCAs -certain general anesthetics

Riboflavin (Vitamin B2)

Actions: -Involved in numerous enzymatic reactions Sources: -Milk -Yogurt -Cheese -bread products -fortified cereals -organ meats Deficiency: -Early -Late Therapeutic uses: -Riboflavin deficiency -Migraine headaches

Common Cold

Acute URI (viral) S/s -Rhinorrhea, nasal congestion, cough, sneezing, sore throat, HA, hoarseness, malaise, myalgia, fever in kids Self limiting Symptomatic Treatment -Fluids -Rx for cough -Acetaminophen for fever and aches OTC -Nasal decongestant -Antitussive -Analgesic -Antihistamine -Caffeine

SGAs

Advantage: less risk of EPS than FGAs Disadvantage: Increased risk of weight gain, diabetes, and dyslipidemia Examples: -Clozapine ** -Risperidone -Olanzapine -Ziprasidone -Quetiapine ** -Aripiprazole

Inhaled Drug therapy

Advantages: -Enhanced therapeutic effects -Systemic effects minimal -Rapid relief depending on drug Delivery mechanisms: -Metered dose inhalers (MDIs) --Hand coordination required --with spacer (helps patient get more of an inhalation, more of the drug inhaled, more drug deposited into lungs instead of the back of throat. -Respimat's --Ipratropium and bromide combo -Dry-powder inhalers (DPIs) --Don't require a lot of coordination between breaths -Nebulizers

Pathophysiology

All cells of heart are potential pacemakers. SA node is primary pacemaker If you have MI that causes damage in the septum, its an anterior MI and it's going to go into the septum, cause damage to AV node, and cause ventricular dysrhythmias. If you have MI further out, like on left ventricle (lateral MI), you are going to damage purkinje fibers, the left bundle branch Contraction goes: Starts in SA node (p wave) --> it goes through to the AV node (pr interval). If it's really slow through AV node, that is going to widen the QRS (quidinine does, it slows things in here). ST segment and T waves become important when talking about STEMI Sometimes see U wave. If you see abnormality in T wave or really pronounced U wave, check potassium level.

Polyenes

Amphotericin B Broad spectrum Highly toxic Use: Systemic mycoses, some protozoa Increases's cell permeability Fungistatic or fungicidal AE: Infusion reaction (pretreat w/ diphenhydramine + acetaminophen or ASA; IV meperidine or dantrolene for rigors), phlebitis (change IV sites frequently, slow rate of admin, use large central vein, pretreat with heparin), nephrotoxicity (hydrate w/1L saline), hypokalemia, hematologic (bone marrow suppression)

Pregabalin (Newer AED)

Analog (similar) of GABA. "Pre-gaba" Uses: -Neuropathic pain associated with diabetic neuropathy -Postherpetic neuralgia (is a painful condition that affects the nerve fibers and skin) -Adjunctive therapy of partial seizures -Fibromyalgia Adverse effects: Common: -Dizziness -Somnolence -Blurred vision -Significant weight gain -Difficulty thinking -Headache -Peripheral edema -Dry mouth Hypersensitivity reactions: -Life-threatening angioedema -Rhabdomyolysis Abuse potential (it can produce euphoria) Physical dependency

Adjuncts (Addition) to Reperfusion Therapy

Anticoagulants -Heparin (all getting heparin for TPA) -Fondaparinux (selective factor Xa inhibitor). Alternative therapy to heparin for patients undergoing reperfusion with fibrinolytics -Bivalirudin (direct thrombin inhibitor). For patients undergoing PCI who are at high risk of bleeding. Antiplatelet Drugs -Thienopyridines: Clopidogrel, ticagrelor, and prasugrel -GP 2b/3a inhibitors: Abciximab -Aspirin: low dose aspirin. Every patient that has MI should take aspirin indefinitely.

Which manifestation would the nurse most clearly associate with a tumor of the hypothalamus? A. Mood swings B. Unstable body temperature C. Irregular respirations D. Increased heart rate

B. Unstable body temperature One function of the hypothalamus is the regulation of body temperature, and a tumor that compresses the hypothalamus would impair this function. Regulation of mood swings, respiratory rate, and heart rate are not functions of the hypothalamus.

Intravenous Anesthetics

Benzodiazepines -Diazepam -Midazolam Propofol Etomidate Ketamine Neuroleptic-opioid combination: Droperidol + fentanyl

A nurse administers naloxone [Narcan] to a postoperative patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication? A. Drowsiness B. Tics and tremors C. Increased pain D. Nausea and vomiting

C. Increased pain Naloxone reverses the effects of narcotics. Although the patient's respiratory status will improve after administration of naloxone, the pain will be more acute.

Centrally Acting Anticholinergic Drugs

Benzotropine and trihexyphenicyl Used as second line therapy for tremor MOA: Block muscarinic receptors in striatum, thereby improving neurotransmitter balance Reduce tremor and possibly rigidity, NO reduction of bradykinesia Less effective than levodopa or dopamine agonists, but better tolerated Most appropriate for younger patients with mild symptoms Avoided in elderly, who are intolerant of CNS side effects (sedation, confusion, delusions, hallucinations)

Newer Anti-epileptic Drugs

Better tolerated Most common are lamotrigine and levetiracetam -Lamotrigine -Gabapentin -Pregabalin -Levetiracetam -Topiramate

Memantine (N-methyl-d-Aspartate receptor antagonist)

Better tolerated than cholinesterase inhibitors Modulates effects of gluconate (neurotransmitter) Use: Moderate to severe AD Adverse effects: -Dizziness -Headache -Confusion -Constipation

Classification of Calcium Channel Blockers

Classified by 3 chemical families: 1. Phenylalkylamine Verapamil Sites: Arterioles & heart 2. Benzothiazepine Dilitiazem Sites: arterioles & heart 3. Dihydropyridines Nifedipine Site: Arterioles Sometimes broken into 2 groups: 1. Non-dihydropyridines Orphans. Your heart goes out to orphans. Work on heart. 2. Dihydropyridines

Dietary Fiber and Constipation

Bowel function is highly dependent on dietary fiber (bran is best source) Benefits of fiber: -helps to absorb water and soften feces and increase the size. -Help with colonic digestion of bacteria to help increase fecal mass Low-fiber diet: frequent cause of constipation Constipation: -Hard stools, infrequent stools, excessive straining, prolonged effort, sense of incomplete evacuation, unsuccessful defecation

Rifampin

Broad spectrum AE: Hepatotoxicity/hepatitis, red-orange discoloration of body fluids, GI Interactions: CYP450, oral contraceptives, warfarin, drugs for HIV infection

Azoles

Broad spectrum Lower toxicity than amphotericin B inhibits fungal CYP450 dependent enzymes Itraconazole Used for: systemic mycoses AE: cardiosuppression, hepatotoxicity, N/V/D Ketoconazole Use for: Chronic fungal infections AE: GI (give with food), hepatotoxicity, inhibit steroid synthesis

A patient is taking glipizide [Glucotrol] and a beta-adrenergic medication. A nurse is teaching hypoglycemia awareness and should warn the patient about the presence of which symptom? A. Vomiting B. Muscle cramps C. Tachycardia D. Chills

C. Tachycardia Glipizide is a sulfonylurea oral hypoglycemic medication that acts to promote insulin release from the pancreas. Beta-adrenergic blockers can mask early signs of sympathetic system responses to hypoglycemia; the most important of these is tachycardia, which is the most common adverse effect of glipizide. Vomiting, muscle cramps, and chills are not symptoms of activation of the sympathetic nervous system that arise when glucose levels fall.

Inflammatory Bowel Disease (IBD)

Caused by exaggerated immune response to normal bowel flora Crohn's Disease (CD) -Characterized by transmural inflammation -Usually affects terminal ileum (can affect all parts of GI tract) Ulcerative colitis (UC) -Inflammation of the mucosa and submucosa of the colon and rectum -May cause rectal bleeding -May require hospitalization

Repaglinide

Class: -Meglitinides "-glinides" Use: -Only for use with T2DM MOA: -Promotes pancreatic insulin release Adverse effect: Generally well tolerated -Hypoglycemia Drug interactions: -Gemfibrozil --> inhibits repaglinide metabolism You get hypoglycemia so avoid

Drugs for Heart Failure

Diuretics: -Thiazide diuretics -Loop diuretics -Potassium-sparing diuretics (may help if patient is on digoxin) RAAS inhibitors: -ACE inhibitors -ARBs -Aldosterone antagonists -Direct renin inhibitors Beta blockers: Vasodilators: Positive Inotropes -Improves force of contraction -Digoxin

Which medication can cause this acid-base disturbance: pH 7.32, paCO2 33, HCO3 20? A. Primidone [Mysoline] B. Lamotrigine [Lamictal] C. Lacosamide [Vimpat] D. Topiramate [Topamax]

D. Topiramate [Topamax] The arterial blood gas results reflect metabolic acidosis with partial respiratory compensation. Topiramate can cause metabolic acidosis, because it inhibits carbonic anhydrase; this increases renal excretion of bicarbonate, causing the plasma pH to fall. Hyperventilation is the most characteristic symptom. Primidone, lamotrigine, and lacosamide do not cause metabolic acidosis.

A nurse should give which instruction about ear hygiene to the parent of a child who has "swimmer's ear"? A. "Keep the ear moist so that abrasions from earplugs are minimized." B. "Regularly use a medicated oil ear wash to remove the earwax." C. "Routinely use a soft cotton-tipped applicator to dry the ear canal." D. "After swimming, tip the head to each side to promote water drainage."

D. "After swimming, tip the head to each side to promote water drainage." Swimmer's ear can be prevented by promoting defenses of the external ear canal. Drying the ear canal and promoting water drainage reduce the risk of excess moisture that can precipitate otitis externa (OE). Earwax is protective and should not be removed. Nothing should be put in the ear, including cotton-tipped swabs, fingers, pencils, or liquids, all of which can cause abrasions, sites of bacterial entry.

Sedative-Hypnotic Drugs

Depress CNS function Primarily used to treat anxiety and insomnia 3 major groups: 1. Barbiturates (secobarbital, phenobarbital) 2. Benzodiazepines (diazepam) 3. Benzodiazepine-like drugs (zolpidem)

Superficial mycoses

Dermatophytic Tinea pedis (feet) Tinea= ringworm Tinea corporis (body) Tinea cruris (groin) Tinea capitis (scalp) Onychomycosis (nails) Candidiasis Vulvovaginal Commonly called Yeast infection Oral (thrush) Griseofulvin Absorption is increased with fatty meal

The nurse should monitor for which adverse effect after administering hydrochlorothiazide [HydroDIURIL] and digoxin [Lanoxin] to a patient?

Digoxin toxicity Digoxin levels have an inverse relationship with potassium levels. Because hydrochlorothiazide can lower potassium levels, combined use of hydrochlorothiazide and digoxin poses a risk for elevated digoxin levels and ensuing digoxin toxicity.

The nurse identifies which of the following as the most common type of laxative abused by the general public?

Docusate sodium

Pilocarpine

Direct-acting cholinergic (muscarinic) agonist that causes: -Miosis(excessive constriction of the pupil of the eye) -Contraction of the ciliary muscle (reduction of IOP) Uses: -Second line drug for POAG -Emergency treatment of acute angle-closure glaucoma Adverse effects: -Retinal detachment (due to contraction of ciliation muscle) -Decreased visual acuity -Others: local irritation, brow pain, and eye pain -Systemic effects are rare due to topical administration (Toxicity would be reversed with atropine)

indirect-Acting Anti-adrenergic Agents

Drugs that prevent activation of peripheral receptors by mechanisms that don't involve direct interaction with those receptors. 2 Groups: Centrally acting alpha 2 agonists -Act in CNS to reduce the outflow of impulses to sympathetic neurons -Effects similar to those of the direct-acting adrenergic receptor blockers Used primarily for hypertension -Clonidine -Guanfacine -Methyldopa Adrenergic neuron-blocking agents MOA: Work in terminals of sympathetic neurons to decrease actual release of NE -Closely resembles alpha and beta blockade -Produces PNS and CNS effects Reserpine (discontinued in the US)

Anticoagulants

End goal: -Reduce formation of fibrin from making that clot Used: -Primarily to prevent thrombosis in the veins and atria of the heart Two mechanisms of action: 1. Inhibit the synthesis of clotting factors (Warfarin) 2. Inhibit the activity of clotting factors Subclasses: Drugs that activate antithrombin -Heparin (unfractionated) -Enoxaparin (LMWH) Vitamin K antagonists -Warfarin Direct Thrombin Inhibitors -Dabigatran Direct Factor Xa Inhibitors -Rivaroxaban -Apixaban Antithrombin (AT) -ATryn

Macrolides ("-mycins") (Bacteriostatic inhibition of protein synthesis)

Erythromycin -Broad spectrum -Inhibition of protein synthesis -Usually bacteriostatic can be bactericidal with high enough dose Use: allergy to penicillin, whooping cough, acute diphtheria, M. pneumoniae, S. pyogenes AE: GI, QT prolongation, sudden cardiac death when combined with 3A4 inhibitor, superinfections (kills good gut flora), thrombophlebitis, transient hearing loss Alernatives: Clarithryomycin, azithromycin

Cough

Expectorants Antitussives CNS cough-reflex pathway Opiod antitussives Codeine Non-opiod antitussives -Dextromethrophan (DM) -Diphenhydramine -Benzonatate Guaifenesin (Mucinex) Renders cough more productive by stimulating flow of respiratory tract secretions Patient education:: hydration Mucolytics Hypertonic saline- 3% NaCl Acetylcysteine Decrease viscosity of mucus AE: Bronchospasm

Histamine2-Receptor Antagonists [anti-secretory agent]

First choice for treating gastric and duodenal ulcers MOA: -Block H2 receptors on parietal cells in the GI tract, particularly stomach and duodenum. -Promote healing by suppressing secretion of gastric acid Serious side effects are uncommon [except for ranitidine] All are equally effective: -Cimetidine -Ranitidine -Famotidine

Herpes virus (Antiviral)

Herpes simplex, varicella-zoster, Epstein-Barr, Cytomegalovirus, Kaposi's sarcoma Acyclovir Active only against herpes -First line for herpes simplex (Genetalia, MM's) and varicella-zoster MOA: Inhibits DNA polymerase Developed resistance AE= IV: phlebitis, nephrotoxicity, neurotoxicity, PO: GI, vertigo Topical: Stinging sensation Valacyclovir Use for: Herpes zoster, herpes simplex gentalis, herpes labialis, varicella Precaution: Immunocompromised AE: thrombolytic thrombocytopenic purpura/ hemolytic uremic syndrome (TTP/HUS; kIdneys!!) Famciclovir Inhibits DNA synthesis and replication -Selective Use for: Acute herpes zoster, genital herpes infection

Benzodiazepines (IV anesthetic)

Induce anesthesia with IV admin Produce unconsciousness, dentist use these for long procedures Diazepam -Unconscious within 1 minute -Very little muscle relaxation -IV Diazepam is NEVER mixed with other drugs or solutions due to known precipitation (crystals) -Respiratory depression can occur so when using IV always have supportive equipment nearby Midazolam -Unconsciousness within 80 seconds -Can cause dangerous cardiorespiratory effects -Amnesic effect for 24 hours

Cholinergic Drugs

Influence activity of cholinergic receptors. Effects: -Most directly act on receptor where it turns off or on -Rest can act indirectly by blocking activity of cholinesterase which breaks down ACh -Most mimic or block actions of acetylcholine (ACh) Toxicology encompasses: -Nicotine -Insecticides -Chemical warfare

Long-Duration Insulin

Insulin glargine [Lantus] "Lantus" = "Long" Modified human insulin Onset: 70 minutes Peak: None (levels are steady, no peak) Duration: 18-24 hours Administration -Route: SC injection only -Once daily SC dosing -Treats T1DM and T2DM in adults and children

Drugs for Diabetes

Insulin preparations Short duration, rapid action -Insulin lispro Short duration, slow acting -Regular insulin Intermediate duration -NPH insulin Long duration -Insulin glargine Oral Hypoglycemic Drugs Biguanides -Metformin Sulfonylureas -Glyburide Meglitinides -Repaglinide Thiazolidinediones -Pioglitazone Alpha-glucosidase inhibitors -Acarbose DPP-4 inhibitors ("gliptins") -Sitagliptin SGLT2 inhibitors ("flozins") -Canagliflozin Non-insulin injectable drugs Incretin mimetics or GLP-1 agonists -Exenatide -Dulaglutide -Semaglutide

Hypothyroidism Agents

Levothyroxine; Synthetic T4 Use: -All forms of hypothyroidism MOA: -Quickly converts to T3 Half-life: -7 days --> takes 1 month to plateau Adverse effects: Hyperthyroid symptoms -Tachycardia -Angina -Heat intolerance -Nervousness -Insomnia Drug interactions: -H2 blockers, PPI, more --> reduce T4 absorption -Phenytoin, sertraline, more --> accelerate T4 metabolism -Warfarin --> intensifies effects of warfarin. If they have clotting disorder, need to be on something besides warfarin -Insulin and digoxin --> they will need increased doses for both Patient teaching: -Take in morning with water only -Wait 30 to 60 minutes before food or other meds -S/S and lab monitoring Other thyroid preparations for hypothyroidism: Liotrix -Synthetic T4 and T3 -Fixed 4:1 ratio Thyroid [Armour thyroid] -Dessicated animal thyroid glands -T3 and T4 -Ratio not less than 5:1 -Rarely used today

Respiratory Acidosis

Low pH, High CO2, Normal HCO3 Causes: -Retaining carbon dioxide, secondary to hypoventilation -Not breathing off enough CO2 Treatment: -correct respiratory impairment -Oxygen or ventilator assistance -Infusion of sodium bicarbonate if severe

Bismuth Compounds [Antibiotic]

MOA: -Act topically to disrupt the cell wall of H. pylori, causing lysis and death -Coat the stomach and may prevent H. pylori from adhering to gastric surface Patient teaching: -Side effect: black coloration of tongue and stool -Aspirin containing Example: Bismuth-Based Quadruple Therapy -Bismuth/Metronidazole/Tetracycline/PPI

Tetracycline [antibiotic]

MOA: -Inhibitor of bacterial protein synthesis Avoid: -Pregnant patients -Young children -It can stain developing teeth

Spironolactone (Aldosterone Antagonist) POTASSIUM-SPARING DIURETIC

MOA: Blocks the actions of aldosterone in the distal nephron -Retains potassium -Increases excretion of sodium Uses: Hypertension, edema -Reduce mortality of heart failure patients -Premenstrual syndrome -Polycystic ovary syndrome -Acne Adverse effects: -Hyperkalemia (too much potassium) -Endocrine effects (hormone type effects such as hetertrophism and deepening of voice) Drug interactions: -Commonly used with thiazide and loop diuretics to balance out potassium levels -Avoid agents that raise potassium levels -ASAs, Arbs, renin inhibitors used with caution because they can also increase potassium.

Cholinesterase Inhibitors

May delay or slow progression of disease, but will not stop it. Used for mild Alzheimer's. Prevent breakdown of ACh (due to ACh dropping way down) Drug interactions: Avoid drugs that block cholinergic receptors such as 1st-gen antihistamines, TCAs, and antipsychotics -Reduce responses to cholinesterase inhibitors -If you are using a cholinesterase inhibitor, you are going to get ACh everywhere! Adverse effects: -Cholinergic side effects -GI effects -Dizziness -Headache -Bronchoconstriction Used in caution with patients who have asthma or COPD

Drug selection: Initial treatment

Mild Symptoms: -use MAO-B Inhibitor (prevents breakdown of dopamine) More severe symptoms: -Levodopa (w/ Carbidopa) or Dopamine agonist -Levodopa is more effective than DA agonists -Long term use leads to higher risk for dyskinesias Long term use associated with motor fluctuations -Called "off times"; it works for a while then stops working -Off times can be reduced with dopamine agonists, catechol-O-methylttransferase (COMT) inhibitors, and MAO-B Inhibitors

Magnesium Hydroxide [antacid]

Milk of Magnesium Frequently used as a laxative ANC: -High, rapid acting, long-lasting effects Adverse effects: Diarrhea Avoid: in patients with undiagnosed abdominal pain (due to bowel stimulating effects) Use with caution: In patients with renal failure (due to potentiation of hypermagnesemia)

Nursing implications for Risk of Bleeding

Monitor for signs of excessive bleeding Minimize... -Physical manipulation of patient. We don't move patient more than you need to. -Invasive procedures like poking them all the time -Concurrent use of anticoagulants -Concurrent use of antiplatelet drugs Avoid Subcutaneous or IM injections

Potassium

Most abundant intracellular cation (sitting inside cells), extracellular concentrations low Normal range = 3.5-5.0 mEq/L Regulated by kidney Insulin stimulate cell to take up potassium (so if patient has hyperkalemia & we are trying to move potassium into cell, use insulin) Major role in: -Conducting nerve impulses -Maintaining electrical excitability of muscle -Regulating Acid base balance Renal excretion increased by: -Aldosterone -Most diuretics except potassium sparing diuretics Exracellular alkalosis = potassium uptake by cells is increased Extracellular acidosis = promotes exit of potassium from cells (results in hyperkalemia)

Succinylcholine: Depolarizing Neuromuscular Blocker

Most discrete murder weapon, super hard to trace, metabolized quickly. Use: Muscle relaxation during ET intubation -Keeps from repolarizing so contraction of muscle can't happen. MOA: -Creates state of constant depolarization by preventing repolarization Pharmacologic effects: Muscle relaxation: state of flaccid paralysis No CNS effect Pharmacokinetics: -Ultrashort-acting --> poorly suited for long procedures -Eliminated by plasma cholinesterases -Peaks at 1 minute, fades after 4 to 10 minutes Adverse effects: Postoperative muscle pain (10 to 70%) -Due to initial contractions of muscle in first phase of succ action. -Most common in neck, shoulders, and back -Develops 12 to 24 hours after surgery; may persist for several hours or even days -Cause may be the muscle contractions that occur during the initial phase of succinylcholine action Hyperkalemia -Promotes release of potassium from tissues -Cause severe hyperkalemia that can cause death from cardiac arrest -Increased risk among those with major burns and multiple trauma (because of potassium loss. Because of major tissue damage, they lost a lot of potassium, so potassium levels will go sky high) Malignant Hyperthermia -Genetically determined reaction -Signs and symptoms: muscle rigidity associated with profound high body temperature which can lead to cardiac dysrhythmias, unstable blood pressure, electrolyte derangements, and metabolic acidosis -Can be fatal if left untreated Malignant hyperthermia treatment: -Immediately stop drug first thing -Cool patient inside and out (put ice packs all around and cool normal saline in IV) -Administer IV dantrolene (muscle relaxant) --> acts directly on skeletal muscle to reduce its metabolic activity --> stop heat generation from skeletal muscles Drug interactions: -Cholinesterase inhibitors: Potentiate the effects of succinylcholine -Antibiotics: aminoglycosides, tetracyclines, and certain other nonpenicillin antibiotics intensify the effect of succinylcholine Toxicology: -Overdose can produce prolonged apnea (not breathing) -No antidote -All management is purely supportive

Levodopa (Dopaminergic agent)

Most effective drug for parkinson's -Diagnosis is questioned if levodopa fails -Several months of treatment needed for full therapeutic response -Symptoms well controlled for first 2 years -Return to pretreatment state at end of 5 years (due to disease progression, not intolerance to drug) Only given in combination with carbidopa or carbidopa/entacapone Highly effective, benefits diminish over time Orally administered; rapidly absorbed from small intestine -Food will delay absorption -High protein foods will reduce therapeutic effects (amino acids compete with levodopa for intestinal absorption) Adverse Effects: Nausea and vomiting -Due to activation of DA receptors in Chemoreceptor trigger zone of medulla -Can be reduced by starting low dose -Giving additional carbidopa (without levodopa) can help reduce Cardiovascular -Postural hypotension (risk for falls) -Increase intake of salt and water (for hypotension) -Alpha-adrenergic agonist Psychosis -Visual hallucinations -Vivid dreams or nightmares -Paranoid ideation -Symptoms can be reduced by lowering levodopa dose CNS effects -Anxiety, agitation, insomnia -Memory and cognitive impairment -Behavioral changes associated with impulsivity, promiscuity, gambling, binge eating, alcohol abuse Dyskinesias -Even though given to alleviate movement disorders, it can also cause them -Managed by reducing dosage, adding amantadine, or surgery and electrical stimulation. Dermatological -Darkens sweat and urine -Activate malignant melanoma Drug Interactions: First generation antipsychotic drugs (Chlorpromazine, Haloperidol) block dopamine receptors, so that is going to decrease therapeutic effects of levodopa. can cause hypertensive crisis if given with nonselective MAO Inhibitors Anticholinergic drugs -Excessive stimulation of cholinergic receptors contributes to dyskinesias of PD -Can enhance responses to levodopa due to tipping balance other way again by blocking cholinergic receptors Food interactions -Meals high in protein = reduce therapeutic response (absorption competition) -Advise patients to spread protein consumption evenly throughout day

Muscle spasm vs Spasticity

Muscle spasm -Involuntary contraction of muscle or muscle group -Causes: Epilepsy, hypocalcemia, Pain syndromes (acute and chronic), trauma (localized skeletal muscle injury) Spasticity -Movement disorders of CNS origin -Causes: MS and cerebral palsy (CP) -Characteristics: heightened muscle tone, spasm, loss of dexterity (skill in performing tasks, especially with the hands)

A patient receives vecuronium to facilitate mechnical ventilation. Which medication would the nurse administer to reverse muscle paralysis?

Neostigmine

Basic Principles of Neuropharmacology

Neuropharmacology: study of drugs that alter processes controlled by the nervous system Can treat conditions such as: -Depression -Epilepsy -Hypertension -Asthma 2 broad categories: -PNS drugs -CNS drugs MOA: Mimick or block neuronal regulation, these agents can modify many processes -Skeletal muscle contraction -Cardiac output -Vascular tone -Respiration -Gastrointestinal function -Uterine motility -Glandular secretion -Ideation, mood, and perception of pain Sites of action: Axons vs synapses Axonal conduction Few agents Not very selective Synaptic transmission Many agents Highly selective Altering receptor activity on target cells.

Urinary Tract Antiseptics

Nitrofurantoin (Macrobid) Methenamine -Denatures bacterial proteins -Chronic lower UTIs (TMP/SMZ is preferred drug) Contraindications: Renal and liver failure Interactions: Urinary alkalinizers, sulfonamides

Albuterol (BETA 2 specific)

Noncatecholamine -Reduces airway resistance and asthma by causing beta 2 bronchodilation. -likely carrying this if you have asthma Use: Asthma Adverse effects: -Minimal at therapeutic doses -Will activate beta 1 receptors at higher doses -Tremor is most common -Tachycardia

IBS Drugs

Nonspecific Drugs -Address certain pieces of disease and symptoms 4 groups historically used: -Anti spasmodics -Bulk-forming agents -Anti-diarrheals -Tricyclic antidepressants IBS-Specific drugs -Alosetron -Lubiprostone

Moderate to strong opioid agonists

Oxycodone -Analgesic actions equivalent to those of codeine -Long-acting analgesics -Immediate release -Controlled-release (abuse; crushes and snorts or injects medication) Hydrocodone Combined with aspirin, acetaminophen, or ibuprofen

Alpha2 Activation

Peripheral activation: No therapeutic effects CNS activation (expected effects and clinical uses): -Reduction of sympathetic outflow to the heart and the blood vessels -Relief of severe pain Adverse effects-- Result from CNS activity: -Drowsiness -Xerostomia -Rebound hypertension

Prednisone, Dexamethasone, and Cortisone

Preferred drugs for oral therapy of chronic adrenal insufficiency -Prednisone -Dexamethasone Cortisone is a prodrug that undergoes conversion to hydrocortisone (active form) in the body -Has both glucocorticoid and mineralocorticoid activity -Used to treat chronic adrenal insufficiency

Class 1A: Quinidine SODIUM CHANNEL BLOCKER

Primarily used for delays in impulse conduction; delays repolarization and blocks vagal input to heart. Indications: Supra- and ventricular dysrhythmias Effects on the heart: -Blocks sodium channels -Slows impulse conduction -Delays repolarization -Blocks vagal input to the heart Adverse effects: -Diarrhea -Cinchonism (a pathological condition caused by an overdose of quinine, ringing in ears, headache, dizziness, rash) -Cardiotoxicity -Arterial embolism -Alpha-adrenergic blockade --> vasodilation --> hypotension Drug interactions: Digoxin Administration: IV

Class II: Propranolol BETA BLOCKER

Propranolol: Nonselective Indications: -Dysrhythmias caused by excess sympathetic stimulation -Supraventricular tachydysrhythmias, especially those of atrial origin --With atrial fib, you get little impulses that fire from SA node and finally one will go through AV and you get QRS. it's irregular. Effects on the heart and ECG: -Decreased automaticity of the SA node -Decreased velocity of conduction through AV node -Decreased myocardial contractility Adverse effects: Heart block Heart failure AV block Sinus arrest Hypotension Bronchospasm (in asthma patients) Administration: PO & IV (emergency) **Given for stage fright and Migraines. Why is it nonselective? Binding to beta 1s and beta 2s. Beta 1 in heart and Beta 2 in lungs.

Aluminum Hydroxide [antacid]

Rarely used alone -Combined with magnesium hydroxide = mylanta ANC: Relatively low, slow acting Effects have long duration Adverse effects: -Constipation Drug interactions: -Reduces effects of tetracyclines, warfarin, and digoxin 0Reduces phosphate absorption

Short-Duration, Slower-Acting Insulin

Regular insulin [Humulin R, Novolin R] -Unmodified human insulin -Onset: 30-60 minutes -Peak: 1-5 hours -Duration: 6-10 hours Administration: -Route: SC injection, SC infusion, IM (rarely used), and oral inhalation (approved but not currently used) -SC injection: 30 minutes before meals Given 30 minutes before a meal

Replacement Therapy in Adrenocortical Insufficiency

Replacement therapy -Glucocorticoid is always required -Some patients also require a mineralcorticoid (Fludrocortisone is the only mineralocorticoid available) Principal glucocorticoids used -Hydrocortisone -Dexamethasone -Prednisone

Class 1B: Lidocaine SODIUM CHANNEL BLOCKER

Saw-toothed on EKG. Indications: Ventricular dysrhythmias; anesthetic Effects on the heart and ECG: Blocks cardiac sodium channels --> slows conduction in the atria, ventricles, and His-Purkinje system -Reduces automaticity in ventricles and His-Purinje system -Accelerates repolarization Adverse effects: CNS effects High doses --> heart blocks Toxic doses --> seizures and cardiac arrest Administration: IV

Parasympathetic Nervous System (PNS)

Seven regulatory functions "rest and digest" 1. slow heart rate 2. increase gastric secretions 3. empty bladder 4. empty bowel 5. focus the eye for near vision 6. Constrict the pupil 7. Contract bronchial smooth muscle.

Type 2 Diabetes

Similar to type 1; requires comprehensive plan Patient should be screened and treated for: -Hypertension -Nephropathy -Retinopathy -Neuropathy -Dyslipidemias Glycemic control with: -Modified diet and physical activity -Drug therapy (oral, non-insulin injectables) -Insulin

Plasma Lipoproteins

Six major classes, but 3 are relevant to coronary atherosclerosis: Very-low-density lipoproteins (VLDLs): Triglycerides Low-density lipoproteins: -Majority of lipoproteins in blood, 60-70% -Target of our drug therapy -Greatest contributor to heart disease -Anthrogenic, bad cholesterol High-density lipoproteins: 20-30% -Considered protective and good cholesterol

Aspirin [Antiplatelet drug] [Cyclooxygenase Inhibitor]

Suppresses platelet aggregation by causing irreversible inhibition of cyclooxygenase (enzyme required by platelets to synthesize certain things in order to be sticky). Therapeutic uses -Ischemic stroke -Transient ischemic attack (TIA) -Chronic stable angina -Unstable angina -Coronary stenting -Acute MI -Previous MI -Primary prevention of MI Adverse effects -At low doses, increase risk of GI bleeding especially -Hemorrhagic stroke -Enteric-coated tablets may not reduce risk

Drugs for Hypertensive Crisis/Emergency

Sodium Nitroprusside -IV nitroprusside -Immediate onset & rapid discontinuation -Treatment controlled by IV infusion rate (titrated) Labetalol MOA: blocks alpha- and beta-adrenergic receptors (beta blockade prevents reflex tachycardia) Administration: Slow IV push Avoid in patients with: Asthma, heart failure, AV block, cardiogenic shock, and bradycardia

Ketamine

Starting and maintaining anesthesia Pain relief, sedation & memory loss Trance like state, sort of out of body experience. 12% of patients experience unpleasant psychotic reactions including hallucinations, disturbing dreams, delirium, usually last a few hours Pre medicating patients with Diazepam or midazolam reduces risk of adverse effects with ketamine

Which medication is used to promote gastric ulcer healing by providing a protective barrier?

Sucralfate

Hydrocortisone

Synthetic steroid with a structure identical to cortisol Therapeutic uses -Preferred drug for all forms of adrenal insufficiency Non-endocrine applications -Allergic reactions -Inflammation -Cancer Adverse effects -Seen with high-dose therapy -Adrenal suppression -Cushing's syndrome Preparations -PO -IM -IV

Migraine preventive/Prophylactic therapy

Takes a while to be effective, like 4 to 6 weeks Prefer drugs = propranolol, divalproex Beta blockers -Propranolol -Timolol -Atenolol -Metoprolol -Nadolol Anti-epileptic drugs -Divalproex -Topiramate -Gabapentin -Tiagabine Tricyclic antidepressants -Amitriptyline

A patient in the emergency department is diagnosed with ST-elevation myocardial infarction (STEMI). The patient has been prescribed 325 mg of aspirin. Which action by the nurse is appropriate?

Tell the patient to chew the tablet thoroughly and follow it with water

Nondrug therapy

Traditional ulcer diet does not accelerate healing Diet with 5 or 6 small meals reduces pH fluctuations. NO convincing evidence against caffeine drinks promote ulcers or delay healing Promote stress reduction. Things to avoid -Smoking -Aspirin and other NSAIDs -Alcohol

Pure Opioid Antagonists

Used to reverse opioid and CNS action of opiates. Naloxone: Prototype Antagonism at mu and kappa receptors Do not produce analgesia or any other effects caused by opioid agonists Reversal of respiratory and CNS depression caused by overdose with opioid agonists

Sucralfate [Mucosal protectants]

Uses: -Acute ulcers and maintenance therapy MOA: -Causes sticky gel over area of ulcer for up to 6 hours -Sulfated sucrose + aluminum hydroxide. Adverse effects: -Few due to minimal systemic absorption -Constipation (only 2% of patients) Drug interactions: Antacids: interfere with effects of sucralfate -Minimized by administering 1-2 hours apart Decreases absorption of: phenytoin, theophylline, digoxin, warfarin, fluoroquinolones -Minimized by administering at least 2 hours apart Think sugar (sucrose), it makes sticky coating over stomach ulcers.

Topiramate (Newer AED)

Uses: -Seizures -Bipolar disorder -Cluster headaches -Neuropathic pain -Diabetic neuropathy -Essential tremor -Binge-eating disorder -Bulimia nervosa -Alcohol and cocaine dependence Adverse effects: -Somnolence -Dizziness -Ataxia -Nervousness -Diplopia -Nausea -Anorexia -Weight loss -Confusion -Memory difficulties -Altered thinking -Reduced concentration -Difficulty finding words -Kidney stones -Paresthesias -Metabolic acidosis -Hypohidrosis -Angle-closure glaucoma -Risk for suicide

Metronidazole [Antibiotic]

Very effective against sensitive strains of H. pylori Most common side effects: -Nausea -Headache Black box warning!!: -Avoid use during pregnancy Avoid: Alcohol -Disulfiram-like reaction can occur

Nicotinic Acid (Niacin)

Vitamin B3 MOA: -Not completely understood -Acts in the liver and adipose tissue to inhibit synthesis of triglycerides --> decreasing VLDLS --> LDL -Not sure how it raises HDL Effects: -Reduces LDL and triglyceride levels -Raises HDL cholesterol Adverse Effects: -Skin (flushing, itching). Intense flushing initially; can pretreat with Aspirin 325mg. Decreased with extended-release version. -Hepatotoxicity -Hyperglycemia -Gouty arthritis

A patient tells the nurse that he would like to start taking orlistat. It is most important for the nurse to obtain the patient's current medication list to determine if the patient is also prescribed which drug?

Warfarin

Stimulant Laxatives (Group 2)

Widely used and abused MOA: -Stimulate intestinal motility -Increase amounts of water and electrolytes in intestinal lumen Uses: -Opioid-induced constipation (OIC) (opiods slow intestine down) -Constipation from slow intestinal transit

Asthma

chronic inflammatory disorder of the airways -Inflammation and bronchoconstriction --Combo inhalers (steroids and bronchodilators) are more effective treatment, but more expensive -Cold air, emotional stress, allergens -Genetic predisposition, smoking, wood smoke, occupational exposure, household sprays/cologne/perfume, respiratory infection, GERD Signs and symptoms: -breathlessness -tightening of chest -wheezing -dyspnea -cough -mucus pearls -poor exercise tolerance 4 classes of severity -Intermittent (cold-induced asthma) -Mild persistent -Moderate persistent -Severe persistent

Antihistamines

Histamine -Locally acting compound -Allergic disorders (acquired immunity) and peptic ulcer disease -Cell injury -Dilates small blood vessels and increases capillary permeabilities -Constriction of smooth muscle in bronchi -Stimulates acid secretion in stomach -Neurotransmitter H1 receptors Vasodilation -Can be seen in face and upper body -Can cause hypotension, edema, bronchoconstriction, CNS effects H2 receptors Promote secretion of gastric acid H1 antagonists (Diphenhydramine/Benadryl) -Blockade of H1 receptors (reduced flushing, itching, pain) Use: Mild allergic reactions, motion sickness, insomnia, common cold AE: CNS stimulation, convulsions (overdose); sedation Contraindications: 3rd trimester, nursing, newborns Overdose treatment: Activated charcoal, benzodiazepines, ice packs Second gen (non-sedating): fexofenadine/Allegra, cetirizine/Zyrtec, Iroatadine (Claritin) H2 Antagonists -Blockade of H2 receptors -PUD (peptic ulcer disease) -NOT used for allergies

The nurse caring for a patient taking furosemide [Lasix] is reviewing the patient's most recent laboratory results, which are: sodium, 136 mEq/L; potassium, 3.2 mEq/L; chloride, 100 mEq/L; blood urea nitrogen, 15 mg/dL. What is the nurse's best action?

Hold the Lasix and notify the physician. The nurse's best action is to hold the Lasix and notify the physician. Loop diuretics, such as furosemide, can cause significant potassium loss. The normal potassium level is 3.5 to 5 mEq/L. The remaining electrolyte levels are normal. Administering the Lasix could result in a critically low potassium level. Effects of low potassium include cardiac dysrhythmias. Placing a patient on a cardiac monitor requires a physician's order and would warrant further assessment first, such as taking vital signs and asking the patient whether he or she is having any cardiac-related symptoms. Collecting a 24-hour urine specimen is not appropriate in this case.

The nurse is reviewing the home medication list with the patient. The nurse recognizes that hydrochlorothiazide is used primarily for which condition?

Hypertension The primary indication for hydrochlorothiazide is hypertension, a condition for which thiazides are often the drugs of first choice. Hydrochlorothiazides are used for other conditions, but the primary indication is hypertension.

Complications of Insulin Treatment

Hypoglycemia: Blood glucose below 70 mg/dL -Rapid treatment mandatory -Conscious patients: fast-acting oral sugar (glucose tablets, orange juice, sugar cubes, non-diet soda) -If swallowing or gag reflex is suppressed = NPO, IV glucose or parenteral glucagon is preferred) Lipohypertrophy -Accumulation of subcutaneous fat -When insulin is injected too frequently in same spot -it happens because insulin stimulates synthesis of fat -Rotate injection site Allergic reactions Hypokalemia -Results from excessive doses -Drugs that lower blood glucose can intensify Drug interactions -Hypoglycemic agents -Hyperglycemic agents -Beta-adrenergic blocking agents Drugs that raise blood glucose = steroids and sympathomimetics (avoid these) Beta blockers can mask or delay awareness of response of hypoglycemia because they mask tachycardia and palpations. (avoid)

A patient is taking orlistat for weight loss. Which statement by the patient indicates an understanding of medication teaching?

I will take a multivitamin 2 hours after breakfast

The nurse administers a medication to a patient that stimulates the function of the parasympathetic nervous system. The nurse should assess the patient for which intended effect?

Improved bladder emptying

Glucocorticoids Effects

Increase availability of glucose -Cortisol is most important glucocorticoid Physiologic effects occur at low levels -Carbohydrate metabolism (promote glucose availability) -Protein metabolism (catabolism/breakdown) -Fat metabolism (lipolysis) -CV system (multiple effects) -Skeletal muscle (function of striated muscle) -CNS (mood, excitability) -Stress -Respiratory system in neonates (accelerate lung maturation) Pharmacologic effects occur at high levels -Asthma -Allergic reactions -Inflammation

What is volume expansion

Increase in total volume of fluid -Can be isotonic, hypertonic, or hypotonic Causes: -Treatment like overdose of therapeutic fluids -Disease states like heart failure, nephrotic syndrome, cirrhosis of liver Treatment: -Diuretics -Selected agents like drugs used for heart failure

Minoxidil "Rogaine"

Indication: Severe hypertension (unresponsive to safer drugs) -Direct vasodilator MOA: -selective dilation of arterioles -More intense dilation than hydralazine = more severe adverse reactions Adverse effects: -Hypertrichosis (hair growth), sometimes in places they don't want. -Sodium and water retention -Headache, fatigue -Increased volume and increased edema = pericardial effusion

Spironolactone ALDOSTERONE ANTAGONIST

Indications: - Hypertension - Heart failure MOA: Blocks aldosterone receptors in kidneys -Binds with receptors for other steroid hormones Adverse Effects: - Hyperkalemia - Gynecomastia - Menstrual Irregularities - Impotence - Hirsutism - Deepening of the voice

Diltiazem NON-DIHYDROPYRIDINE

Indications: -Angina -Hypertension -Dysrhythmias MOA: Similar to verapamil -Lowers BP via arteriolar dilation Pharmacokinetics: -PO (most common) -Rapid effects (within minutes) -IV used for dysrhythmias Adverse effects: -Similar to verapamil, except for less constipation -Dizziness -Flushing -Headache -Edema of ankles and feet -Exacerbates bradycardia, sick sinus syndrome (SA node fires intermittently --> heart block) Drug Interactions: -Digoxin -Beta blockers

Nifedipine DIHYDROPYRIDINE

Indications: -Angina -Hypertension -Off label: migraine relief & suppress preterm labor (slows contraction of smooth muscle because uterus is a smooth muscle) MOA: -Blocks calcium channels in vascular smooth muscle --> vasodilation --> lowers AP Pharmacokinetics: -Extensive first-pass effect with 50% of first oral dose available Drug interactions: -Manifestations and treatment of overdose are same as verapamil -Gastric lavage with activated charcoal -IV Calcium gluconate to counteract vasodilation Adverse effects: Like Verapamil -Flushing -Dizziness -Headache -Peripheral edema -Gingival hyperplasia -Chronic eczematous rash in older patients Unlike Verapamil -Reflex tachycardia --> increases cardiac oxygen demand --> increase pain in angina patients --Minimized/prevented by combining with a beta blocker **Beta blockers decrease adverse cardiac effects of nifedipine but can intensify adverse cardiac effects of verapamil and dilitiazem

Eplerenone ALDOSTERONE ANTAGONIST

Indications: -Hypertension -Heart failure MOA: Selective blockade of aldosterone receptors Adverse Effects: -Hyperkalemia Drug Interactions: Inhibitors of CYP3A4 -Weak (erythromycin, verapamil) --> 2x eplerenone increase -Strong (ketoconazole) --> 5x eplerenone increase Drugs that raise potassium levels Eplerenone is more selective than spironolactone, so you don't get as many side effects as you do with spironolactone.

ACE Inhibitors (ACEIs)

Indications: -Hypertension -Heart failure -Has to be used with caution with heart failure and an acute MI (keep blood pressure down, but help produce collateral circulation of coronary arteries) -Left Ventricular dysnfunction -diabetic and nondiabetic nephropathy (a disease of the kidneys caused by damage to the small blood vessels or to the units in the kidneys that clean the blood) Side effects: -Dry hacky cough Contraindicated: Asthma MOA: Reduce levels of angiotensin 2 and dilate the blood vessels to bring down blood volume and blood pressure. -Increase levels of bradykinin --> vasodilation; cough, angioedema (asthmatics can very easily get angioedema) Administration: -PO (most common) & IV -All are excreted by kidneys Black box warning!: Fetal Toxicity -Fetal injury in 2nd and 3rd trimesters -Crosses placental barrier and hurts babies Adverse effects: -On very first dose, may get severe hypotension (need to get up slowly). If on diuretics, blood pressure can fall quicker, or if sodium or water depleted. -Cough -Angioedema (edema of mouth, tongue, eyes). Seek immediate care, and NEVER take ace inhibitors again. -Hyperkalemia -Long term renal failure because of renal artery stenosis (occurs when there is a narrowing of the arteries that supply blood to one or both of your kidneys.) Can't be used in patients that have bilateral renal artery stenosis Drug interactions: -Diuretics -Antihypertensives -Drugs that raise potassium levels -Lithium, can cause lithium accumulation and toxicity -NSAIDs (aspirin, ibuprofen, naproxyn); reduce effect of ACEI. If you have renal artery stenosis & give patient ACE inhibitor, you are going to slow everything down --> severe renal insufficiency (kidneys aren't getting enough blood pressure) --> acute renal failure. Need at least one kidney that doesn't have it.

ARBs (Angiotensin II Receptor Blockers)

Indications: -Hypertension -Heart failure -MI (help keep blood pressure down or help promote collateral circulation) -Diabetic nephropathy (not effective in primary prevention in normotensive diabetics. Not effective if their blood pressure is not out of control) -Unable to tolerate ACE inhibitors -Protection against MI (because of collateral circulation), stroke, and death (if you keep blood pressure down, then you're not going to cause vasospasm in brain vessels) -Diabetic nephropathy prevention MOA: -Block access of angiotensin II and the ACE inhibitor effects by vasodilation (vaso meaning veins). -Decrease aldosterone release through reduced sodium secretion -Increased renal secretion of sodium and water Administration: -PO -With or without food Black box warning!: Fetal Toxicity -If you are lower in blood pressure then you can cut off blood supply to baby and it can be directly toxic Adverse effects: -Similar to ACE inhibitors (Angioedema; incidence lower than with ACEIs) -Renal failure -Less ill effects than ACEI -May produce cough but ARBs not contraindicated in asthmatics, Do not cause significant hyperkalemia Drug interactions: Antihypertensive agents Losartan is popular ARB

Class III: Amiodarone POTASSIUM CHANNEL BLOCKER

Indications: -Life-threatening ventricular dysrhythmias only -Recurrent ventricular fibrillation -Recurrent hemodynamically unstable ventricular tachycardia Effects on the heart and ECG: -Reduced automaticity A Node -Reduced contractility -Reduced conduction velocity -QRS widening -Prolongation of the PR and QT intervals Adverse effects- can be VERY toxic: -very LONG half life -Pulmonary toxicity -Cardiotoxicity -Toxicity in pregnancy and breast-feeding -Corneal microdeposits -Optic neuropathy Drug interactions (increases levels of other drugs): About every other antidysrhymic -Quinidine -Cyclosporine -Digoxin -Procainamide -Diltiazem -Phenytoin -Warfarin -Lovastatin, simvastatin, atorvastatin Toxic Effects: Photosensitivity- Reymans Syndrome (skin turns yucky looking grey) Severe extravasation Levels can be INCREASED by grapefruit juice and by inhibitors of CYP3A4 which leads to toxicity Levels can be DECREASED by Cholestyramine (decreases absorption) and by agents that induce CYP3A4 (ex: St. John's wort, rifampin) for hyperlipidima Risk of severe dysrhythmias is increased by diuretics and drugs that prolong QT interval Combining with a beta blocker, verapamil, or dilitiazem can lead to excessive slowing of heart rate

Hydralazine

Indications: -Primary hypertension -Hypertensive crisis -Heat failure MOA: -Mechanism unknown -Selective dilation of arterioles Administration: -PO (effects w/in 45 min; last 6+ hours) -IV (effects w/in 10 min; last 2-4 hrs) Minimal postural hypotension because there is little effect on veins. Adverse effects: -Headache -Dizziness (decrease in blood supply to brain = dizzy) -Postural hypotension -Weakness, fatigue (if it is lowering blood pressure, they will feel weak) -Reflex tachycardia -dilation of the veins = loss of fluids into the tissues in edema, so you end up increased blood volume and increased edema -Systemic Lupus like syndrome (rash across the face, drug has to be stopped) Drug interactions: -other antihypertensive agents -Avoid excessive hypotension -+Beta blockers may help protect against reflex tachycardia -+Diuretics will help prevent sodium and water retention and expansion of blood volume

Digoxin

Indications: Chronic heart failure, Afib, PSVT (Supraventricular tachycardia) conversion MOA: -Increases ventricular contraction and myocardial contractility through sodium potassium, ATP pump. Relationship of potassium to inotropic action: -Potassium competes with digoxin, but potassium must be kept normal so digoxin can move into the cell. -Potassium must be kept within normal range, 3.5-5.0. Adverse effects: Dysrhythmias Predisposing factors: hypokalemia, elevated digoxin level (normal range is 0.5-0.9), heart disease Managing digoxin-induced dysrhythmias: withdraw digoxin and potassium-wasting diuretics, monitor serum potassium, administer antidysrhythmics, atropine or pacing, Digibind/Digifab Noncardiac adverse effects, S/S -Yellow-green halo around light (visual changes) -Anorexia -Nausea, vomiting -Fatigue Measures to reduce adverse effects Adequate education so they are taking drugs appropriately Drug interactions: Diuretics -loop diuretics cause a lot of loss of potassium Ace inhibitors & ARBs -early contraindicated in heart failure Sympathomimetics Quinidine -Antirhythmic that is used in a lot of heart patients -Hydroxychloroquine -Slows conduction of AV node and causes severe bradycardia and heart blocks Verapamil Administration: -PO & IV -PO has variable absorption; 60-80% decreased by foods (high in bran) and many drugs -Crosses placenta -Half life = 1.5 to about 6 days to reach plateau -Determine HR auscultating apical pulse; if below 60, hold it and notify prescriber.

Overview of Therapeutic Uses

Indications: Hypertension uncontrolled by other meds; People who are coming in with stroke level blood pressures (220/190), and you have to get blood pressure down Hypertensive crisis Angina; nitroglycerin helps to open the coronary arteries so there is more blood supply and more oxygen going to the myocardium Heart failure MI; with MI, they are given lots of drips of nitroglycerin to bring blood pressure down to help open coronary vessels and try to stop MI in progress Pheochromocytoma; high blood pressures. Try to control blood pressure till they can have tumor removed (surgery is curative) Alpha 1 and alpha 2 agonists given to help dilate blood vessels (direct vasodilators) to help with uncontrolled hypertension (unresponsive to other drugs) -Sometimes you want patients to be hypotensive during surgery

Organic Nitrates: Nitroglycerin

Indications: Stable and variant angina MOA: Acts directly on vascular smooth muscle to promote vasodilation. Causes venous dilation Adverse effects: -Headache -Hypotension (including orthostatic) -Reflex tachycarida Drug interactions: -Anti-hypertensives -Phosphodiesterase type 5 inhibitors (ED meds) -Beta blockers, verapamil, and diltiazem Tolerance: -Can develop rapidly -Cross-tolerance to all other nitrates -To minimize, use lowest effective dose -Long-acting formulas: 8 drug-free hours per day Preparations and routes of administration: -Sublingual tablets -Sustained-release oral capsules; D/C slowly -Transdermal delivery systems -Translingual spray -Topical ointment -IV infusion

Allergic Rhinitis

Inflammatory disorder of upper airway, lower airway, and eyes Seasonal or perennial S/s -Sneezing, rhinorrhea, pruritis, nasal congestion -Conjunctivitis, sinusitis, asthma exacerbations Intranasal glucocorticoids -Mometasone, Fluticasone propionate (Flonase) -First line therapy -Metered-dose spray PO antihistamines Diphenhydramine (max dose 300 mg), cetirizine, Loratadine (Claritin) Use: Do not reduce nasal congestion, prophylactically throughout allergy season AE: Sedation, constipation Contraindications: high BP Intranasal antihistamines -Azelastine (topical, bad taste) -Olopatadine Over 12 y/o AE: Systemic absorption, somnolence, epistaxis, anticholinergic effect Intranasal cromolyn sodium -Suppresses release of histamine Use for: Prophylaxis Metered dose spray SE: cough, bronchospasm Safest of all anti-asthma drugs Sympathomimetics (decongestants) -Oxymetazoline (Afrin, inhaled), pseudoephedrine (Sudafed, PO) Use: Reduce/relieve nasal congestion/stuffiness ---Not rhinorrhea, sneezing, itching Vasoconstriction of nasal blood vessels Should not use > 5 consecutive days AE: Rebound congestion, CNS stimulation, CV effects, stroke, abuse, dehydration

Mineralocorticoids

Influence renal processing of sodium, potassium, and hydrogen Aldosterone is most important -Secretion is regulated by RAAS system Renal actions -Promotes sodium and potassium hemostasis -Maintains intravascular volume Cardiovascular actions -Acts on heart and blood vessels -Harmful at high levels --> HF and HTN risk

Immunosuppressants

Inhibit immune response Use these: transplants, autoimmune disease (long term) Complications: Risk of infection Risk of neoplasms Cyclosporine (calcineurin inhibitor) Use: Organ rejection, autoimmune disease MOA: IL-2, interferon gamma, cytokine suppression AE: nephrotoxicity, infection, hepatotoxicity, lymphoma, HTN, tremor, hirsutism, gingival hyperplasia, gynecomastia, hyperkalemia Interactions: Grapefruit juice, Repaglinade, CYP3A4 Inhibitors/ activators, nephrotoxic drugs Glucocorticoids/corticosteroids Prednisone/Prednisolone Use: suppress immune responses, inflammation --RA, SLE, IBD, other inflammatory disorders -Allergies, asthma -Prevent rejection Modulation of glucose metabolism, suppresses vasoconstriction SE: metabolic, increase BG, decrease BP, reduced muscle mass, decrease protein matrix of bone, thin skin, lipolysis, redistribution of fat (potbelly, moon face, buffalo hump) AE: Hypernatremia, hypokalemia, edema, adrenal insufficiency (long-term), osteoporosis, infection, hyperglycemia, glycosuria, myopathy, psychologic disturbances, cataracts, glaucoma, PUD Contraindications: PT's w/ systemic fungal infections, live virus vaccines Precaution: Peds/pregnancy/breast feeding Interactions: NSAIDs, insulin, vaccines TAPER! Cytotoxic Drugs Methotrexate, Azathioprine, Mitoxantrone Non-specific Kill T and B lymphocytes AE: bone marrow suppression (neutropenia, thrombocytopenia) -GI disturbances -Reduced fertility -Alopecia Antibodies Basiliximab, lymphocyte immunoglobulin Use: prevent rejection after renal transplantations AE: hypersensitivity reactions

Ethambutol

Initial treatment of TB, treatment if prior therapy received, multidrug regimen AE: Optic neuritis, allergy, GI, confusion

Short-Duration, Rapid-Acting Insulin

Insulin lispro [Humalog] -Rapid-acting analog of regular insulin -Onset: 15-30 minutes after subQ injection -Peak: 0.5-2.5 hours -Duration: 3-6 hours Administration: -Route: SC injection, SC infusion, IV -SC injection: 15 min before or just after meal Given with meals

Drug-Drug Interactions

Intensification of effects -Increase therapeutic effects (Sulfamethoxazole/Trimethoprim (Bactrim)) -Increase adverse effects (Aspirin and warfarin) Reduction of effects -Inhibitory; result in reduced drug effects (OCPs and Antibiotics) -Reduced therapeutic effects (Propranolol and albuterol inhaled) -Reduced adverse effects (Naloxone) Creation of unique response Disulfiram (Antabuse) and EtOH --> Disulfiram-like reaction. If they drink alcohol, they will get sick as a dog. Interact through 4 basic mechanisms 1. Direct chemical or physical interaction -most common in IV solutions -If you see precipitate, do not administer. It crystallizes. EX; Diazepam (Valium) 2. Pharmacokinetic interaction Alter absorption (laxatives), altered distribution (alteration of extracellular pH), altered renal excretion (ex; select antibiotics), altered metabolism (CYP450) -Inducers increase metabolism -Inhibitors decrease metabolism 3. Pharmacodynamic interaction -At same receptor; they are fighting for it. 4. Combined toxicity -Drugs with overlapping toxicities should not be used together Ex; Gentamicin (toxic to ears) and furosemide (ototoxic)

Organic Nitrates: Other

Isosorbide mononitrate and Isosorbide Dinitrate -For long term control of angina -Actions identical to those of nitroglycerin -Taken orally -Adverse effects identical to those of nitroglycerin; major adverse effects is headache. -Can develop tolerance to the long-acting preparations

The nurse identifies which of the following laxatives as having the added response of ridding the body of ammonia?

Lactulose

What are laxatives?

Laxative Effect: -Production of soft, formed stool over 1 or more days -Slower and relatively mild Catharsis: -Prompt, fluid evacuation of the bowel -Fast and intense Uses: -Ease or stimulate defecation -Soften the stool -Increase the volume -Hasten fecal passage through the intestine -Facilitate evacuation from rectum -Misuse comes from misconceptions of what constitutes normal bowel function. Anorexic people; people who want to lose weight.

S/S of Congestive Heart Failure

Left-sided heart failure: -Crackles in the lungs (posterior lung fields) -Tachycardia -Dyspnea -Tachypnea -Low Spo2 -Paroxysmal nocturnal dyspnea -GI symptoms (blood vessels surrounding gut engorge; anorexia, nausea, bloating, constipation) -Reduced urinary output -Cool, cold, pale, possibly cyanotic extremities Right-sided heart failure: -Jugular venous distention -Liver engorgement -Ascites (build up of fluid in belly) -Peripheral edema (elephant leg syndrome) -Massive weight gain

Levodopa/Carbidopa

Levodopa is now only available in combo prep. Carbidopa doesn't have therapeutic effect on it's own, it's only there for levodopa to get into the brain. Carbidopa has no adverse effects on it's own. Advantages -Most effective therapy for PD MOA: Carbidopa is used to enhance effects of levodopa, carbidopa makes more levodopa available to the CNS. -Increased amount of levodopa available for CNS --> reduced dosage of levodopa -Reduces cardiovascular response and N/V -Eliminates concerns about taking vitamin B6 (B6 reduces effects of levodopa, but carbidopa takes away this adverse effect) Disadvantages -Any adverse responses are result of the potentiating effects of levodopa -Abnormal movements and psychiatric disturbances can occur sooner and be more intense than with levodopa alone

Fluoroquinolones

Levofloxacin, moxifloxacin Broad spectrum Disrupt DNA replication and cell division AE: Tendon rupture (low risk) Ciprofloxacin Use: TB, anthrax, infections (respiratory, UTI, GI, bones, joints, skin, soft tissue) AE: Mild= N/V/D, abdominal pain, dizziness, HA, restlessness, confusion, seizures, phototoxicity, Candida infections, C. diff infections In older adults: Confusion, somnolence, psychosis, visual disturbances, exacerbate myasthenia gravis Interactions: Na, K, Ca, Mg; Al/Mg antacids; Iron and zinc salts, sucralfate, milk/dairy (reduce absorption), theophylline, warfarin, tinidazole (elevate drug levels)

Oxazolidinones (Bacteriostatic inhibition of protein synthesis)

Linezolid Use for treating multi drug resistant microorganisms Active against VRE (vancomycin-resistant enterococci) and MRSA (methicillin-resistant staphylococcus aureus) Weekly blood counts Do not use with MAOIs (Monoamine oxidase inhibitors) or SSIs Treat depression

Differentiate loading and maintenance doses of medications and the concept of therapeutic range

Loading dose -Jump start dose that gets drug to therapeutic range (bring drug to plateau quickly) Maintenance dose -Once high drug levels have been established through the use of loading dose, plateau can be maintained by giving smaller doses on a regular schedule -Maintains plateau -Will always take about 4 half lives to reach plateau Therapeutic range -Enough drug present to produce therapeutic responses without toxicity levels -Objective of drug dosing is to maintain plasma drug levels within this range -Width of range = ease of safety EXAMPLE: Acetaminophine has a wide range. Dosage does not need to be highly precise Lithium has a narrow range. Dosing needs to be done carefully. -Focus more on patients taking narrow range drugs -Ratio of the drugs LD50 to ED50

Types of Anesthesia

Local Numbs one small area of the body, you stay alert and awake Monitored Anesthesia Care (MAC) Local anesthesia together with sedation and analgesia Regional Anesthesia -Blocks pain in an area of the body such as an arm or leg -epidural anesthesia which is sometimes used during childbirth, is a type of regional anesthesia General Anesthesia Affects the entire body -You go to sleep and feel nothing; you have no memory of the procedure after

General Considerations: Topical Application

Location for application -Put it on clean and really dry skin of shoulders and upper arms and abdomen, never on genitals Skin to skin contact transfer -Wash hands with soap and water, cover application sit with clothing after it is dried Women and children: Avoid contact Swimming/showering -Wait 5-6 hours before going swimming or showering because it will come off

Monitoring of Antimicrobial Therapy

Look at blood count!! Indicators of success: -Reduction of fever -Resolution of signs and symptoms

Hypotonic Contraction

Loss of sodium is greater than loss of water -Both volume and osmolality of ECF are reduced (osmolality inside of cell is higher than outside of cell) -Causes cell to BURST. Causes: Excessive loss of sodium through kidney (might be from diuretics) -Renal insufficiency -Lack of aldosterone Treatment: Mild: Normal saline is used Severe: Hypertonic solution (3% NaCl) (draws fluid out of cells and into blood) -Monitor for signs of fluid overload

Hypertonic Contraction

Loss of water is greater than the loss of sodium. Causes: -Excessive sweating -Osmotic diuresis -Feeding excessively concentrated food to babies -Burns Treatment: -Volume replacement with hypotonic fluids (draws fluid from vessels into cells) -0.45% NaCl (half normal saline) -Fluids that contain no solutes at all -Initial therapy: drink water

Dopamine (receptor specificity is dose dependent)

Low dose: ONLY dopamine receptors Moderate dose: Dopamine and beta 1 receptors Very high dose: Alpha 1, beta 1, and dopamine receptors Uses: Shock -Increases cardiac output -Increases renal perfusion (with low doses) Heart failure -Increases myocardial contractility Adverse effects: -Tachycardia -Dysrhythmias -Anginal pain -Necrosis with extravasation -Activating receptors in heart so think about heart problems Drug interactions: -MAOIs (can intensify dopamine in heart) -TCAs (also do this but not as much) -Certain general anesthetics -Diuretics (can compliment beneficial of dopamine on kidneys, so they are often given together) Preparations, dosage, and administration Preparations: Dispensed in aqueous solutions Dosage: Must be diluted Administration: Administered by IV

Menopausal Hormone Therapy

Low doses of estrogen with or without progesterone taken to compensate for low levels of estrogen Approved indications: 1. Treatment of moderate to severe vasomotor symptoms associated with menopause 2. Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with menopause 3. Prevention of postmenopausal osteoporosis

Enoxaparin (Lovenox) [Anticoagulant][Activate antithrombin]

Low-Molecular-Weight Heparins (LMWH) -Heparin, but composed of shorter molecules Therapeutic uses: -Prevent post-op DVT -Treatment of established DVT with or without PE -Prevention of ischemic complications Ex; unstable angina, non-Q wave myocardial infarction (MI), and ST-elevation MI (STEMI) Administration: Subcutaneous injection in belly Pros: -No required labs -Can be given at home (education is super important) Cons: -Costs more than heparin -Adverse effects and interactions (bleeding but less than heparin, immune-mediated thrombocytopenia, severe neuro injury for patients undergoing spinal puncture or epidural anesthesia) Antidote: Protamine sulfate

MAO-B Inhibitors

MAO-B is an enzyme that inactivates dopamine in the striatum First line drug Combination with levodopa can reduce "wearing-off" effect 2 MAO-B Inhibitors: -Selegiline -Rasagiline

Alpha1-Adrenergic Antagonists

MOA -Alpha1 blockade relaxes smooth muscle in the bladder neck (trigone and sphincter) Indications BPH Selective for alpha1 receptors in the prostate -Tamsulosin -Alfuzosin -Silodosin BPH & HTN -Also block alpha receptors in the blood vessels -Promote vasodilation and can lower blood pressure -Terazosin -Doxazosin Adverse effects Terazosin and Doxazosin -Hypotension -Fainting -Dizziness -Somnolence -Nasal congestion Tamsulosin and Alfuzosin -Less likely to cause effects of terazosin and doxazosin -Tamsulosin can cause abnormal ejaculation These drugs do not decrease PSA levels -As prostate makes more cells, that PSA levels go up and they watch PSA as a marker for potential cancer of prostate Cataract surgery: "Floppy-iris syndrome" -Delay medication until after surgery Drug interactions -organic nitrates **NEVER COMBINE PDE5 inhibitors and nitrates -Antihypertensive drugs -PDE5 Inhibitors used for ED -Inhibitors of CYP3A4 Exercise caution with other medications that lower blood pressure Use in women: -Urinary hesitancy or urinary retention associated with bladder outlet obstruction or insufficient contraction of the bladder detrusor muscle MOA: Relax smooth muscle in the bladder neck and urethra to improve flow and help empty bladder more completely Maximal improvement may take several weeks to develop

Chloride Channel Activator (Group 3)

MOA: -Activates (opens) chloride channels in intestine -Secretion of chloride-rich fluid into intestine -Enhances motility in the small intestine and colon Results: Spontaneous evacuation of a semisoft stool, usually within 24 hours Uses: -Chronic idiopathic constipation -IBS-C -OIC

Clozapine (SGA)

MOA: -Blocks dopamine and serotonin -Affinity for D2 blockade is low compared to FGAs Uses: -Schizophrenia (most effective agent for treating schizo) -Levodopa-induced psychosis Pharmacokinetics: -Rapid PO absorption -Half-life = 12 hours -Preparations: PO tabs, ODT, suspension Adverse effects & interactions: -Agranulocytosis (gradual onset in first 6 months --> WBC and ANC monitoring) -Seizures (dose related) -EPS -Metabolic effects -Myocarditis -Dementia patients (older) -Common: sedation, weight gain, orthostatic hypotension, and typical anticholinergic side effects Drug interactions: Contraindicated: anything that can suppress bone marrow & anti-cancer drugs

Competitive Neuromuscular Blockers

MOA: -Competes with ACh for nicotinic M receptors -Blocks receptor activation of ACh Pharmacologic effects: -Muscle relaxation: Flaccid paralysis -Hypotension (some agents) -No CNS effect Pharmacokinetics: -Rapid onset of paralysis -Generally, peak effects last 20-40 min, then decline -Complete recovery in 1 hour Adverse effects: Respiratory arrest Do not diminish pain response and do not diminish consciousness, even in complete paralysis

Phentolamine (nonselective alpha1 antagonist)

MOA: -Competitive alpha1 and alpha2 antagonist (blocks alpha 1 and alpha 2) Use: -Diagnosis and treatment of pheochromocytoma -Necrosis prevention after extravasation (specifically drugs that produce alpha1-mediated vasoconstriction like NE) -Reversal of soft tissue anesthesia -Contraindicated in patients with angina and MI Adverse effects: -Orthostatic hypotension -Reflex tachycardia -Nasal congestion -Inhibition of ejaculation -Profound hypotension: treat with NE (a catecholamine)

Prazosin (Selective A1 antagonist)

MOA: -Competitive antagonist; selective blocker of alpha1 receptors -Dilation in arterials and veins -Relaxes smooth muscle of bladder, neck, prostate Use: -Approved only for hypertension -Can also provide benefits for men with BPH Pharmacokinetics: -Administered orally -Effects peak in 1-3 hours; persist for 10 hours -Half life: 2 to 3 hours -Metabolized in liver (hepatic) Adverse effects: -Orthostatic hypotension -Reflex tachycardia -Inhibition of ejaculation -Nasal congestion "First dose" effect -1% of patients -Lose consciousness 30-60 min after first dose -Avoid "being responsible" such as driving -Risk is eliminated by taking first dose right before bedtime

Mannitol OSMOTIC DIURETIC

MOA: -Creates osmotic force in the lumen of nephron that leads to diuresis - Sugar molecules pull large amounts of fluid into the tubules to increase urinary output Uses: -Reduces risk of renal failure -Reduce intracranial pressure by drawing excess fluid into the blood -Reduce intraocular pressure if other agents haven't worked Given parenterally Adverse effects: -Used in caution with patients with heart failure and pulmonary edema -Causes edema when exiting capillaries -Headache, nausea, vomiting -Fluid and electrolyte imbalance Most of the time you will see this used to decrease intracranial pressure (head injuries)

Immunomodulators: Infliximab

MOA: -Monoclonal antibody designed to neutralize tumor necrosis factor (TNF), a key immunoinflammatory modulator. Use: -Moderate to severe CD and UC Adverse effects: -Infections (you are stopping TNF, knocking out a key part of the immune system) -Infusion reactions: fever, chills, pruritus, urticaria, cardiopulmonary reactions (angina, Hypo- and hypertension, dyspnea -Increased risk of lymphoma

Methyldopa (Centrally acting alpha 2 agonist)

MOA: -Oral anti hypertensive that lowers blood pressure within CNS. -Taken up into brainstem and converted into alpha 2 agonist -Not an alpha 2 agonist Pharmacologic effects: Vasodilation: not cardiosuppression -Lowers blood pressure in supine and standing positions Use: Hypertension (preferred drug for management of hypertension during pregnancy) Adverse effects: -Hepatotoxicity --> hepatitis, jaundice, and rarely fatal hepatic necrosis -Positive Coombs' test and hemolytic anemia -Others: black tongue, xerostomia, orthostatic hypotension, headache, sedation

Clonidine (Centrally acting alpha 2 agonist)

MOA: -Selective activation of CNS alpha 2 receptors --> reduced sympathetic outflow to blood vessels and heart. Pharmacologic effects: -Bradycardia and a decrease in cardiac output -Minimal orthostatic hypotension Uses: -Approved: Hypertension, severe pain, pediatric ADHD -Investigational: managing opioid withdrawal, smoking cessation, Tourette's syndrome Pharmacokinetics: -lipid soluble (readily absorbed and widely distributed) -PO -Transdermal (applied every 7 days to hairless upper arm or torso) Adverse effects: -Xerostomia: 40% of patients -Drowsiness: 35% of patients -Rebound hypertension-- withdraw slowly over 2-4 days -Others: constipation, impotence, gynecomastia -Not recommended for use during pregnancy

Terazosin (Selective A1 antagonist)

MOA: -Selective and competitive alpha1 antagonist Use: -Hypertension -BPH Pharmacokinetics: -Administered orally -Peak effects: 1 to 2 hours after oral dosing -Half life: prolonged (9 to 12 hours) -Liver metabolism Adverse effects: -Orthostatic hypotension -Reflex tachycardia -Nasal congestion -Headache -"First-dose" effect

Propranolol (Nonselective beta blocker)

MOA: By blocking... Cardiac beta 1 receptors -Decrease in cardiac output Renal beta 1 receptors -Decrease renin secretion Lung beta 2 receptors -Bronchoconstriction Beta 2 blockade results in vasoconstriction of blood vessels and reduced glycogenolysis (skeletal muscle and liver beta2 receptors) Uses: -Hypertension -Angina pectoris -Myocardial infarction -Prevention of migraine -"Stage fright" Pharmacokinetics: -Highly lipid soluble --> readily crosses membranes -Widely distributed to all tissues and organs, including CNS -liver metabolism -excretion in urine -well absorbed after oral administration Adverse effects: -Bradycardia: Atropine and isoproterenol PRN (needed or as the situation arises) -AV heart block -Heart failure -Rebound cardiac excitation --> tachycardia and ventricular dysrhythmias -Bronchoconstriction -Inhibition of glycogenolysis -CNS effects: CNS depression (insomnia, weird nightmares, etc) Drug interactions: -Calcium channel blockers -Insulin Precautions, warnings, and contraindications: -Severe allergy -Diabetes (don't use beta blockers with diabetic patients because it can mask early signs of hypoglycemia like tremors, tachycardia, tremors, etc.) -Cardiac, respiratory, and psychiatric disorders -Neonates

Insulin

MOA: Cellular uptake of glucose, potassium, and amino acids -Also used to treat emergency hyperkalemia (because of potassium uptake) Preparations: "high alert" agents Sources of insulin: Recombinant DNA technology -Human Insulin: identical to insulin produced by human pancreas -Human insulin analogs: Modified forms of human insulin; have same actions but different time courses Properties of Insulin Types: -Name -Appearance (cloudy or clear) -Route -Administration options

Bulk-forming laxatives (Group 3 laxative)

MOA: Functions similarly to dietary fiber -Absorb water back into gut and soften and increase fecal mass -Fecal swelling promotes peristalsis Use: -Preferred treatment of constipation -Used in and with caution with diverticulosis and IBS-D (it makes fecal mass larger so thats why you use it with diarrhea) Adverse effects: -Minimal (no systemic absorption) -Esophageal obstruction -Intestinal obstruction -impaction Administered with a full glass of water or juice (it can form mass in esophagus otherwise)

Bile Acid Sequestrants: Colesevelam

MOA: Increases LDL receptors on hepatocytes (pulls LDL out of the blood) -Prevents reabsorption of bile acids Effects: Lowers LDL cholesterol Administration: BID (twice a day) with meals Adverse effects: -Constipation -Bloating -Indigestion -Nausea Drug interactions: Compared to others in class: -Does not decrease uptake of fat-soluble vitamins -Does not significantly reduce the absorption Statins, Thiazides, digoxin, warfarin -Give 1 hour before the sequestrate (Colesevelam) or 4 hours after

Propylthiouracil (PTU)

MOA: Inhibits thyroid hormone synthesis Use: Second-line drug -Graves' disease -Adjunct to radiation therapy -Preparation for thyroid gland surgery Preferred for: -Pregnant women (1st trimester only) -Thyrotoxic crisis (thyroid storm) -Patients intolerant of methimazole Pharmacokinetics: Short half life (about 90 minutes) --> BID to TID dosing -Full benefits may take 6 to 12 months Adverse effects: -Severe liver injury (all of these pass through liver and cause injury) -Agranulocytosis (most serious)

Osmotic Laxatives (Group 1 (high doses), Group 2 (low doses))

MOA: Osmotic action --> water retention --> fecal swelling --> peristalsis Uses: -Diagnostic/surgical bowel prep -Post-anthelmintic therapy -Purge bowel of ingested poisons Adverse effects: -Dehydration (can have so much stool so frequently that they can be dehydrated) -Go into acute renal failure (sodium reabsorption and loss of water) -Sodium retention: Exacerbated heart failure, hypertension, edema

Omeprazole [PPI][anti-secretory agent]

MOA: Prodrug converted to active form in parietal cells -Causes irreversible inhibition of hydrogen potassium ATPase proton pump -Inhibits basal and stimulated acid release Uses: Short term therapy -Duodenal ulcers -Gastric ulcers -Erosive esophagitis -GERD Long term therapy -Hyper-secretory conditions (Zollinger-Ellison syndrome) In hospitals -Stress ulcer prevention -Recommendation: patients in ICUs, only if they have an additional risk factor (multiple trauma, SCI, or prolonged ventilation) Adverse effects: Minor: Headache, nausea, vomiting, diarrhea -Pneumonia -Fractures (less absorption of calcium, causes bone demineralization) -Hypomagnesemia -Gastric cancer risk -Rebound acid hyper-secretion Drug interactions: -Reduced absorption of: HIV/AIDs antivirals, select antifungals -Reduced beneficial effects: Clopidogrel

Thrombolytic Drugs

MOA: Promote breakdown of fibrin in thrombi. Remove thrombi that have already formed. Uses: Dissolve newly formed thrombi Prototypes: Streptokinase Alteplase AKA "Tissue plasminogen activator" (tPA) Timely intervention is super important. the sooner you administer the better the outcome.

Alpha2-Adrenergic Agonists

MOA: Reduces aqueous humor production 2 agents approved for use: Apraclonidine -Only for short term therapy -Adverse effects: headache, dry mouth, dry nose, altered taste, conjunctivitis, lid reactions, pruritus, tearing, and blurred vision Brimonidine -First line drug for long-term therapy -Adverse effects: dry mouth, ocular hyperemia, local burning and stinging, headache, blurred vision, foreign body sensation, ocular itching; crosses BBB -> drowsiness, fatigue, hypotension

Metoprolol (Selective beta 1 blocker)

MOA: Selective blockade of beta 1 receptors in the heart -Not likely to cause bronchoconstriction or hypoglycemia -Preferred over the nonselective beta blockers for patients with asthma or diabetes -Safer than propranolol for patients with asthma or a history of severe allergic reactions, and patients with diabetes Therapeutic uses: -Hypertension -Angina pectoris -Heart failure -Myocardial infarction Pharmacokinetics: -Very lipid soluble -Well absorbed after oral administration -Elimination is by liver metabolism and renal excretion Adverse effects: -Bradycardia -Reduced cardiac output -AV heart block -Rebound cardiac excitation -Minimal bronchoconstriction and interference with beta 2 glycogenolysis Contraindications and precautions: Contraindications: sinus bradycardia, AV block Caution: patients with heart failure

Doxazosin. (Selective A1 antagonist)

MOA: Selective competitive inhibitor of alpha1 receptors use: -Hypertension -BPH pharmacokinetics: -Administered orally -Peak effects: develop after 2 to 3 hours -Half life: 22 hours -Protein bound -Extensive liver metabolism Adverse effects: -Orthostatic hypotension -Reflex tachycardia -Nasal congestion -"First-dose" effect

Surfactant Laxatives (Group 3)

MOA: Stool softening -Facilitates water into stool -Causes secretion of water and electrolytes into intestine Produce a soft stool several days --> onset of treatment Adverse effects: -Gas -Diarrhea at high doses Administer with full glass of water

Clarithromycin [Antibiotic]

MOA: Suppresses growth of H. pylori by inhibiting protein synthesis Most common side effects: -Nausea -Diarrhea -Distortion of taste Example: Clarithromycin-Based Triple Therapy -Clarithromycin/Amoxicillin/PPI OR -Clarithromycin/Metronidazole/PPI

Diuretics Overview

MOA: Block sodium and calcium reabsorption -Water follows sodium. -Promotes secretion -Aim to reduce blood pressure by increasing excretion of water and sodium in urine Site of action: Proximal tubule -Where active tubular secretion process occurs -produce greatest diuresis Adverse Effects: -Hypovolemia (volume depletion. Too much secretion) -Acid base imbalance -Electrolyte imbalances Classifications: 1. Loop -Furosemide -Ascending limb of Henle's loop 2. Thiazide -Hydrochlorothiazide -Early Convoluted Tubule 3. Osmotic -Mannitol -Proximal Convoluted Tubule 4. Potassium-sparing -Aldosterone antagonists (Spironolactone) -Nonaldosterone antagonists (Triameterene) -Late Distal Convoluted Tubule & Collecting Duct Fifth class technically: Carbonic anhydrase inhibitors -Used to reduce interocular pressure

Triamterene (Non-aldosterone antagonist) POTASSIUM-SPARING DIURETIC

MOA: Direct inhibitor of (disrupts) sodium-potassium exchange pump in the distal nephron -Acts directly on pump itself, so it acts quicker than spironolactone (hours vs days) -Decreases sodium reuptake -Inhibits ion transport Uses: Used alone or in combination -Hypertension -Edema Adverse effects: -Excessive potassium accumulation (more likely to happen when used by itself as opposed to combination) (Hyperkalemia) -Leg cramps -Nausea -Vomiting -Dizziness

Which of the following statements about mannitol [Osmitrol] are correct? (Select all that apply.)

Mannitol cannot be given orally. Mannitol can cause edema. Diuresis begins in 30 to 60 minutes after administration. Mannitol does not diffuse across the GI epithelium and cannot be transported by the uptake systems that absorb dietary sugars. Accordingly, to reach the circulation, the drug must be given parenterally. Diuresis begins in 30 to 60 minutes and persists 6 to 8 hours. Mannitol can leave the vascular system at all capillary beds except those of the brain. When the drug exits capillaries, it draws water along, causing edema. Mannitol is used in prophylaxis of renal failure. Mannitol is an osmotic diuretic, not a loop diuretic.

Neurotransmitter Life Cycles

Many drugs produce their effects by interfering with specific life cycles: Acetylcholine; agents may... -Acetylcholine is stored in vesicles and get released in response to action potential. -Binds to receptor, once it releases from receptor it is immediately broken down from ACh enzyme -We can mimic or block ACh at receptor, or we can inhibit Acetylcholine (AChE), which gives us more ACh Norepinephrine; agents may... -Alter synthesis, storage, and release -Inhibit reuptake (ex; cocaine and TCAs) -Inhibit breakdown by MAO

Insulin-Like Growth Factor-1

Mecasermin -Synthetic of natural insulin-like growth factor-1 (IGF-1) -Used in GH deficiency that is not responsive to GH treatment Adverse effects -Hypoglycemia -Tonsillar hypertrophy -Intracranial hypertension --> can lead to CVA -Increased liver enzymes and lipids -Overgrowth of fat, facial bones, and kidneys

Other laxatives (Group 3)

Mineral oil -Laxative action is produced by lubrication -Useful when administered by enema to treat fecal impaction Adverse effects -Lipid PNE (from aspiration), anal leakage, and deposition of mineral oil in the liver Glycerin suppository -Stimulant -Softens and lubricates impacted feces -May stimulate rectal contraction -Effects ~30 min after insertion -Useful for reestablishing normal bowel function after chronic laxative cessation Lactulose Composed of galactose and fructose Use: -For those who don't respond to bulk-forming agents -Portal hypertension and hepatic encephalopathy secondary to chronic liver disease MOA: -Enhances intestinal excretion of ammonia -Cannot be digested by intestinal enzymes --> bacteria in colon metabolize lactulose --> lactic acid, formic acid, acetic acid --> osmotic actions Result: -Soft, formed stool in 1-3 days

Abciximab [antiplatelet drug] [Glycoprotein IIb/IIIa Receptor Antagonists]

Monoclonal antibody. Most effective of the antiplatelet drugs. "Super aspirins" Uses: Short term to prevent ischemic events that have acute coronary syndromes (medical emergency) IV- ACS and percutaneous coronary intervention (PCI) -Accelerates revascularization in patients undergoing thrombolytic therapy for AMI MOA: GP 2b/3a receptor antagonist -Reversibly binds to platelets in vicinity of GP 2b/3a receptors, preventing them from binding fibrinogen Effects persist 24 hours after infusion stopped Used in conjunction with aspirin and heparin

Schizophrenia Drug Therapy

Most FGAs and SGAs are equally effective, except for Clozapine (it is more effective than the rest) FGAS: Significant risk of EPS SGAS: Risk of metabolic effects FGAs: Cost less than SGAs Promoting adherence/compliance: -Ensure medication is taken -Encourage family to oversee medication admin -Provide with instructions -Inform patients and families that antipsychotics must be taken on a regular schedule -Inform patients about side effects of treatment -Assure patients that antipsychotic drug use does not lead to addiction -Establish good therapeutic relationship -Use of IM depot preparation for long-term therapy

Irritable Bowel Syndrome

Most common disorder of GI tract May occur with diarrhea, constipation, or both Characterized by: Cramping abdominal pain present for 12 weeks not explained by structural or chemical abnormalities, with at least 2 of the following features: -Pain is relieved by defecation -Onset was associated with change in frequency of stool -Onset of pain occurred in association with a change in stool consistency (normal to loose, watery, or pellet-like)

SSRIs (selective serotonin reuptake inhibitors)

Most commonly prescribed antidepressants. Increases levels of serotonin Fluoxetine Uses: -Bipolar disorder -Obsessive-compulsive disorder -Panic disorder -Bulimia nervosa -Premenstrual dysphoric disorder MOA: -Selective inhibition of serotonin reuptake Adverse effects: Safer and better tolerated than TCAs and MOAIs, one of ways you can minimize effect is reduce dose, or patients have "drug holiday" Most common: -Sexual dysfunction (impotence, delayed or absent orgasm and/or ejaculation, decreased sexual interest) -Nausea -Headache -CNS stimulation (nervousness, insomnia, anxiety) -Weight gain Withdrawal syndrome -Abrupt discontinuation -minimzied by tapering dose down Neonatal effects when used during pregnancy -Neonatal abstinence syndrome (NAS) -Persistent pulmonary hypertension of the newborn (PPHN) EPS Bruxism (grinding of teeth) Bleeding disorders (impairs platelet aggregation) Serotonin Syndrome -Result of too much serotonin brainstem/spinal cord -Begins 2 to 72 hours after treatment S/S -AMS: Agitation, confusion, disorientation, anxiety, hallucinations, and poor concentration -Incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, fever -Deaths have occured - Resolves spontaneously after stopping the drug -Risk increase by concurrent use of MAOIs and other drugs (both increase serotonin levels) Drug interactions: Monoamine oxidase inhibitors (MAOIs) -Risk of serotonin syndrome SSRIs and MAOIs must not be combined -Stop MAOI at least 14 days before starting SSRI -Stop SSRI at least 14 days before starting MAOI Antiplatelet drugs and anticoagulants (ASA and NSAIDs, Warfarin) -Increase risk of GI bleeds TCAs and lithium -Can increase levels of these drugs

Finasteride (5-alpha-reductase inhibitor)

Most effective in patients with very large prostate (mechanical obstruction) MOA: -Reduces dihydrotestosterone (DH) --> prostate shrinkage --> reducing obstruction Adverse effects: -Impotence -Decreases ejaculate volume -Decreases libido -Gynecomastia -Orthostatic hypotension

Propofol (IV anesthetic)

Most widely used anesthetic (sedative-hypnotic) "Milk of Amnesia" (it looks like milk, white) -Induction & maintenance of analgesia Action -Unconscious within 1 min; lasts 3 to 5 minutes Adverse effects -Profound respiratory depression -Hypotension -Associated risk of infection (it has to be in a lipid based solution and that can be breeding ground for bacteria. To minimize risk, when you open vial of propofol, you have to use it within 6 hours or discard it) Risks for abuse -Not a controlled substance -Supplies are not closely monitored -Widely available in operating rooms and other areas of hospitals and clinics -No "high" -Instantaneous, but brief, sleep period -Patients awaken "refreshed" and talkative -Many report feeling elated and even euphoric

Nomenclature

Myocardial infarction (MI) = necrosis of the myocardium resulting from ischemia STEMI: Acute MI caused by complete interruption of regional myocardial blood flow -ST elevated means ischemia. -Actual injury or dead tissue is denoted by Q wave -ST elevation is injury or ischemia.

Intermediate-Duration Insulin

NPH Insulin [Humulin N, Novolin N] -NPH insulin is only one suitable for mixing with short-acting insulins (Mixing = "clear before cloudy" = short-acting drawn first) -Onset: 60-120 minutes -Peak: 6-14 hours -Duration: 16-24 hours Administration -Route: SC injection only -Injected twice daily for control between meals and during the night -NPH insulins are cloudy suspensions that must be gently agitated before administration (rolled between hands, NOT shaken) Administer 30 to 60 minutes before meal

NSAIDs and Acetaminophen

NSAIDs (Nonsteroidal anti-inflammatory drugs) -Aspirin (ASA), celecoxib, ibuprofen, naproxen Use for: Anti-inflammatories, analgesics, antipyretics -RA, OA, Bursitis -mild to moderate pain -Fever -Dysmenorrhea Cyclooxygenase (COX) Inhibitors AE: Gastric ulcers, bleeding, renal impairment, increased risk for MI and stroke ASA -Non-selective Use: anti-inflammatory, analgesic, antipyretic, antiPLT, cancer prevention, Alzheimer's disease prevention AE: GI, bleeding, renal impairment; tinnitus, sweating, HA, dizziness (Salicysm); respiratory depression, hyperthermia, dehydration, acidosis (toxicity) Contraindication: Pregnancy Interactions: Anticoagulants, glucocorticoids, ETOH, ibuprofen, ACEIs, ARBs Celecoxib/Celebrex Uses: OA, RA, acute pain, dysmenorrhea AE: dyspepsia, abdominal pain, renal impairment, CV Contraindication: pregnancy Interactions: Warfarin, furosemide, ACEIs, lithium, fluconazole Acetaminophen/Tylenol Use: Analgesic, antipyretic; NOT an anti-inflammatory Inhibits prostaglandin synthesis (CNS) Generally well tolerated at normal doses AE: Stevens-Johnson Syndrome (SJS), hepatotoxicity, hepatic necrosis Antidote: Acetylcysteine

Anti-ischemic Therapy

Nitroglycerin Three doses sublingually every 15 minutes. -Followed by IV if persistent ischemia (Reduced blood flow) or hypertension Beta blocker Supplemental oxygen IV morphine ACE inhibitor

Benign Prostatic Hyperplasia

Nonmalignant prostate enlargement Caused by excessive growth of epithelial (glandular) cells and smooth muscle cells S/S -urinary hesitancy, urgency, or frequency -Dysuria -Nocturia -Straining to void -Post-void dribbling -Decreased force and caliber of stream -Sensation of incomplete bladder emptying Treatment Surgery or watchful waiting Drug therapy: 5-Alpha-reductase inhibitors -5 alpha reductase: enzyme responsible for converting testosterone to dihydrotestosterone (DHT), the active form of testosterone in prostate -Treats mechanical obstruction by decreasing available DHT-- ideal for patient with very large prostate -Take months for benefits to develop -Avoid handling during pregnancy because of absorption through skin-- harmful to developing male fetus Alpha1-adrenergic antagonists -Treats dynamic obstruction-- ideal for patients with relatively small prostates -Benefits develop rapidly

Magnesium

Normal range: 1.8-3.0 mg/dl -Required for activity of many enzymes -helps RNA work -Helps neurochemical transmission of muscle impulses.

Drugs for IBD

Not curative; may control disease process -40% of IBD patients require colostomy 5-Aminosalicylates -Sulfasalazine -5-ASA Glucocorticoids -Budesonide Immunosupressants -Azathioprine -Mercaptopurine Immunomodulators -Infliximab Antibiotics -Metronidazole

Drug Therapy

Not first line therapy (only if TLCs fail) Classes & Prototypes HMG-CoA Reductase inhibitors ("Statins") -Most effective drugs -Lovastatin Bile acid sequestrants -Colesevelam Others -Nicotinic acid (Niacin) -Fibrates -Ezetimibe -PCSK9 Inhibitors

Monoamine Oxidase Inhibitors (MAOIs)

Not first line, second or third choice antidepressants for most patients As effective as TCAs and SSRIs but more hazardous Risk for hypertensive crisis if patient eats foods with high tyramine content Uses: -Depression -Bulimia nervosa -Agoraphobia -Attention-deficit/hyperactivity disorder -Obsessive-compulsive disorder -Panic attacks MOA: -Convert monoamine neurotransmitters (NE, 5-HT, and DA) into inactive products -Inactivate tyramine and other biogenic amines -Two forms in the body (MAO-A; MAO-B) -Affected by antidepressants Act on MAO in 2 ways: reversible and irreversible -Reversible: Lasts 3 to 5 days -Irreversible: Lasts about 2 weeks All of MAOIs in current use cause irreversible inhibition Adverse effects: -CNS stimulation -Orthostatic hypotension Hypertension crisis from dietary tyramine -Tyramine (aged cheeses, smoked meat, cured meat, beer, fruits that are overly ripe): promotes release of NE from sympathetic neurons -Hypertensive crisis (severe headache, tachycardia, hypertension, N/V, confusion, profuse sweating, stroke, death) Hypertensive crisis treatment: Prevention --> patient teaching Treatment: IV vasodilator -Sodium nitroprusside (a nitric oxide donor) -Phentolamine (an alpha-adrenergic antagonist) -Labetalol (an alpha and beta-adrenergic antagonist) Drug interactions: -Indirect acting sympathomimetic agents -Antidepressants: TCAs and SSRIs -Meperidine --> can precipitate hyperthermia Patients should be instructed not to take any other drug prescribed or OTC without approval of prescriber of MAOI

A patient is experiencing chemotherapy-induced nausea. Which prescribed medication would be most effective for this patient?

Odansetron (serotonin receptor antagonist)

Other products used to Alter Plasma Lipid Levels

Omega 3-acid ethyl ester -want high level EPA and DHA Fish oil Plant stanol and sterol esters -use spread for bagel Estrogen --> does not decrease CV risk Cholestin (Red Yeast Rice) CoQ10 (powerful antioxidant) -Recommend this if you take statin. Statin reduce levels of naturally occurring, so they recommend this.

Regulation of Blood pressure

One of first ways we try to regulate BP is via kidneys with increased urine output and decrease fluid volume or blood volume. -If you have increased volume = increased pressure. -Decrease volume = help control blood pressure If you have high blood pressure (hypertension) you are going to receive diuretics first. If diuretics don't work, move to ACE inhibitors, beta blockers, or arbs. ACE inhibitors keep renin from turning into angiotensin. Angiotensin receptor blockers do same thing but only at receptor sites. Calcium channel blockers = Since calcium causes blood vessels to contract, the blockers will decrease that to decrease the tone of the blood vessels. Alpha blockers and alpha antagonists that work on alpha receptors. Beta blockers work primarily in heart.

Additional Ophthalmic Drugs

Opthalmic demulcents [artifical tears] Isotonic solutions: Polyvinyl alcohol, cellulose esters Cyclosporine ophthalmic emulsion: -Suppresses the immune response, promoting resumption of tear production -Treat dry eyes due to inflammation Glucocorticoids -We use for inflammatory disorders of eye Dyes -Used to aid in seeing lesions and abrasions in eye Fluroescein --> yellow --> cornea --> cobalt light Rose bengal --> red --> conjunctiva --> white light Lissamine green --> green --> conjunctivaa --> white

Apixaban [Anticoagulant][Direct Factor Xa Inhibitor]

Oral anticoagulant Uses: -Prevent stroke in patients with non-valvular Afib -DVT/PE prevention and treatment MOA: Direct factor Xa inhibitor -Inhibits free and clot-bound factor Xa, and prothrombinase activity Cardiologists prefer this one.

Rivaroxaban [Anticoagulant][Direct Factor Xa Inhibitors]

Oral anticoagulant. Uses: -Prevent DVT and PE after total hip or knee placement -DVT and PE treatment unrelated to orthopedic surgery -Prevention of stroke with Afib MOA: Direct Factor Xa inhibitor -Causes selective inhibition of that factor 10. -Binds directly with factor Xa --> inactivation -Epidural/spinal hematoma risk Adverse effects: -Similar to other anticoagulants -Hemorrhage stroke where you are bleeding out in brain is much less with rivaroxaban than warfarin.

Drugs for Angina (anti-anginal agents)

Organic nitrates -Nitroglycerin -1 every 5 minutes, up to 3 times, then call 911 -Nitro tablets go under tongue for best absorption Beta Blockers -Propranolol -Metoprolol -Help decrease anginal pain on a chronic basis, NOT acute basis -Help promote circulation Calcium channel blockers -Verapamil -Nifedipine -Help chronically to help increase cardiac perfusion and decrease chance of pain Other: Ranolazine -Newer drug with limited indications -Can be combined with other drugs Antianginal MOAs -Stable -Variant

Monoclonal Antibodies (PCSK9 Inhibitors)

PCSK9 Inhibitors MOA: inhibits the bind of protein PCSK9 to LDL receptors on hepatocytes -Results in the lowering of LDL levels Administration: -Subcutaneously Adverse effects: -Hypersensitivity -Immunogenicity (body makes antibodies against it) Drug interactions: None significant

Neuroanatomy Review

PNS has Somatic nervous system and autonomic nervous system. Somatic nervous system Spinal nerves (31) Cranial nerves (12) Autonomic nervous system Does things without you having to tell you to do things Sympathetic NS- "Stress" Parasympathetic NS- "peace"

PTU vs Methimazole

PTU can cause severe liver injury Methimazole does NOT PTU (90 minutes) has shorter half life than methimazole (6 to 13 hours) PTU requires two or three daily doses Methimazole requires one PTU crosses placenta less readily than methimazole Use PTU in pregnancy PTU blocks conversion of T4 to T3 in the periphery Methimazole does NOT

Age-Related Macular Degeneration (ARMD)

Painless, progressive disease that blurs central vision and limits perception of fine detail Management Begins as dry, and if it's not stopped it can progress to wet Dry is more prevalent than wet Goal Slow or prevent progression of disease Dry High doses of antioxidants and zinc can reduce risk of developing advanced ARMD -Vitamin C, vitamin E, beta-carotene, zinc, copper Wet Angiogenesis inhibitors: Ranibizumab *prototype* MOA: suppress growth of new blood vessels -Direct injection into vitreous humor Adverse effect: Endophthalmitis (inflammation inside the eye due to bacterial, viral, or fungal infection). If you experience symptoms like pain or light sensitive, immediately contact provider Common: blurred vision, cataracts, conjunctival hemorrhage, corneal edema, eye discharge, increased IOP, ocular discomfort, floaters, reduced visual acuity Laser therapy Photodynamic therapy (PDT)

Antidepressants

Panic disorders responds well to all 4 antidepressant classes (SSRIs, SRNIs, TCAs, and MAOIs) -Takes 6 to 12 weeks to have full ebnefits -SSRIs are usually go to drugs Venlafaxine -First antidepressant approved for generalized anxiety disorder -Proved effective for both short-term/long-term -Nausea: most common side effect -Other common reactions: headache, anorexia, nervousness, sweating, daytime somnolence, insomnia, and hypertension Duloxetine Paroxetine -Short and long term use Escitalopram

Other Drugs for ED treatment

Papaverine (smooth muscle relaxant) + Phentolamine (alpha-adrenergic blocker) MOA: Increase arterial flow and decrease venous outflow Administration: Injected directly into corpus cavernosum Adverse effects: -Priapism (prolonged erection of the penis) -Painless fibrotic nodules in corpus cavernosum -Orthostatic hypotension with dizziness Alprostadil (prostaglandin E1) Not to be used more than 3x per week or more than 1x in 24 hours Adverse effects: -Burning sensations -Priapism -Penile fibrosis Transurethral: Alprostadil pellets -Do not use more than twice in 24 hours -no priapism or penile fibrosis

Use of Drugs for ANS

Parasympathetic Agents -Digestion of food -Excretion of waste -Control of vision -Conservation of energy Sympathetic Agents -Heart and blood vessels (hypertension, heart failure, angina) -Lungs (asthma)

Types of Seizures

Partial (focal) seizures -Simple partial -Complex partial -Secondarily generalized Generalized seizures Tonic-clonic -manifested by loss of consciousness, jaw clenching, muscle relaxation alternating with muscle contractions, periods of cyanosis Absence (petit mal) -characterized by loss of consciousness for a brief period and usually involve eye blinking and staring into space Atonic Characterized by sudden loss of muscle tone Myoclonic -Sudden contractions that may be limited to one limb or may involve entire body Status epilepticus A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes Febrile a convulsion in a child caused by a spike in body temperature, often from an infection. They occur in young children with normal development without a history of neurologic symptoms. Partial happens in one area where generalized happens in broad area

Acute Otitis Externa (AOE) "Swimmer's Ear"

Patho -Bacterial infection of the EAC (external auditory canal) -Pseudomonas aeruginosa -Staphylococcus aureus S/S -Rapid onset ear pain associated with pruritus (feeling fullness in ear) -external ear could be tender to touch -nasty drainage Treatment Topical -2% acetic acid + alcohol solution as ear drops Antibiotics: -Ciprofloxacin + hydrocortisone -Ciprofloxacin + dexamethasone -Ofloxacin alone Oral Adults: Ciprofloxacin Children: Cephalexin (PO fluoroquinolones can cause tendon rupture in young patients; should not be given to patients younger than 18. Can't give ciprofloxacin to children) Prevention -Don't put anything in ear that can remove cerumen and or damage the skin -Dry EAC after swimming and showering -Don't remove cerumen -Restrict use of earplugs to swimming only

Allergic Conjunctivitis

Patho -Conjunctival inflammation in response to an allergen; seasonal or perennial Symptoms are from biphasic immune response -Initially, release of inflammatory mediators --> symptoms (discharge, itching, redness, congestion) -Symptoms peak 20 minutes after allergen exposure, abate 20 minutes later -Symptoms reappear after 6 hours due to recruitment of immune cells --> amplify inflammatory response Agents Mast-cell stabilizers -Prevent release of inflammatory mediators -Takes days for benefits/effects H1-receptor antagonists -Inhibits histamine release from mast cells -Provide immediate symptomatic relief Nonsteroidal anti-inflammatory drugs (NSAIDs) -Inhibits cyclooxygenase required for prostaglandin synthesis Glucocorticoids (short term) -Inhibit production of prostaglandins and leukotrienes Ocular decongestants -Activate alpha1-adrenergic receptors on blood vessels --> vasoconstriction -Regular use --> risk for rebound congestion -Relief redness and edema but doesn't address any part of inflammatory process itself, so you get rebound congestion

Glaucoma

Patho -Increased ocular pressure (IOP) Aqueous humor; plasma-like, maintains IOP -Fluid secreted into post chamber of eye. If outf low or drain gets clogged up, back pressure develops and IOP goes up. -When pressure goes up, you get progressive optic nerve damage End result: visual field loss 2 degrees to optic nerve damage. Drug therapy Drugs lower IOP by: Reducing aqueous humor production -Beta blockers (first go to drug) -Alpha2-adrenergic agonists -Carbonic anhydrase inhibitors (less effective, so they are used as add on therapy) Facilitating aqueous humor outflow -Prostaglandin analogs (as effective as beta blockers and have less adverse effects. First line agents) -Cholinergic drugs (second line agents) Preferred route: Topical (eye drop) -Systemic effects are limited and uncommon Combined therapy more effective If drugs are ineffective, surgical intervention is needed to promote outflow First line *prototypes* Beta-adrenergic blocking agents -Timolol (blocks beta1 and beta2) -Betaxolol (beta1 selective) Alpha2-adrenergic agonists -Brimonidine (topical, approved for long term reduction of pressure in open angle glaucoma or ocular hypertension) Prostaglandin analogs -Latanoprost Second line Cholinergic drugs -Muscarinic agonists -Cholinesterase inhibitors Carbonic anhydrase inhibitors -Topical OR systemic administration Primary Open-Angle Glaucoma (POAG) Characteristics -Most common form in US -Progressive optic nerve damage --> eventual vision impairment -No symptoms until significant and irreversible optic nerve injury has occurred Risk factors -Elevation of IOP (only modifiable risk factor) -Family history of POAG -Advancing age -African and South American ancestry treatment -Directed at reducing elevated IOP -Primary method: Chronic drug therapy Angle-Closure Glaucoma "narrow-angle glaucoma" -Much less common -Precipitated by displacement of iris actually moving, which prevents aqueous humor from flowing out the drain. -Sudden, rapid, and painful increased IOP -Without treatment --> irreversible vision loss in 1 to 2 days Treatment: Drug therapy -- control the acute increased IOP -Combo of agents used to suppress symptoms Corrective surgery-- after reduced by drug therapy -Laser iridotomy -Iridectomy

Acute Otitis Media (AOM)

Patho -inflammation of and fluid in middle ear. Very prevalent in children. S/S -Otalgia: ear pain -Child may tug or hold affected ear -Fever -Vomiting -Anorexia -Irritability -Sleeplessness -Diarrhea Etiology -Bacterial, viral, or both -Usually starts as nasopharyngeal viral infection Treatment -Age-appropraite analgesia -antibitoics when indicated -High-dose amoxicillin (antibitoic-resistant OM = high dose amoxicillin-clavulanate) Prevention -Breast feeding for at least 6 months -Avoiding child care centers when respiratory infections are prevalent -Eliminating exposure to tobacco smoke -Reducing pacifier use in the second 6 months of life -Avoid supine bottle feeding -Vaccination for and treatment of influenza -Vaccination against Streptococcus pneumoniae

What is Parkinson's Disease?

Patho -neurogenerative disorder of the EPS in brain (complex network of nerves that help regulate movement). -When disrupted, dyskinesia results (abnormal/impaired voluntary movement) & akinesia (loss of voluntary movement) -Striatum function requires balance between dopamine and ACh (an imbalance develops from degeneration of the neurons that supply dopamine to the striatum) -Drug therapy can maintain functional mobility for years, but no cure for motor symptoms. Symptoms -Dyskinesias (Tic/tremor with movement or at rest, rigidity, postural instability, bradykinesia which is slowed movement) -Disruption in sleep -Depression -Psychosis and dementia Therapeutic Goals -Improve patient's ability to carry out activities of daily life

Acromegaly

Patho: -GH excess in adults caused (usually) by pituitary adenoma (polyp made up of tissue that looks much like the normal lining of your colon) Clinical manifestations: -Coarsening of facial features: enlarged nose, jaw enlargement, separation of teeth -Skin changes, joint pain Treatment: -Surgical excision -Radiation Drug therapy -Prolonged and expensive -Reserved for those non-responsive to other options, or if options are unavailable -Two options: 1. Somatostatin analogs-- octreotide 2. GH receptor antagonists -- pegvisomant

Diabetes insipidus

Patho: Deficiency of ADH -Polydipsia (excessive thirst) -Excretion of large volumes of dilute urine Treatment: -ADH replacement Vasopressin- IM, SQ Desmopressin (agent of choice) -Longer duration of action -Easy administration- Nasal, SQ, PO, IV -Lack of significant side effects (vasoconstriction) Adverse effects: Water intoxication (from excessive water retention) -Drowsy, listless, confused, headache --> could result in coma

Variant Angina (Prinzmetal's/Vasospastic)

Pathophysiology -we want to decrease Coronary artery spasms that reduce oxygen supply to heart, causing pain. -Reduced oxygen supply --> pain/angina -May happen at any time (activity or at rest) Goal Reduce incidence and severity of angina. -Increase cardiac O2 supply Therapeutic agents Symptomatic only -Have them sit down and rest, take deep breaths, get more oxygen, give them nitro, check their oxygen. Relax coronary artery spasms -Calcium channel blockers -Organic nitrates Treatment of vasospastic angina -Initial therapy -If monotherapy is inadequate + short-acting nitrate -If combination fails, a coronary artery bypass graft (CABG) may be indicated -Beta blockers are not effective with vasospastic angina

Myasthenia Gravis (MG)

Pathophysiology Characterized by: -Fluctuating muscle weakness and predisposition to rapid fatigue Common symptoms: -Ptosis (Abnormal low-lying or drooping upper eyelid.) -Dysphagia -Weakness of skeletal muscles What is it?: Autoimmune process in which antibodies attack nicotinicM receptors on skeletal muscle -A chronic, autoimmune neuromuscular disorder that causes weakness in skeletal muscles, moving arms and legs, also breathing like diaphragm. Other muscles are those of eyes, face, chewing, talking and swallowing. It happens when body starts to make antibodies to nicotinic M (muscle) receptors on skeletal muscle. Treatment with cholinesterase inhibitors Prevent ACh inactivation, we intensify effects of ACh increasing muscle strength. Beneficial effects: -increased muscle strength Side effects: -Excessive muscarinic response Dosage adjustment: -Start small and adjust to patient response -May need to modify dosage in anticipation of exertion -Signs of undermedication (ptosis and dysphagia) -Signs of overmedication (excessive salivation and other muscarinic responses)

Which patient does the nurse identify as most likely needing an increased dose of warfarin to have the same anticoagulant effect?

Patient taking oral contraceptives to prevent pregnancy

Using specific examples, explain the difference between pharmacological & therapeutic methods of classifying drugs

Pharmacology: The study of drugs in humans Therapeutics: Use of drugs to diagnose, prevent, or treat disease or to prevent pregnancy. The medical use of drugs. Therapeutic classification -Describes what is being treated by the drug -Drugs are placed into classes based on their usefulness in treating a specific disease -State what condition is being treated by the particular drug EXAMPLES Anticoagulants --> influence blood clotting Antihyperlipidemics --> lower blood cholesterol Antihypertensives --> lower blood pressure (these 2 treat cardiovascular disorders) Antidysrhythmis --> restore normal cardiac rhythm Antianginals --> treat Angina Pharmacologic classification -Describes how the drug acts -Addresses a drugs mechanism of action or how a drug produces its effects in the body EXAMPLES Diuretic --> MOA: Lowers plasma volume Calcium channel blocker --> MOA: Blocks heart calcium channels Angiotensin (converting enzyme inhibitor) --> MOA: blocks hormonal activity Adrenergic antagonist --> MOA: blocks physiological reactions to stress Vasodilator --> MOA: dilates peripheral blood vessels

Cholesterol

Physiologic roles: -Cell and cell membranes have to have cholesterol -Required for synthesis of hormones and bile salts -Deposited in stratum corneum of skin to reduce evaporation of water -Blocks transdermal absorption of water-soluble compounds Sources: -Comes from dietary sources -Manufactured by cells, primarily in liver

Other Reversible Cholinesterase Inhibitors

Physostigmine -Identical to neostigmine, except it readily crosses membrane. -Used to treat MG -Readily crosses membranes Edrophonium -Used to diagnose MG (IV) -Short duration Drugs for Alzheimer's disease -Donepezil -Rivastigmine

Compare and contrast the terms potency and efficacy

Potency -Strength of a drug at a specified concentration or dose -How much that concentration is effecting someone at that dose EXAMPLE: It takes drug B 10x the amount than drug A to effect someone the same Efficacy -Greatest maximal response that can be produced from a particular drug -Indicated by height of dose-response curve Effective drug is more important than potent drug Drug A is much more effective than drug B. This will effect prescription

Antacids

Potency = acid-neutralizing capacity (ANC) MOA: -React with gastric acid to produce neutral salts or salts of low acidity -Except for sodium bicarbonate, antacids do not alter systemic pH. Therapeutic effects: -Reduce destruction of gut wall by neutralizing acid -May stimulate production of prostaglandins Adverse effects: Constipation: Aluminum hydroxide Diarrhea: Magnesium hydroxide Sodium loading: caution with hypertension/Heart failure patients Drug interactions: -H2 Blockers: Cimetidine & Ranitidine -Sucralfate Administer at least 2-4 hours in between doses

Fludrocortisone

Potent mineralocorticoid Preferred drug for treating: -Addison's disease (primary adrenal insufficiency) -Primary hypoaldosteronism -Congenital adrenal hyperplasia Adverse effects: High doses --> retained salt and water, excessive potassium loss -Expansion of blood volume -Hypertension -Edema -Cardiac enlargement -Hypokalemia

Non-ergot derivatives (Dopamine Agonist)

Pramipexole -Maximal benefits take several weeks to develop Uses: -Monotherapy in early PD -Combined with levodopa in advanced PD -Treats restless leg syndrome Adverse effects: Monotherapy: -Nausea -Dizziness -Daytime Somnolence (daytime sleepiness) -Insomnia -Constipation -Weakness -Hallucinations Combined: -Orthostatic hypotension -Dyskinesias -Increase in hallucinations Rare instances of pathologic gambling and other compulsive self-rewarding behaviors Ropinirole Very similar to premapexole Uses: -Monotherapy in early PD -Combined with levodopa in advancing PD -Treats Restless legs syndrome Adverse effects: Common: -Nausea -Dizziness -Sleepiness (somnolence) -Hallucinations When combined with levodopa: -Dyskinesias -Hallucinations -Postural hypotension Compulsive gambling, shopping, eating, and hypersexuality NOT BE USED DURING PREGNANCY

Glucagon for Treatment of Severe Hypoglycemia

Preferred treatment is IV glucose -Immediately raises blood glucose level Glucagon used if IV glucose is not available -Delayed elevation of blood glucose -Can't correct hypoglycemia resulting from starvation (It promotes glycogen breakdown; may not be enough glycogen to break down, so it may not work)

Cholinesterase Inhibitors

Prevent the degradation of ACh by acetylcholinesterase (AChE) Because they lack selectivity, they have limited therapeutic applications Indirect-acting cholinergic agonists Overdoses can cause excessive respiratory depression --> cholinergic crisis 2 basic categories: "reversible" cholinesterase inhibitors -Neostigmine "Irreversibe" cholinesterase inhibitors -Echothiophate ophthalmic-- glaucoma -Toxicology

Addison's Disease

Primary adrenocortical insufficiency Causes: -Autoimmune destruction (80%) -TB and other infections (15%) -Adrenal hemorrhage, cancer, drugs (5%) Clinical presentation: -Weakness and hypotension -Emaciation (abnormally thin or weak) -Hypoglycemia, hyperkalemia, hyponatremia -Increased pigmentation of skin and mucous membranes Treatment: -Replacement therapy with adrenocorticoids -Hydrocortisone is drug of choice (both glucocorticoid and mineralcorticoid)

Prolactin

Produced by anterior pituitary Function: Stimulate milk production after birth Effects of hypersecretion (excessive secretion): Females: Amenorrhea (absence of monthly menstrual periods), galactorrhea, infertility, possible delay of puberty in girls Males: reduced libido, impotency, galactorrhea, possible delay of puberty in boys Treatment: Dopamine agonists: bind receptors in pituitary --> suppression of prolactin release -Cabergoline -Bromocriptine

Progesterone

Produced by ovaries and placenta Adverse effects -Teratogenic effects -Gynecologic effects -Breast cancer -Depression -Breast tenderness -Bloating Therapeutic uses -Postmenopausal HRT -Dysfunctional uterine bleeding -Amenorrhea (absence of menstruation) -Infertility -Prematurity prevention -Endometrial carcinoma and hyperplasia

Beta Blockers

Propranolol (non-selective) Metoprolol (selective) -- hits mostly Beta 1 (heart) -Used for stable angina (angina of effort) -Reduce pain by decreasing cardiac oxygen demand Adverse effects -Sexual dysfunction -Bradycardia is common (decreases AV conduction) -Caution in patients with diabetes -Depression is common

Vitamin E

RDA = 22.5 IU/day (15 mg), males and females -Increased for those breast feeding Sources: -Vegetable oils (corn, olive, cottonseed, safflower, canola) -Nuts -Wheat germ -Whole-grain products -Mustard greens Toxicity: -increased risk for bleeding and hemorrhagic CVA Deficiency: -Rare --> neurologic deficits (ataxia, sensory neuropathy, areflexia), muscle hypertrophy

Heparin [Anticoagulant][Activate antithrombin]

Rapid-acting anticoagulant Sources: -Lungs of cattle -Intestines of pig MOA: -Activates antithrombin -Binds to and enhances antithrombin effect at multiple sites -Assists antithrombin in inactivating a lot of clotting factors Administration: -Infection only -IV (Continuous and intermittent) -Deep Subcutaneous Therapeutic uses: Preferred anticoagulant in pregnancy & when you need rapid anticoagulation such as when you have a PE or DVT. -Evolving stroke -Open heart surgery -Dialysis -Low dose therapy postoperatively to keep you from having PE or DVT -Treats Disseminated intravascular coagulation(DIC) -Addition to thrombolytic therapy especially when patients are having an MI. Adverse effects: -Hemorrhage -Heparin-induced thrombocytopenia (HIT) [immune disorder where platelets are all used up or being rendered inactive so platelet count drops and you have increase in clots. Body produces antibodies against heparin platelet complex] -Hypersensitivity reactions [it is derived from other animal tissues, so it may be contaminated from other antigens you can have allergic response to] Contraindicated: -In patients with thrombocytopenia [low blood count] -Uncontrollable bleeding -During and immediate post-op eye, brain, or spinal cord Antidote: Protamine Sulfate. *** Lab Monitoring: -To measure coagulation status with heparin is partial aPTT.

Malignant Hyperthermia (MH)

Rare, life threatening syndrome Triggered by general anesthetics Genetics play role, family history Symptoms very abrupt Muscle rigidity/profound elevated Temp (109.4 F) -Heat of MH is generated secondary to massive release of calcium within the muscle cells Treatment -Turn OFF all anesthetic gases (first thing you want to do) -Switch to non-triggering anesthetics -Obtain MH cart -Cooling of patient with ice packs, cold IV saline -Dantrolene -Treatment of hyperkalemia and acidosis (hyperventilation)

Panic Disorder

Reach a peak in few minutes generally and then dissipate in 30 minutes typically People feel like they are having a heart attack Characteristics -Palpitations, pounding heart, and racing heart beat -Chest pain or discomfort -Sensation of shortness of breath -Feeling of choking -Dizziness and lightheadedness -Nausea or abdominal discomfort -Derealization or depersonalization -Fear of losing control -Fear of dying -Tingling or numbness in the hands -Flushes or chills

Describe the relationship between receptors and drug action

Receptors -Special chemical sites in body that most drugs interact with to produce effects -Any functional macromolecule in a cell to which a drug binds to produce it's effects -Drugs bind to many cellular components (enzymes, ribosomes, tubulin) to produce effects -Most important group of macromolecules through which drugs act = body's own receptors for hormones, neurotransmitters, and other regulatory molecules. -Enzymes & Ribosomes = target molecules rater than receptors. Equation for interaction between drugs & receptors D+R -> <- D-R complex -> response -Binding of drug to it's receptor is usually reversible. -either mimi actions of endogenous NE (increase)*AGONIST* or block actions of endogenous NE (decrease output)*ANTAGONIST* "lOCK AND KEY"

Intake of Vitamins

Recommended dietary allowances (RDAs) Adequate intake (AI) Tolerable upper intake limit (UL) Estimated average requirement (EAR) Acceptable macronutrient distribution range (AMDR) -Range of macronutrients (proteins, carbs, fats) associated with optimal health -Intake below the established range for that nutrient increases the risk of malnourishment -Intake above the established range for that nutrient increases the risk of chronic diseases

Thiazolidinediones (TZDs)

Reduce glucose levels primarily by decreasing insulin resistance Only indication is type 2 diabetes, mainly as an add on to metformin -Rosiglitazone -Pioglitazone Increase risk of heart failure so avoid if history of HF

A patient is prescribed a medication that lowers the arterial blood pressure. the nurse should assess for which response by the body to restore the blood pressure?

Reflex tachycardia

Adverse effects of Alpha 2 Blockers

Reflex tachycardia

Hypothalamus and Pituitary

Regulate all bodily processes 15 hormones and regulatory factors Hypothalamus = brain Pituitary = storing reservoir for all these hormones Posterior pituitary = oxytocin and ADH Anterior pituitary = growth hormone, dopamine, somatostatin Releasing factors come from hypothalamus

4 Subtypes of MS

Relapsing-remitting MS -Clearly defined episodes of neurologic dysfunction -Remission: periods of partial or full recovery -Symptoms develop over several days and then typically resolve within weeks -Affects twice as many women as men Secondary Progressive MS -Patient with relapsing-remitting MS develops steadily worsening dysfunction, with or without occasional plateaus, acute exacerbations, or minor remissions -Within 10 to 20 years of symptom onset, about 50% of patients with relapsing-remitting MS develop secondary progressive MS Primary progressive MS -Symptoms grow progressively more intense from the outset -Some patients may experience occasional plateaus or temporary improvement -Clear remissions do not occur Progressive-relapsing MS -Rare -Presents like primary progressive MS -Acute exacerbations superimposed on the steady intensification of symptoms

Insulin: Therapeutic use

Required by all patients with T1DM; and by many patients with T2DM IV insulin for diabetic ketoacidosis Gestational diabetes Hyperkalemia: promotes cellular uptake of potassium Aids in the diagnosis of growth hormone deficiency

Type 1 Diabetes

Requires insulin Requires a comprehensive plan -Diet and exercise -Self-monitoring of blood glucose (SMBG) -Insulin replacement *mandatory* Dietary measures -No ideal % calories from CHO, fat, or protein -Macronutrient distribution: based on person's current eating patterns, preferences, and goals Physical activity Insulin replacement Management of hypertension -ACE inhibitor (lisinopril) -ARB (losartan) -Reduce risk of diabetic nephropathy Dyslipidemia -Statins (atorvastatin)

Management of STEMI

Routine drug therapy MONA (not necessarily in that order) Morphine oxygen Nitroglycerin Aspirin Beta blockers Usually oxygen first, then nitroglycerin , and aspirin, then morphine. Reperfusion therapy options -Want to occur quickly Percutaneous coronary intervention (PCI) -Use of angioplasty (often balloon) Fibrinolytic (thrombolytic) therapy -All patients undergoing should receive an anticoagulant at the same time. IV heparin is usually what is given. (bivalirudin, enoxaparin, fondaparinux) -Plus any antiplatelet drugs, maybe aspirin or clopidogrel. -NOT a GP 2b/3a inhibitor like abciximab.

Lithium

Salt/sodium formulations Therapeutic uses -BPD -Alcoholism -Bulimia -Schizophrenia -Glucocorticoid-induced psychosis MOA (theory) -Alters glutamate uptake and release -Blocking binding of 5-HT to its receptors Pharmacokinetics -Short half-life (dose it in daily divided doses) -Excreted by the kidneys -Sodium levels: reduced excretion when Na levels decrease -Plasma levels: low therapeutic index (0.4 to 1 mEql) You should have levels checked every 3 months or so to make sure you are in therapeutic range. Adverse effects Therapeutic lithium levels -GI effects -Tremors -Polyuria -Renal toxicity -Goiter and hypothyroidism -Teratogenesis Excessive lithium levels -Greater than 1.5 mEq/L -Serious side effects like EKG changes, convulsions, death Monitoring -Every 2 to 3 days at initiation of therapy -Then every 3 to 6 months and PRN Drug interactions -Diuretics --> decrease sodium --> increase lithium levels. Do not use diuretic because they promote sodium loss -NSAIDs --> increase lithium levels. Avoid NSAIDS -Anticholinergic drugs (urinary hesitancy). Avoid because they cause urinary hesitancy. that combined with polyuria would be uncomfortable.

Dutasteride (5-Alpha Reductase Inhibitor)

Same MOA and effect as finasteride Major differences: -Reduction in circulating dihydrotestosterone (DHT) is more complete -Extremely long half life (5 weeks) Adverse effects: -Impotence -Decreases ejaculate volume -Decreases libido -Decreased sperm count

Other Muscarinic Antagonists

Scopolamine Actions like atropine -Therapeutic doses of atropine = CNS excitation (flushing); whereas therapeutic doses of scopolamine = sedation. -Suppresses emesis and motion sickness; atropine doesn't. Uses: motion sickness, production of cycloplegia and mydriasis for ophthalmic procedures, production of preanesthetic sedation and obstetric amnesia Ipratropium bromide Uses: -Treat asthma -Treat COPD -Treat Rhinitis caused by allergies or common cold Not associated with typical antimuscarinic side effects Dicyclomine Functions as GI antispasmotic Uses: -IBS, functional bowel disorders such as diarrhea or hypermotility

Hypomagnesemia

Serum magnesium LESS than 1.8 mg/dl Causes: -Diarrhea -Hemodialysis -Kidney disease -Prolonged IV feedings that have no magnesium in them (poor nutritional states) Prevention and treatment: -Replacement of magnesium oxide or sulfate -IM or IV Adverse effects: -Too much magnesium = neuromuscular blockade, respiratory muscle paralysis -Too much magnesium = Suppress cardiac impulse conduction in AV node, cardiac arrest Contraindicated: patients with AV heart block

Hypermagnesemia

Serum magnesium is GREATER than 3.0 mg/dl Toxic levels common in people with renal insufficiency (especially when magnesium antiacids are being used) Symptoms: -Muscle weakness -Hypotension -Sedation -ECG changes Treatment: -Diuresis -IV Calcium gluconate -Dialysis (remove excess water)

Hypokalemia

Serum potassium level LESS than 3.5 Causes: -treatment with a thiazide or loop diuretic Adverse effects: -skeletal and smooth muscle, blood pressure, and heart -Increases risk for hypertension and stroke Symptoms: weakness or paralysis of skeletal muscle -Hypokalemia is cause of toxicity with Digoxin. Treatment: Mild- Potassium chloride (PO). Take with meals and full glass of water. Abdominal discomfort. Severe- Potassium chloride (IV). Must be diluted 40mEq or less. Infused slowly. Contraindications to potassium use: -Patients predisposed to hyperkalemia Complication: -Hyperkalemia. -If you overshoot treatment, you get hyperkalemia which can also be fatal.

Hyperkalemia

Serum potassium levels OVER 5.0 mEq/L Causes: -Severe tissue trauma (potassium is sitting in cell, so if cells are destroyed, the potassium gets out) -Untreated Addison's disease -Acute acidosis -Renal failure -Misuse of potassium-sparing diuretics -Overdose with IV potassium Consequences: -Disruption of cardiac electrical activity within heart -It alters generation, so start as well as conduction of cardiac impulses -Earliest signs of dangers that potassium levels are off are cardiac rhythm changes -May be confused, anxious, trouble breathing, weakness or heaviness in legs, numbness or tingling of hands, feet, lips. Treatment: -Hold potassium containing food or salt substitutes that can promote accumulation -Counteract potassium-induced cardiotoxicity -Lower extracellular levels of potassium --Calcium salt --Infuse glucose and insulin to promote potassium being driven into cells --Infuse sodium bicarbonate to increase pH

Thyroid function tests

Serum thyroid-stimulating hormone (TSH) -Screening and diagnosis of hypothyroidism -elevated TSH is an indicator of hypothyroidism Serum T4 Test -Total T4 -Free T4 Serum T3 test -Total T3 -Free T3

Explain why certain drugs with carcinogenic or teratogenic potential are used in pharmacology

Several drugs used to treat cancer are among those with greatest carcinogenic potential. Evaluating drugs is difficult; it may take decades for evidence of carcinogenesis to appear after exposure.

Diabetic Ketoacidosis (DKA)

Severe manifestation of insulin deficiency Symptoms evolve quickly within hours or days Happens in patients that have type 1 diabetes Characteristics Altered glucose metabolism -Hyperglycemia -Water loss -Hemo-concentration Altered fat metabolism -Production of ketoacids (ketones) -if you don't have insulin, your body will start breaking down fat for energy which leads to ketosis and hyperventilation Acidosis -Sweet (acetone-like) smell to urine or breath Treatment -Insulin replacement and normalization of glucose -Bicarbonate for acidosis -Water, sodium, and potassium replacement -Begins with IV fluids and electrolytes, followed by IV insulin

Ranitidine [Histamine2-Receptor antagonist][anti-secretory agent]

Shares properties of cimetidine -More potent, fewer adverse effects, fewer drug interactions Therapeutic uses: -Short term treatment of gastric/duodenal ulcers -Prevention of recurrent duodenal ulcers -Treatment of Zollinger-Ellison syndrome -GERD Adverse effects: -Significant ones are uncommon -Does not bind to androgen receptors -Elevation of gastric pH may increase risk of pneumonia

Etomidate

Short acting IV anesthetic agent used for induction of general anesthesia and sedation for short procedures -Reduction of dislocated joints -Tracheal intubation -Cardioversion Induces unconsciousness very quickly and last only about 5 minutes.

Complications of Diabetes

Short term -Hyperglycemia -Ketoacidosis -Hypoglycemia Long term (macrovascular damage) -Heart disease -Hypertension -Stroke -Hyperglycemia -Altered lipid metabolism Long term (microvascular damage) -Retinopathy -Nephropathy: ACE inhibitor or ARB -Sensory and motor neuropathy -Gastroparesis -Amputation secondary to infection -Erectile dysfunction

Terms related to Adverse Drug Reactions

Side effect Nearly unavoidable secondary drug effect produced at therapeutic doses -Develop soon after drug is initiated or not until drug has been taken for weeks or months Toxicity -Caused by excessive dosing. -May occur even with normal dosing -Neutropenia (risk for infection) caused by anticancer medications (chemotherapy) Allergic reaction "Hypersensitivity" -Immune response goes crazy -Sensitivity to drug can change over time -Penicillins are most common to cause severe allergic reactions -NSAIDs and sulfonamides Idiosyncratic effect -Uncommon drug response resulting from a genetic predisposition -Succinylcholine-induced paralysis Paradoxical effect -Opposite of the intended drug response -If you give something to kid and it is supposed to make them sleepy, they are jazzed up for next 4 hours, that is paradoxical. Latrogenic disease -Doctor gave you the disease. Result of healthcare. Physical dependence -Develops during long term use of certain drugs -If you stop using that drug, results in abstinence syndrome. Serious things happen, you get sick. Carcinogenic effect -Causes some kind of malignancy Teratogenic effect -Birth defect -"Monster making" -Drug induced birth defect

Thiazides

Similar to effects to loop diuretics Maximum diuresis (urine production) is much lower than loop. Can't give thiazides when urine flow is decreased or when there is severe kidney impairment unlike furosemide. -Ineffective if low GFR (less than 15-20 mL/min)

Vardenafil & Tadalafil (Phosphodiesterase type 5 (PDE5) Inhibitors)

Similar to sildenafil: -PDE5 Inhibitors -Approved for oral therapy of ED Differences: Vardenafil -Prolongs QT interval Tadalafil -Effects last up to 36 hours (longest duration) -Approved for daily dosing if sexual activity anticipated twice weekly -Tamsulosin is safe to use

Isotonic Contraction

Sodium and water are lost in equal proportions. -Volume is off (decrease in total volume) -Osmolality is good Causes: -Vomiting -Diarrhea -Kidney disease -Misuse of diuretics (anorexic people usually) Treatment: -Fluids that are isotonic to plasma (stays inside bloodstream) -0.9% NaCl (Normal saline) -Infuse normal saline slowly (to avoid pulmonary edema)

Toxicology of Muscarinic Antagonists

Sources of antimuscarinic poisoning -Natural products like belladonna -Selective antimuscarinic drugs -Drugs with pronounced anti-muscarinic properties Symptoms -Dry mouth -Blurred vision -Photophobia -Hyperthermia -Central nervous system effects -Hot, dry, and flushed skin Treatment -Physostigmine (AChE inhibitor) Warning -Differentiate between antimuscarinic poisoning and actual psychotic episode Signs and symptoms of atropine overdose Hot as a Hare -Temperature goes up, not sweating Mad as a Hatter -Confusion, delirium Red as a Beet -Flushed face, tachycardia Dry as a Bone -Decreased secretions, thirsty Full as a Flask -Urinary retention Blind as a Bat -Not seeing very well

The nurse is caring for a patient with heart failure who needs a diuretic. Which agent is likely to be chosen, because it has been shown to greatly reduce mortality in patients with heart failure?

Spironolactone [Aldactone] Spironolactone is a potassium-sparing diuretic used to treat both hypertension and edema. It is a preferred drug in heart failure, because it has been shown to have a cardioprotective effect, reducing mortality in patients with heart failure.

Tricyclic Antidepressants (TCAs)

Structurally similar to phenothiazine antipsychotics SSRIs are used more Increase risk of suicide during early treatment Uses: -Depression -Bipolar disorder -Fibromyalgia -Neuropathic pain -Chronic insomnia -Attention-deficit/hyperactivity disorder -Panic disorder -OCD MOA: -Block reuptake of two monoamine transmitters (NE and serotonin) adverse effects: -Sedation (common) -Orthostatic hypotension (common) -Anticholinergic (common) -Diaphoresis -Seizures -Hypomania most dangerous AE: Cardiac toxicity Drug interactions: -Using with MAOIs can cause severe hypertension -Poteniate effects of direct-acting sympathomimetic drugs (jazz you up even more) & indirect-acting sympathomimetic drugs -Anticholinergic agents -Don't combine with CNS depressants like alcohol Toxicity: -Overdose can be life threatening -In small children, it might only take 1 or 2 pills -Severely depressed patients shouldn't be given more than a week of drug at a time -Easy to kill yourself with Clinical manifestations Primarily from anticholinergic and cardiotoxic actions -Dysrhythmias -Tachycardia -Intraventricular blocks -Complete atrioventricular (AV) block -Ventricular tachycardia -Ventricular fibrillation Treatment -Gastric lavage -Activated charcoal -IV sodium bicarbonate to treat cardiac dysrhythmias

Insulin Administration Devices

Subcutaneous injection -Syringe and needle -Pen injectors -Jet injectors (don't have needle, they just shoot insulin right through skin) Subcutaneous infusion -Portable insulin pumps -Implantable insulin pumps Intravenous infusion -usually done in emergency situation where patient's can be monitored closely Inhalation

What is Angina

Sudden pain beneath the sternum, often radiating to left shoulder and arm, even up the neck. Oxygen supply is decreased to the heart, it is insufficient to meet the oxygen needs of cells. Two goals of drug therapy: 1. Prevention of MI and death 2. Prevention of myocardial ischemia and anginal pain Forms: Chronic stable angina -"exertional angina" or "angina of effort" Variant Angina -"Prinzmetal's angina" or "vasospastic angina" Unstable Angina -Medical emergency

Serotonin 1B/1D Receptor Agonists (Triptans) (Migraine-specific abortive drug)

Sumatriptan First line drug for stopping migraine in progress Use: Aborting an ongoing migraine attack MOA: -Binds to receptors on intracranial blood vessels --> causes vasoconstriction --> diminish perivascular inflammation -Binds receptors on the sensory nerves Pharmacokinetics: -PO, SC, or intranasal -Onset = 0.5-1 hr -Half life = 2+ hours Adverse effects: -Chest symptoms: "heavy arms" or "chest pressure" -Coronary vasospasm (angina), rare -Teratogenesis -Others: Vertigo, malaise, fatigue, tingling sensations; bad taste from intranasal administration Drug interactions: -Ergot alkaloids, sumatriptan, and other triptans (all cause vasoconstriction) -If a triptan or ergot is given together, you will get excessive vasospasm

Local Anesthetics

Suppress pain by blocking sodium channels and by blocking impulse conduction along axons Only blocks neurons near site of administration Suppress pain without CNS depression Can be administered topically and by injection May be used with a vasoconstrictor -Decreases blood flow and delays systemic absorption of the anesthetic (prolongs effects of anesthesia and reduces risk of toxicity) -Potential for tissue necrosis Topical -Applied to mucous membranes and skin topically -Preparations: Cream, ointment, jelly, aerosol -Used on eyes, nose, mouth, urethra, rectum Guidelines: -Apply smallest amount needed -Avoid application to large areas -Avoid application to broken or irritated skin -Avoid strenuous exercise, wrapping the site, and heating the site, all of which can accelerate absorption by increasing skin temperature Injection Carries significant risk and requires special skills Severe systemic reactions may occur (seizures, heart block, anaphylaxis) -Rarely seen -Usually happens soon after initial injection (1-5 min) -Early symptoms: numbness, tongue paresthesia, dizziness, tinnitus, blurred vision, metal taste -Potentially lethal Resuscitation equipment -IV access in place -Oxygen -Defibrillator Methods of Injection Infiltration: Injecting a local anesthetic directly into the immediate area of surgery or manipulation Nerve block: Injecting a local anesthetic into or near nerves IV regional: Used to anesthetize extremities (hands, feet, arms, and legs) -Turnicate is used to keep anesthetic in region during surgery -Bier's block anesthesia is an anesthetic technique on the body's extremities where a local anesthetic is injected intravenously and isolated from circulation in a target area.

Anti-epileptic Drugs

Suppress that mania and depression and stabilize mood Divalproex sodium -Controls symptoms in manic episodes -Helps prevent relapse into mania Carbamazepine -Prevention of mania -Reduces symptoms -Protects against recurrence of mania and depression -Target trough plasma level: 4 to 12 mcg/mL Lamotrigine -Indicated for long-term maintenance -Can be used alone or in combination with other drugs -A lot of people get rash. Most of the time it is benign and goes away, HOWEVER it can progress to Steven-Johnson Syndrome (skin falls off, ulcers in mouth, any rash at all should be reported to the prescriber so it can evaluated)

Common Dysrhythmias

Supraventricular Impulse arises above the ventricle -Atrial fibrillation (Afib) - can cause emboli "showers: -Atrial flutter (Aflutter) -Sustained Supraventricular tachycardia (SVT) Ventricular Scary and worry nurses; Look like tombstones on EKG -Ventricular tachycardia (Vtach) You can't pick out Ps, cant pick out QRS -Ventricular fibrillation (Vfib) Heart is sitting there, wiggling (need defibrillation) -Premature ventricular complexes (PVC) If I drink too much coffee, stress can cause it, PMS can cause it -Digoxin-induced ventricular dysrhythmias -Torsades de pointes long QT interval.

What is Alzheimer's Disease?

Symptoms: -Progressive memory loss -Confusion -Feeling disoriented -Impaired Judgement -Personality changes -Difficulty with self-care -Behavior problems (ex; wandering, pacing, agitation, screaming) -"Sundowning" (symptoms are more exacerbated at night, around 4/5 o clock) -Inability to recognize family members -Inability to communicate Patho: Degeneration of neurons -Early in hippocampus = memory -Later in cerebral cortex = speech, perception, reasoning, and other higher functions. Decline in cerebral volume Reduced cholinergic transmission -Levels of ACh 90% below normal (neurotransmitter is critical to forming memories) -Loss of cholinergic function

Selection of Antibiotics

Take a blood sample for culture BEFORE giving first dose of broad-spectrum antibiotic Identify organism and drug sensitivity Drugs may be ruled out due to allergies, inability to penetrate site of infection, and patient variables. Empiric Therapy = antibiotic therapy for patients before causative organism is positively identified. Drug is based on clinical evaluation and knowledge of microbes most likely to have caused infection.

Anti-inflammatory Agents

Taken daily or for cute exacerbations Glucocorticoids First line treatment for inflammation PO- Prednisone Use for: Prophylaxis of chronic asthma. - Slow effects - Ineffective for acute exacerbations -Fixed schedule Suppresses inflammation, reduces bronchial hyperactivity, decreases mucus production. AE: Adrenal suppression (fight or flight), osteoporosis, hyperglycemia Contraindications: systemic fungal infections, live virus vaccines Patient education: Taper. Take with food. Increase dose in times of stress Inhaled corticosteroid- beclomethasone, fluticasone (Afrin) -Suppresses inflammation -AE: adrenal suppression, oropharyngeal candidiasis, dysphonia, growth suppression, bone loss, cataracts, glaucoma. Leukotriene modifiers PO- Montelukast (Singulair) -Same MOA as ASA (smooth muscle constriction, blood vessel permeability, promote inflammatory responses) -Reduce bronchoconstriction and inflammatory response (Edema, mucus secretion) Use to: Prophylactically to reduce number of attacks. 2nd line add on if glucocorticoid is ineffective Very safe. Do not take with food. Zafirlukast Interactions: Food decreases absorption, CYP450 AE: HA, GI, arthralgia, myalgia, neuropsychiatric effects, liver injury (rare) Mast Cell stabilizer Inhaled- Cromolyn Use for: Prophylaxis- moderate to severe asthma, chronic asthma -Use before exercise -Allergic rhinitis (nasal) Suppresses inflammation AE: cough or bronchospasm IgE antagonist SQ- omalizumab (Xolair) "-mab" = monoclonal antibody Use for: Exercise-induced asthma, eosinophilic asthma Antagonism of IgE. Se: Injection-site reactions, viral infections, URI, sinusitis, HA, pharyngitis AE: Anaphylaxis, CV, malignancy Observe patient for 2 hours after first 3 doses, 30 min after all other doses (anaphylaxis) Single injection can't exceed 150 mg -Switch sites

Tetracyclines (Bacteriostatic inhibitors of protein synthesis)

Tetracycline, demeclocycline, doxycyclin, minocycline Broad-spectrum Inhibit protein synthesis Uses: Acne, Peptic ulcer disease (PUD), periodontal disease, RA, H. pylori Absorption of tetracyclines is reduced by taking it with food because they form insoluble chelates with calcium, milk products, iron supplements, laxatives. AE: GI, superinfection, hepatoxicity, renal toxicity, photosensitivity, affect bones and teeth Precautions: kidney disease, children (teeth), suprainfection of bowel, liver damage (especially pregnancy/postpartum with kidney disease) Interactions: Chelation -Reduce with food (form insoluble chelates) -Calcium/iron supplements, milk products, Mg-containing laxatives, antacids

Alpha 1 Blockers

Therapeutic applications: -Result from blocking alpha 1 receptors on blood vessel -Reversal of toxicity from alpha1 agonists -Overdose of alpha-adrenergic agonist (Epi) Hypertension -Due to excessive activation of alpha1 receptors on blood vessels Extravasated Necrosis -Treat with Phentolamine (blocks vasoconstriction and prevents injury) Essential Hypertension MOA: Alpha antagonists lower blood pressure by causing vasodilation by blocking alpha1 receptors on arterioles and veins In response to venous dilation: -Return of blood to the heart decreases -Cardiac output decreases -Arterial pressure is reduced Benign prostatic hyperplasia (BPH) Symptoms: -Dysuria -Increased frequency of daytime urination -Nocturia -Urinary hesitancy and/or urgency -incomplete voiding sensation -Reduced size and force of stream Alpha1 receptor MOA: -Reduce contraction of smooth muscle in the prostatic capsule and the bladder neck (trigone and sphincter) Pheochromocytoma -Catecholamine-secreting tumor; located in adrenal medulla -Causes hypertension usually from activation of alpha1 receptors; but beta1 receptors can also contribute Treatment: Best option is surgery -Inoperable tumor; suppress hypertension with alpha blockers to control hypertension from catecholamine. -Before surgery: manipulation of tumor can cause massive catecholamine release. Alpha blockers given pre op because of the large release of catecholamine from tumor. Raynaud's disease -Peripheral vascular disorder characterized by vasospasms in the toes and fingers. MOA: Alpha blockers can suppress symptoms by preventing that vasoconstriction. -Ineffective against other peripheral vascular disorders that involve inappropriate vasoconstriction Adverse effects: Orthostatic hypotension -most serious response -when you block alpha receptors on veins, you reduce muscle tone in venous wall, and blood starts to pool in the vein when patient stands up. -Return of blood to heart is reduced as a result -Cardiac output drops and blood pressure drops (Educate patients about symptoms to sit or lie down if they feel dizzy) Reflex tachycardia -Increase heart rate by triggering baroreceptor reflex -Vasodilation reduces BP, baroreceptors sense drop in blood pressure, and they restore the heart rate -We can address reflex tachycardia by adding on a beta blocker Nasal congestion -Dilates the blood vessels of nasal mucosa -Agonist would reduce congestion Inhibition of ejaculation -Alpha 1 activation is required for ejaculation -Impotence is reversible; resolves when drug is discontinued Sodium retention and increased blood volume -Reducing blood pressure promotes renal retention of sodium and water -Alpha blockers can promote renal retention of sodium and water -When using alpha blockers for hypertension, they are combined with diuretic usually

Treatment of High- LDL Cholesterol

Therapeutic lifestyle changes (TLCs) -Diet that is low in cholesterol and low in saturated fats -Regular cardiac or aerobic exercise -Smoking cessation -Getting weight under control

Lamotrigine (Newer AED)

Therapeutic use: -Broad spectrum of anti-seizure activity -Bipolar disorder Adverse effects: -Dizziness -Diplopia (double vision) -Blurred vision -Nausea -Vomiting -Headache -Severe skin reactions -Aseptic meningitis -Risk for suicide

Benzodiazepines

Therapeutic uses -Anxiety * -Insomnia * -Seizure disorders * -Muscle spasm -Alcohol withdrawal -Perioperative applications (in prolong dental procedures) Adverse effects -CNS depression -Anterograde amnesia (happens post dose) -Sleep driving -Paradoxical effects (jazzed up instead) -Respiratory depression -Abuse -Use in pregnancy and lactation. DON'T USE DURING PREGNANCY Drug interactions CNS depressants (its additive) Tolerance -With prolonged use, tolerance develops to some effects but not others Physical dependence -Can cause physical dependence, but the incidence of substantial dependence is low Acute toxicity Oral overdose: drowsiness, lethargy, and confusion IV toxicity: life-threatening reactions, profound hypotension, respiratory arrest, and cardiac arrest General treatment measures: Oral- gastric lavage, activated charcoal, saline cathartic, and dialysis Treatment with flumazenil -competitive benzodiazepine receptor antagonist -Reverses sedative effects, may not reverse respiratory depression -Approved for benzodiazepine overdose and for reversing benzodiazepine effects after general anesthesia

Clinical pharmacology of the Androgens

Therapeutic uses -Male hypogonadism -Replacement therapy -Delayed puberty -Replacement therapy in menopausal women -Wasting in AIDS patients -Anemias Adverse effects -Virilization in women, girls, boys -Premature epiphyseal closure -Hepatotoxicity -Effects on cholesterol levels -Use in pregnancy (AVOID!!!!) -Prostate cancer -Edema -Abuse potential (athletic performance, so they are scheduled drugs) Preparations for male patients Oral androgens: -Fluoxymesterone -Methyltestosterone Testosterone formulations (most common to least): -IM -Transdermal gels -Transdermal patches -SC; Implanted pellets -Buccal tablets

Phenytoin (Traditional Anti-epileptic drug)

Therapeutic uses: -Epilepsy -Cardiac dysrhythmias -used for all seizures except absent seizures MOA: -Selective inhibition of sodium channels Pharmacokinetics: Dosing: Highly individualized Administration: with food Varied oral absorption Half life: 8 to 60 hours Therapeutic levels: 10 to 20 mcg/mL Drug interactions: -Decreases the effects of oral contraceptives, warfarin, and glucocorticoids (it increases synthesis of drug metabolizing enzymes) -Diazepam, Isoniazid, cimetidine, alcohol, and valproic acid increase phenytoin levels (very narrow therapeutic range-- even slight uptick can cause toxicity.) Adverse effects: AVOID IN PREGNANCY -Nystagmus (side to side shaking of eyes) -Sedation -Ataxia -Diplopia (double vision) -Cognitive impairment -Skin rash -Effects in pregnancy -Cardiovascular effects -Gingival hyperplasia: folic acid may prevent gum overgrowth, risk can be minimized by good oral hygiene, including flossing and gum massage

Cimetidine [Histamine2-Receptor antagonist][anti-secretory agent]

Therapeutic uses: -Gastric and duodenal ulcers -Gastroesophageal reflux disease (GERD) -Zollinger-Ellison syndrome -Heartburn, acid indigestion, sour stomach Pharmacokinetics: -Absorption is slowed if taken with meals (take it before meals or at night to be more effective) -Can cross BBB Adverse effects: -Anti-androgenic effects (it can bind to androgen receptors, blocking something else from binding like testosterone) -CNS effects -Pneumonia -IV bolus: can cause hypotension and dysrhythmias Drug interactions: -Warfarin -Phenytoin (Seizures) -Theophylline (respiratory diseases) -Lidocaine Antacids can reduce absorption, should be administered at least 1 hour apart

Valproic Acid (Traditional AED)

Therapeutic uses: -Seizure disorders -Bipolar disorder -Migraine -Treats all seizure types MOA: -Suppresses high-frequency neuronal firing through blockade of sodium channels -Suppresses calcium influx through T-Type calcium channels -Augment (increase) inhibitory influence of GABA Drug interactions: -Phenobarbital -Phenytoin -Topiramate Adverse effects: -Gastrointestinal effects (#1 effect) -NOT USED IN PREGNANCY -Hepatotoxicity: Liver failure -Pancreatitis -Teratogenic effects -Hyperammonemia

Opioid Receptors

Three main classes of opioid receptors: Mu receptors: -Most important because it is where most of opioid analgesics do their work -Analgesia, respiratory depression, euphoria, sedation, and physical dependence Kappa receptors: -Analgesia and sedation -Kappa activation may underlie psychotomimetic effects seen with certain opioids Delta receptors

Other Anterior Pituitary hormones

Thyrotropin (TSH) -Acts on thyroid gland -Limited to thyroid cancer diagnostic use Corticotropin (ACTH) -Acts on adrenal cortex -Produces adrenocortical hormones (ex; cortisol, aldosterone) -Used to diagnose adrenocortical dysfunction Gonadotropins -Follicle-stimulating hormone (FSH) -Luteinizing hormone (LH) -Regulate gonadal function in both sexes --Females: acts on ovaries --Males: acts on testes -Used to treat infertility in both men and women

Selective Toxicity

Toxic to microbes but harmless to host -Difference in cellular chemistry of mammals & microbes -Disruption of bacterial cell wall (causes cell to explode) Ex; Penicillins, cephalopsporins (weaken cell wall --> promote bacterial lysis and death. -Amphotericin B (increases permability of cell membrane -> leakage) -Inhibits an enzyme that is unique to the bacteria. -precursor of folic acid -Disruption of bacterial protein synthesis -Aminoglycosides (gentamicin) -Tetracyclines Disrupt specific biochemical reactions -Sulfonamides Suppress viral replication

Types of Diabetes Mellitus

Type 1 Diabetes -5% of all cases of DM -Common during childhood or adolescence -Can develop during adulthood -Abrupt symptom onset Patho: Autoimmune process -> destruction of pancreatic beta cells (make insulin for us) Immune response trigger is not known -Genetic -environmental -infectious factors Type 2 Diabetes -Most prevalent form of diabetes (90 to 95% cases) -Symptoms due to combination of insulin resistance and impaired insulin secretion -Hyperinsulinemia (lots of insulin in their blood, but no longer tied to blood glucose so it's not working right) -Insulin resistance -Strong family association Ominous Octet 8 core defects that are type 2 diabetes

Immunizations (Vaccines)

Types Live-attenuated -MMR, Rabies -Most dangerous but also most effective -must be refridgerated Inactivated -Hep A, Hep B -Most common Toxoid Tetanus, Diphtheria Bacterial toxin changed to nontoxic Conjugate Polysaccharide coating on virus is conjugated Complications Precautions -Immunocompromised -With radiation therapy or glucocorticoids Contraindications -Hypersensitivity (anaphylaxis) -Sick patient's

Drug Therapy

Types of drugs: Mood stabilizers -Lithium -Divalproex sodium -Carbamazepine -Select anti-epileptics share dual indication -Relieve symptoms during manic and depressive episodes -Prevent recurrence of manic and depressive episodes -Do not worsen symptoms of mania or depression -Do not accelerate the rate of cycling Antipsychotics -Given during severe manic episodes Antidepressants -Given during depressive episodes Drug selection Short-term therapy Manic episodes: Lithium (#1 drug choice for manic episodes) Depressive episodes: Lithium or valproate, bupropion, venlafaxine, or a SSRI (usually treated with 1 or more drug, but antidepressant not given alone) Long-term preventive treatment Antipsychotics (with or without mood stabilizer) Promoting adherence -Short term hospitalization -Long-term prophylactic therapy -Education for both patient and family

Levetiracetam (Newer AED)

Unique agent that is chemically and pharmacologically different from all other AEDs MOA: Unknown Adverse effects: -Mild to moderate Drug interactions: -Does not interact with other AEDs

Insulin Storage

Unopened vials: refrigerated until needed DO NOT FREEZE If refrigerated, can be used until expiration date After opening, can be kept up to 1 month without any loss of activity Keep out of direct sunlight and extreme heat Mixtures in vials: -Stable for 1 month at room temp -Stable for 3 months under refrigeration Mixtures in prefilled syringes -Stored in a refrigerator for at least 1 week -Stored vertically with the needle pointing up

Combination Agents: Phentermine/Topiramate

Use: Long term obesity treatment MOA: Specific to each medication Phentermine -Sympathomimetic --> stimulates CNS activity. -Makes heart rate go up Topiramate -Exact MOA unknown --> enhances satiety -Makes you feel full so you don't want to eat as much

Neostigmine [reversible cholinesterase inhibitor]

Use: Management of MG Non-MG use: Neuromuscular blockade reversal Pharmacologic effects: -Decreasing the breakdown of ACh --> more ACh available; this can intensify transmission at virtually all junctions where ACh is the transmitter MOA: Neuromuscular effects -Therapeutic dose: increases force of contraction in skeletal muscle Toxic levels: decrease force of contraction Central nervous system Therapeutic levels: Mild stimulation Toxic levels: CNS depression Precautions and contraindications: -Obstruction of gastrointestinal or urinary tract -Peptic ulcer disease -Asthma -Coronary insufficiency -Hyperthyroidism Adverse effects/acute toxicity: -Excessive muscarinic stimulation -Neuromuscular blockade -Treatment with antagonist [Atropine] Drug interactions: -Muscarinic antagonists -Nondepolarizing neuromuscular blockers -Depolarizing neuromuscular blockers

Methimazole

Use: first-line for hyperthyroidism -Sole therapy for Graves' disease -Adjunct to radiation therapy (until radiation effects begin) -Suppress hormone synthesis prior to thyroid surgery -Thyrotoxic crisis MOA: -Blocks synthesis of thyroid hormones -Does not destroy existing stores of thyroid hormone -May take 3-4 weeks for euthyroid state Adverse effects: -More dangerous than PTU during lactation and during the first trimester of pregnancy -Agranulocytosis (severe reduction in the number of white blood cells (granulocytes) in the circulating blood.)

Antipsychotic Agents

Used in: -Schizophrenia -Delusional Disorders -Bipolar disorders -Depressive psychoses -Drug-induced psychoses People with depression or bipolar, it's more cold. With schizophrenia or OCD, brain is firing a lot and we want to tampen it down and calm it down. Two different generations: 1st gen antipsychotics (FGAs) -"Conventional antipsychotics" or "neuroleptics" -MOA: Block receptors for Dopamine in the CNS -Cause serious movement disorders known as extrapyramidal symptoms (EPS) 2nd gen antipsychotics (SGAs) -"Atypical antipsychotics" -MOA: Moderate blockade for dopamine receptors; however, stronger blockade for 5-HT -Fewer EPS

Antidepressants

Used to relieve symptoms of depression -Can also help with anxiety disorders -Don't work for uncomplicated bereavement (normal sadness or grief) Groups: -Tricyclic antidepressants (TCAs) -Selective serotonin reuptake inhibitors (SSRIs) -Serotonin/NE reuptake inhibitors (SNRIs) -Monoamine oxidase inhibitors (MAOIs) -Atypical antidepressants Clinical features (symptoms) -Depressed mood -Loss of pleasure or interest -Insomnia (or sometimes hypersomnia) -Anorexia (or sometimes hyperphagia) -Mental slowing, and loss of concentration -Feelings of guilt, worthlessness, and helplessness -Thoughts of death and suicide -Overt suicidal behavior -Symptoms must be present most of the day, nearly every day, for at least 2 weeks Pathogenesis -Complex and incomplete -Possible contributing factors: genetic heritage, difficult childhood, chronic low self-esteem -Monoamine hypothesis of depression (caused by functional insufficiency of monoamine neurotransmitters such as dopamine, epinephrine, norepinephrine, serotonin) Need to find way to boost level of neurotransmitters Time course of response -Symptoms resolve slowly -Initial responses: 1 to 3 weeks -Maximal responses: not seen for 12 weeks -Failure = when taken 1 month without success Drug selection -Antidepressants have nearly equal efficacy -Selection and use for 4-8 weeks to assess efficacy -Once symptoms are controlled, patients will stay on drug for at least 4 to 9 months to prevent relapse. when they don't need them anymore, we gradually taper off Managing treatment; four options; 1. Increase dose 2. Switch to another drug in the same class 3. Switch to another class 4. Add a second drug (lithium, atypical antidepressant, antipsychotic) BBW: Suicide Risk with Antidepressants: May increase suicidal tendencies during early treatment Observe for: -Suicidality -Worsening mood -Changes in behavior -Dosing of inpatients should be directly observed

Verapamil NON-DIHYDROPYRIDINE

Uses: -Angina -Hypertension -Cardiac dysrhythmias (atrial tachydysrhythmias, or paroxysmal super ventricular tachycardia) -Migraines MOA: -Inhibit calcium ion influx into vascular smooth muscle and myocardium that would then cause contraction (Calcium moves in to cause contraction, but we are inhibiting that to get more relaxation of the smooth muscle) Administration: -PO (most common) -IV used for dysrhythmias Adverse Effects: -Constipation -Dizziness -facial flushing -Headache -Edema of ankles/feet -Heart block -Slows down contraction or impulses going to QRS. Drug interactions: -Digotoxin-plasma levels increase by 60% when they are on verapamil and can get digtoxic very quickly. -Grapefruit juice to avoid with calcium channel blockers -Beta-adrenergic blocking agents Toxicity: -Severe hypotension -Bradycardia -AV block (it slows conduction through QRST complex) -Reflexive ventricular tachydysrhythmias Interventions/antidotes: -Gastric lavage with activated charcoal -IV Calcium gluconate to counteract vasodilation

Epinephrine (All 4 receptors, A1, A2, B1, B2)

Uses: -Delays absorption of local anesthetic (alpha1 you get vasoconstriction) -Controls bleeding (alpha 1) -Elevates blood pressure (alpha 1) -Overcomes AV block (beta 1) -Restores cardiac function during arrest (beta 1) -Causes bronchial dilation in patients with asthma (beta 2) -Treatment of choice for anaphylactic shock Pharmacokinetics: Preparations: -IV (monitor closely) -IM (EpiPen) -SQ -Intracardiac -Intraspinal -Inhalation -topical Inactivation: -Short half-life Adverse effects: Hypertensive crisis -Excessive alpha 1 activation --> vasoconstriction -Dramatic increase in blood pressure -Cerebral hemorrhage can occur Dysrhythmias -Excessive activation --> dysrhythmias -Cautious use in hyperthyroid patients: sensitivity to catecholamines, at high risk for epinephrine-induced dysrhythmias Angina pectoris -Activation of beta 1 receptors --> increase cardiac work and oxygen demand --> if oxygen is significant --> angina attack -Especially likely in patients with coronary atherosclerosis Necrosis after extravasation -Treat with local infiltration/irrigation of phentolamine Hyperglycemia -Dosage adjustments need to be made for medications used to manage diabetes Drug interactions: Monoamine oxidase inhibitors (MAOIs) -One of enzymes that inactivate epinephrine and other catecholamines -Inhibition of MAO --> prolong and intensify Epi's effects -Those receiving MAO inhibitors should NOT receive Epi Tricyclic antidepressants (TCAs) -Block the uptake of catecholamines into adrenergic neurons -Blocking uptake --> prolong and intensify Epi's effects -Those receiving a TCA may require a reduction in Epi dosage General anesthetics -Several inhalation anesthetics -Produce tachydysrhythmias (render myocardium hypersensitive to activation by beta 1 agonists) Alpha-adrenergic blocking agents -Can prevent alpha-adrenergic receptor activation by Epi -Some alpha blockers (such as phentolamine) can be used to treat toxicity (hypertension or local vasoconstriction) caused by excessive Epi-induced alpha activation Beta-adrenergic blocking agents -Can prevent beta-adrenergic receptor activation by Epi -Beta blocking agents (such as metoprolol) can reduce adverse effects (dysrhythmias, angina) caused by Epi and other beta1 agonists

Carbamazepine (Traditional anti-epileptic drug)

Uses: -Epilepsy -Bipolar Disorder -Trigeminal and glossopharyngeal neuralgias -Seizure disorders but not absent seizures MOA: Suppresses high-frequency neuronal discharge in and around seizure foci Drug and food interactions: -Warfarin --> decreases INR (risk of developing blood clot) -Oral contraceptives --> decreases effects and see baby -Phenytoin --> additive effects -Phenobarbital --> additive effects -Grapefruit juice --> increase effects. Increase levels by 40%, which is really high. Adverse effects: Neurologic effects: -Nystagmus/blurry vision -Ataxia Hematologic effects: -Leukopenia -Anemia -Thrombocytopenia Dermatologic effects: -Rash -Photosensitivity reactions Birth defects Hypo-osmolarity

Sildenafil [Viagra] (Phosphodiesterase type 5 (PDE5) Inhibitor)

Uses: -First oral agent for ED -Pulmonary arterial hypertension [Revatio] MOA: -Only enhances erectile response in presence of stimuli -No significant impact on men who not have ED -Not approved for women Adverse effects: -Hypotension -Priapism -Headache -Dyspepsia (Upper abdominal discomfort, described as burning sensation, bloating or gassiness, nausea, or feeling full too quickly after starting to eat) -Flushing -Nasal congestion -Diarrhea -Rash -Dizziness -Mild transient visual disturbances -Intensification of obstructive sleep apnea Rare side effects: -Nonarteritic ischemic optic neuropathy -Sudden hearing loss -REPORT IMMEDIATELY and discontinue immediately Pharmacokinetics: Absorption slowed by high-fat meals Drug interactions: Nitrates -SL Nitroglycerin; Isosorbide mononitrate -Life threatening hypotension -At least 24 hours between these medications Alpha blockers -Tamsulosin -Symptomatic postural hypotension Inhibitors of cytochrome P450 (CYP3A4) -Carbamaepine -Pioglitazone -Can decrease sildenafil levels/efficacy -Don't take sildenafil with statins Caution use with following conditions: -MI, CVAV, and life-threatening dysrhythmia within past 6 months -Resting hypotension (<90/50 mm Hg) -Resting hypertension (>170/110 mm Hg) -Heart failure -Unstable angina NOT FOR USE by men routinely taking nitroglycerin or any other drug in nitrate family

Biotin (B7)

Uses: -Hair loss -Brittle nails -Skin rash -others AI: 30 mcg males and females Actions: Essential cofactor for several reactions involved in metabolism of CHO and fats Sources: Wide variety of foods; synthesized by intestinal bacteria Toxicity: None, no UL Deficiency: -Extremely rare; dermatitis, conjunctivitis, hair loss, muscle pain, peripheral paresthesias, psychological effects (lethargy, hallucinations, depression)

HMG-CoA Reductase Inhibitors - "Statins"

Uses: -Hypercholesterolemia (high amounts of cholesterol in blood) -Primary and secondary prevention of CV events -Post-MI therapy -Diabetes MOA: Complex -Increasing number of LDL receptors on hepatocytes (the liver up-regulates LDL receptors on surface of the liver to attract LDL from the circulation back to the liver) Effects: -Lower LDL cholesterol -Increase HDL cholesterol -Lower triglyceride levels Adverse effects: Common: Headache, rash, GI disturbances Serious: liver toxicity, myopathy/rhabdomyolysis (A breakdown of muscle tissue) Drug interactions: -Many drugs -Most go through 3A4. -Grapefruit can block metabolism so drug builds up to toxic levels Pregnancy Risk: Category X. -lots of cells are being built and cell membranes during pregnancy so you don't want to do that Administration: -Once daily in evening (only one that has different administration time is Relestatin) -Most manufacturing of cholesterol is done overnight

Norepinephrine (Alpha 1, alpha 2, Beta 1)

Uses: -Hypotensive states -cardiac arrest Differs from epinephrine: -No beta 2 activation -No hyperglycemia Pharmacokinetics: -Cannot be given orally (given by IV only) -Always have cardiac monitoring going Adverse effects: -Necrosis with extravasation Drug interactions: -MAO inhibitors (MAOIs) -TCAs -General anesthetics -Adrenergic blocking agents

Benzodiazepines and Benzodiazepine Receptor Agonists

Uses: -Induce general anesthesia -Manage seizure disorders, muscle spasms, panic disorder, and withdrawal from alcohol Most familiar member: -Diazepam Most prescribed: -Lorazepam -Alprazolam Produce less tolerance and physical dependence Few drug interactions

Alteplase (tPA) [Thrombolytics]

Uses: -MI (less than 6 hours; may be used less than 12 hours) -Ischemic stroke -Massive PE MOA: -Binds with plasminogen to catalyze conversion of other plasminogen into plasmin. That plasmin digests the network. Adverse effects: -Bleeding. Worrisome for brain bleeds. Advantages: -Does not cause allergic reactions -Does not induce hypotension

Baclofen (Drug for spasticity)

Uses: -MS -Spinal cord injury -CP MOA: -Acts in the spinal cord ---> suppress hyperactive reflexes that are involved in regulation in muscle movement -May mimic the action of GABA on spinal neurons Therapeutic effects: -Decreases flexor and extensor spasms -Suppresses resistance to passive movement -No direct effect on skeletal muscle Adverse effects: -no antidote for overdose -Gradual withdrawal over 1 to 2 weeks -Abrupt intrathecal withdrawal --> risk for rhabdo -CNS depressant -GI symptoms: nausea, constipation -Urinary retention

Pancuronium [competitive neuromuscular blocker]

Uses: -Muscle relaxation during general anesthesia, intubation, and mechanical ventilation Does not cause histamine release, ganglionic blockade, or hypotension Vagolytic effects may produce tachycardia Hepatic metabolism, so caution in those with liver disease

Atropine [Muscarinic Antagonists]

Uses: -Pre-anesthetic medication -Disorders of the eye -Bradycardia -Intestinal hypertonicity and hyper-motility -Muscarinic agonist poisoning -Peptic ulcer disease -Asthma -Biliary colic (relaxes biliary smooth muscle) Think heart, exocrine glands, smooth muscle, eyes. MOA: -No direct effect on it's own. All of it's responses are from preventing receptor activation from acetylcholine -Competitive and selective muscarinic receptor blockade Pharmacologic effects (opposite of activation): -Heart: Increases heart rate -Exocrine glands: Decreases secretions -Smooth muscle: relaxes bronchi, relaxes detrusor muscles (which increases tone of urinary sphincter), and decreases tone and motility of GI tract -Eyes: Mydriasis and cycloplegia -CNS: mild excitation to hallucinations and delirium Adverse effects: -Xerostomia (dry mouth) -Blurred vision and photophobia -Elevation of intraocular pressure (IOP) -Urinary retention -Constipation -Anhidrosis -Tachycardia (from don't make sweat anymore) Drug interactions: -Avoid combining with other drugs capable of causing muscarinic blockade (it is additive) Preparations and Administration: -General systemic therapy (SC, IM, IV, drops) -AtroPen for cholinesterase inhibitor poisoning (IM) -Ophthalmologic preparations

Anti-platelet Drugs

Uses: -Prevents thrombosis in arteries MOA: Suppress platelet aggregation (make platelets less sticky) Subclasses & Prototypes: Cyclooxygenase Inhibitor -Aspirin (ASA) P2Y12 Adenosine Diphosphate (ADP) Receptor Antagonists -Clopidogrel Glycoprotein IIb/IIIa Receptor Antagonists -Abciximab Other Antiplatelet drugs -Dipyridamole -Cilostazol

Phenylephrine (Alpha 1 Specific)

Uses: -Reduces nasal congestion (locally) -Elevates blood pressure (parenterally) -Dilates pupils (eyedrops) -Local anesthetic (Often given together because it delays absorption to keep it around longer)

Ezetimibe

Uses: -Reduces total cholesterol, LDL cholesterol -Approved for mono-therapy and use with statins MOA: -Inhibits cholesterol absorption in small intestine -Acts on brush border of small intestine Administration: -Can take with or without food Adverse effects: -Myopathy -Rhabdomyolysis (muscle breakdown) -Hepatitis -Pancreatitis -Thrombocytopenia Drug interactions: Statins -Increase possibility of liver damage Fibrates -Increase risk of gall stones and myopathy Bile acid sequestrates Cyclosporine -Increase levels

Ziprasidone (SGA)

Uses: -Schizophrenia -Acute bipolar mania MOA: Blocks multiple receptors -D2 -5-HT2 -H1 -Reuptake of serotonin and norepinephrine Side effects: -Generally well tolerated -Somnolence -Orthostatic hypotension -Rash Drug interactions: -TCAs --> increase CNS depression -Anti-dysrhythmic (ex: Amiodarone, quinidine) - & Antibiotics (clarithromycin, erythromycin, moxifloxacin) --> increase ziprasidone levels Can cause QT interval prolongation so don't combine with drugs who have QT prolongation

Ergotamine (Ergot alkaloids)

Uses: -Second line abortive agent for those who have not responded to a triptan -Because there is super high risk for dependence, shouldn't be taken on long term basis MOA: -Agonist activity at serotonin subtypes; specifically 5-HT1B and 5-HT1D receptors -Suppresses CGRP release --> blocked inflammation Administration: -PO -SL -PR Adverse effects: -Nausea/Vomiting -Others: weakness in the legs, myalgia, numbness and tingling in fingers and toes, angina-like pain, and tachycardia or bradycardia Toxicity: Ergotism -Peripheral arterial/arteriole constriction --> cold, pale, and numb extremities; muscle pain; possible gangrene Drug interactions: -Triptans; do not use within 24 hours of given ergot derivative Physical dependence leads to withdrawal syndrome Contraindications: -Hepatic or renal impairment -Sepsis (gangrene has resulted) -Coronary artery disease (CAD) -Peripheral vascular disease (PVD) -Pregnancy (Category X)

Class IV: Verapamil CALCIUM CHANNEL BLOCKER

Uses: -Slows ventricular rate (atrial fibrillation or atrial flutter) -Terminate SVT caused by an aV nodal reentrant circuit Effects on heart: -Reduce SA node conduction -Delays AV node conduction -Reduce myocardial contractility Adverse effects: -Bradycardia -Hypotension -AV block (you are going to have bradycardia) -Heart failure -Peripheral edema -Constipation Drug interactions: -Can elevate digoxin levels -Increased risk Adverse effects when combined with a beta blocker

Niacin (Nicotinic Acid; B3)

Uses: -lower cholesterol (high doses); prevention or treatment of niacin deficiency Action: -Necessary coenzyme for cellular respiration Sources: -poultry, -fish, -meat, -whole grains, and -fortified cereals. Toxicity: -High doses --> flushing, dizziness, nausea Deficiency: -Pellagra "rough skin" -GI disturbances -CNS disturbances

5-Aminosalicylates: Sulfasalazine

Uses: Acute episode of mild to moderate UC MOA: -5-ASA reduces inflammation -Suppresses prostaglandin synthesis and migration of inflammatory cells into affected region Adverse effects: Common: Nausea, fever, rash, arthralgia -Hematologic disorders (agranulocytosis, hemolytic anemia, macrocytic anemia) --Periodic CBCs to monitor.

Misoprostol (Anti-secretory agents that enhance mucosal defenses)

Uses: GI: NSAID-associated ulcer prevention OB/GYN indications MOA: -Replaces endogenous prostaglandins (stimulate secretion of mucus & bicarbonate) Adverse effects: -Most common: Dose-related diarrhea and abdominal pain -Spotting and dysmenorrhea BLACK BOX WARNING!: -Do not take during pregnancy -Category X

Donepezil (Cholinesterase inhibitor)

Uses: Indicated for mild, moderate, or severe AD MOA: -Causes reversible inhibition of cholinesterase -More selective in brain rather than periphery -Still can cause cholinergic effects, and to minimize these, it is dosed lowered initially and stabilized for several months, and then increasing dose Adverse effects: -Nausea, diarrhea -Bradycardia -Fainting -Falls -Fall-related fractures

Potassium-Sparing Diuretics

Uses: -Increase in urine production -decrease in excretion of potassium. Rarely used alone for therapy. 2 Sub-categories: Aldosterone antagonist -Spironolactone Non-aldosterone antagonist -Triamterene & Amilroide

Vitamin K

Uses: Vitamin K replacement; Warfarin antidote Sources: -Green leafy vegetables (spinach, broccoli, iceberg lettuce, etc.) vegetable oils Deficiency: Bleeding tendencies Adverse effects: -Hypersensitivity reaction -Hyperbilirubinemia (IV) in neonates

Vitamin C (Ascorbic Acid)

Uses: Prevention and treatment of scurvy Sources: -citrus fruits -tomatoes -potatoes -peppers -broccoli Deficiency: -Scurvy; faulty bone/tooth development, loosening of teeth, gingivitis, bleeding gums, poor wound healing, hemorrhage into muscles and joints

Succinylcholine

Usually called SUX Succinylcholine - depolarizing agent that allows the anesthelogists to use less of anesthetic during a procedure Rapid onset 30-60 secs, short duration of action 10 min

SNRI (serotonin and norepinephrine reuptake inhibitors)

Venlafaxine Uses: -Major depression -Generalized anxiety disorder -Social anxiety disorder MOA: -Blocks NE and serotonin uptake Adverse effects: -Nausea -Headache -Anorexia -Nervousness -Sweating -Sleepiness -Insomnia -Weight loss -Diastolic hypertension -Sexual dysfunction -Hyponatremia (in older adult patients) -Neonatal withdrawal syndrome Drug interactions: -MAOIs, don't want to use with them because of serotonin syndrome risk Duloxetine Use: -Major depressive disorder -Diabetic neuropathic pain -Generalized anxiety disorder -Fibromyalgia -Chronic musculoskeletal pain MOA: -Inhibits 5-HT2 and NE reuptake; weakly inhibits D2 reuptake Pharmocokinetics: -Food reduces rate of absorption -Highly bound to albumin in the blood -Half life; 12 hours Adverse effects: -Nausea -Sleepiness -Dry mouth -Sweating -Insomnia -Blurred vision Drug interactions: -Alcohol (increase risk of liver damage) -Don't use with MAOIs -Don't use with drugs that inhibit CYP1A2 or CYP2D6

Complications of STEMI

Ventricular dysrhythmias -Heart blocks -Frequently develop --> major cause of post-MI death -Prophylactic antidysrhythmics not successful Cardiogenic shock - it's worse than heart failure. Heart just can't pump enough blood supply and the pressure falls -7% to 15% of post-MI develop shock Heart failure Cardiac rupture -MI is so large and LV is so stretched from trying to pump adequately, it ruptures -Heart wall rupture --> shock --> circulatory collapse -Often results in immediate death -Relatively rare (<2% incidence)

Calcium Channel Blockers

Verapamil, Diltiazem, Nifedipine Uses: Variant angina, you are relaxing that spasm of the vessel, so you are increasing oxygen supply Stable angina you want to reduce oxygen demand. -Block calcium channels in vascular smooth muscle Adverse effects: -Dilation of peripheral arterioles -Reflex tachycardia -Hypotension -Bradycardia -Heart failure -AV block

Phenobarbital (Traditional AED)

Very effective, very cheap, and only take it once a day Uses: -Epilepsy -Sedation -Induction of sleep MOA: -Potentiates the effects of GABA -Reduces seizures without causing sedation --Anticonvulsant barbiturate Because it can suppress seizures without causing sedations it's sometimes referred to as "Anticonvulsant barbiturate" Drug interactions: -Oral contraceptives -Warfarin -Central nervous system depressants -Valproic acid ---when you stop taking this drug, it needs to be withdrawn slowly--- Adverse effects: -Most common CNS effect = drowsiness -Dependency -Exacerbation of intermittent porphyria (Disorders resulting from buildup of certain chemicals related to red blood cell proteins) -Rickets and osteomalacia -Nystagmus -Ataxia -Interfere with a lot of synthesis of vitamins

What do you need for good health?

Volume -ECF and ICF fluid remain in normal parameters Osmolality -number of dissolved stuff in the fluid Maintenance is job of our kidneys -When regulatory capacity of kidneys is exceeded = disruption of fluid volume, osmolality, or both. Changes in osmolality = sodium content of plasma

Physiology of RAAS

We are trying to keep Angiotensin 2 from being produced or decrease the amount of angiotensin 2, and that works on aldosterone. Actions of angiotensin 2: -vasoconstrictor -creates aldosterone -hypertrophy and remodeling in heart -thickening of blood vessels Actions of aldosterone: -Regulates blood volume and blood pressure -Cardiovascular effects (remodeling, fibrosis, dysrhythmias) If we can decrease angiotensin 2 then adrenals won't be producing as much aldosterone to affect the heart, kidneys, and blood vessels --> lower blood pressure Angiotensin 2 is formed by renin and ACE (angiotensin-converting enzyme)

Benzodiazepine-like Drugs

Zolpidem -Sedative-hypnotic. -Most widely used hypnotic (it's generic and super cheap, works quickly) -Patients need to be in bed when they take it. -Short term management of insomnia -Long term use: no apparent tolerance or increase in adverse effects -Adverse effects: sleep eating, daytime drowsiness, dizziness Zaleplon -short term management of insomnia -Prolonged use does not appear to cause tolerance -Most common side effects: Headache, nausea, drowsiness, dizziness, myalgia, and abdominal pain Eszopiclone -Treatment of insomnia -No limitation on how long it can be used -Most common adverse effect: bitter/metallic taste -Other common side effects: headache, somnolence, dizziness, dry mouth -You go to sleep but wake up in middle of night and can't go back to sleep

Barbiturates

a kind of depressant or sedative drug. used to relax the body and help people sleep. Used much less now because we have safer drugs Cause tolerance & dependence High abuse potential Multiple drug interactions Powerful respiratory depressants that can be fatal with overdose 3 classifications: -Ultrashort-acting (thiopental) -Short-to intermediate-acting (secobarbital) -Long-acting (phenobarbital) MOA: -Binds to GABA receptor-chloride channel complex -GABA Is inhibitory receptor.

The nurse is caring for a group of patients diagnosed with Alzheimer's disease (AD). Which neurotransmitter level is decreased by as much as 90% in patients with severe AD? A. Norepinephrine B. Serotonin C. Acetylcholine D. Dopamine

c. Acetylcholine Acetylcholine (ACh) levels naturally decline by a small percentage with age. Patients with severe AD may have ACh levels that are as much as 90% below normal. This is likely part of the explanation for the pathophysiology of AD.

Muscarinic Antagonists

"Anticholinergics" Fight or flight Atropine Anticholinergic drugs for OAB (urge incontinence) -Oxybutynin -Darifenacin -Solifenacin -Tolterodine Other common muscarinic antagonists -Scopolamine -Ipratropium -Dicyclomine -Benztropine AKA: -Parasympatholytic drugs -Anti-muscarinic drugs -Muscarinic blockers -Anticholinergic drugs** MOA: Blocks actions of ACh at muscarinic receptors --> selective blockade of muscarinic receptors (not all cholinergic receptors) Certain drugs: -Antihistamines, TCAs, and Antipsychotics have anti-muscarinic actions -Use these with caution - or not at all - for patients receiving other muscarinic antagonists

The nurse is teaching a patient who has a new prescription for spironolactone [Aldactone]. Which statement by the patient indicates that the teaching was effective?

"I will call my doctor if I begin having menstrual irregularities." Spironolactone is a potassium-sparing, aldosterone-blocking diuretic. As such, it can cause endocrine effects, such as gynecomastia, menstrual irregularities, impotence, hirsutism, and deepening of the voice. Patients taking spironolactone should avoid salt substitutes because they contain potassium, and high-potassium foods should be avoided with this drug. Ideally, all diuretics should be taken in the morning to prevent nocturia.

Nitrous Oxide

"Laughing gas" Dentists use this a lot NEVER used as a primary anesthetic -Very low anesthetic potency -Very high analgesic potency (frequently combined with other inhalation agents to enhance analgesia) 20% nitrous oxide = pain relief of morphine No serious side effects -Nausea -Vomiting

What is Bipolar Disorder?

"Manic-depressive illness" Mainstays for therapy are lithium and valproic acid, though patients get antipsychotic drug or antidepressant to address certain parts of the disease A cyclic disorder that has recurrent fluctuations in mood -Pure manic episode (euphoric mania) -Hypomanic episode (hypomania) -Major depressive episode (depression) -Mixed episode Episodes of mania and depression persist for months without treatment Treatment -Drugs -Psychotherapy

Muscarinic Agonists

"Parasympathomimetics" Bethanechol Selective agonist at muscarinic cholinergic receptors Binds reversibly to muscarinic cholinergic receptors to cause activation. Heart: Bradycardia Smooth muscle: Lung: constriction of the bronchi Gastrointestinal system: Increased tone and motility Bladder: Contraction of detrusor muscle and relaxation of the trigone and sphincter Exocrine glands: -Increased sweating, salivation, bronchial secretions, and secretion of gastric acid Eye: -Miosis -contraction of ciliary muscle Uses: Urinary retention MOA: Direct acting muscarinic agonist; relaxes trigone and sphincter muscles and increases voiding pressure Adverse effects: -Cardiovascular system: Hypotension, Bradycardia -Gastrointestinal system: Increased tone and motility -Exacerbation of asthma -Dysrhythmias in patients with hyperthyroidism (can increase heart rate in patients who have hyperthyroidism to point of dysrhythmias) Contraindicated: -Patients who already have low blood pressure or low cardiac output -Patients who have asthma Toxicology: Sources: -Certain mushrooms -Direct-acting muscarinic agonists -Cholinesterase Inhibitors (indirect) Symptoms ("Cholinergic Crisis") Results from excessive activation of these receptors. You get stuff coming out of everywhere. -Profuse salivation -Lacrimation (Tearing) -Visual disturbances -Bronchospasm -Diarrhea -Bradcycardia -Hypotension with possible cardiovascular collapse *SLUD* S- Salivation L- Lacrimation U- Urination D- defecation. Treatment: Atropine (blocking agent) -Supportive therapy

A patient is prescribed the dopamine agonist pramipexole. Which statement made by the patient indicates a need for further teaching? A. "The drug should be taken with food to prevent nausea" B. "I may experience hallucinations while taking this drug" C. "I should rise slowly to prevent dizziness and fainting" D. "This drug will stop the progression of parkinson disease."

"This drug will stop the progression of Parkinson disease" NOTHING stops the progression of parkinson disease. We hope to slow it down and minimize symptoms, but nothing will STOP progression.

Identify examples of food-drug interactions

-Can result in toxicity or therapeutic failure -Decreases rate of drug absorption -Decreases extent of absorption Calcium-containing foods & Tetracycline antibiotics Tetracyclines bind with calcium to form insoluble complex -Absorption reduced and antibacterial effects lost Wheat bran, rolled oats, sunflower seeds & Digoxin (Lanoxin); used for cardiac disorders Result in therapeutic failure High-calorie meal doubles absorption of Saquinavir (Invirase); used for HIV Grapefruit juice inhibits metabolism of certain drugs (raises blood levels) MAO Inhibitor & Tyramine-rich food Increase drug toxicity Theophylline and caffeine = you can hit toxic levels.

Secondary prevention of STEMI

-Discharge 72 hours after event -5 to 15% of patients have another infarct in first year (because of lifestyle. hard to change lifestyle) Outcome improved with risk factor reduction: -cholesterol control -smoking cessation -exercise -BP & DM control All post MI patients should take 4 drugs; all 4 should be taken indefinitely. 1. Beta blocker 2. ACE or ARBs 3. Antiplatelet or anticoagulant 4. Statin

Types of Anxiety Disorders

-Generalized anxiety disorder -Panic disorder -Obsessive-compulsive disorder -Social anxiety disorder (social phobia) -post-traumatic stress disorder

What is Peptic Ulcer Disease

-Group of upper GI disorders -Caused by imbalance between protective and aggressive factors -Degrees of erosion of the gut wall -Severe erosion --> hemorrhage and perforation Hydrochloric acid in the stomach. Stress, H. Pylori, different infections can cause erosion in the gut. IN stomach wall, we have all of these ruggaetions in stomach that help with digestion. That is where erosions may occur, and can occur all the way down into upper part of small intestine into duodenum.

Pathophysiology of Heart Failure

-Inadequate tissue perfusion -Volume overload -Chronic hypertension -MI -Valvular heart disease -Congenital heart disease -Dysrhythmias -Aging of the myocardium -Cardiac remodeling (left ventricle enlarges. Frank-starling law; if you stretch a muscle, it will have more snap. Heart muscle is stretching and stretching and can't snap back. Causes heart to slow down.) Physiological adaptations to the reduced cardiac output: -Cardiac dilation -Increased sympathetic tone -Water retention, you get all this blood built up and it increases blood volume, preload. -Release of natriuretic peptides which work in the heart cells

What do we need to know about peripheral nervous system drugs?

-Know the receptors that the drug affects -Know normal responses to activation of those receptors -Know whether drug in question increases or decreases receptor activation

Depot Preparations

-Long-acting, injectable formulations -Used for long-term maintenance therapy of schizophrenia (we don't want them to have relapse of acute episode and function in daily life) Six depot preparations available: 1. Haloperidol decanoate 2. Risperidone microspheres 3. Olanzapine pamoate 4. Aripiprazole 5. Fluphenazine decanoate 6. Paliperidone palmitate

Describe the incidence and characteristics of drug allergies and organ-specific adverse effects

-Many drugs are toxic to specific organs Common examples: Kidneys: Amphotericin B (anti-fungal) Heart: Doxorubicin (anti-cancer) Lungs: Amiodarone (anti-dysrhythmic) Inner ear: Aminoglycoside (antibiotic) Hepatotoxic Drugs (Toxic to the liver) -leading cause of liver failure in US -drugs converted to toxic products that injure liver cells -Monitor for liver injury: Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) QT Interval Drugs (Heart problems) Drugs that prolong the QT interval on ECG. -Creates life-threatening dysrhythmias and heart blocks -At risk: females, older adults, patients with bradycardia, congestive heart failure (CHF), congenital QT prolongation, low potassium, low magnesium

Furosemide LOOP DIURETIC

-Most frequently prescribed loop diuretic MOA: Acts on thick segment of ascending limb of the Loop of Henle to block reabsorption of NaCl. Uses: Reserved for rapid diaresis (excessive production of urine), such as when you patient with: -Pulmonary edema -Edematous states -Hypertension Or if patient hasn't responded to something first line Rapid Onset -PO = 60 min -IV = 5 min (Don't want to give it later in evening or patient will be getting up to go to bathroom all night long) Adverse effects: Can produce loss of sodium in excess, patients become severely dehydrated = blood clots. -Hypokalemia -Hyponatremia, hypochloremia -Hypotension (from loss of volume and relaxation of smooth muscle) -ototoxicity (don't combine with aminoglycosides) -Hyperglycemia -Hyperuricemia (elevation of uric acid, can lead to flares of Gout) Drug interactions: -Avoid digoxin (presence of low potassium, heart failure, cardiac dysrhythmias) -Avoid other Ototoxic drugs (like Gentamicin) -Give with Potassium-sparing diuretics (Spironolactone and Triamterene) to balance potassium wasting effect -Avoid Lithium -Antihypertensive agents (effects are additive) -Aspirin and other NSAIDs can reduce effect of furosemide (reduces blood flow to kidney)

Metabolism Cytochrome P450 System

-Most metabolism happens in the liver and in the Cytochrome P450 system -Group of enzymes that metabolize drugs. -3A4 is like the I-35 of the cytochrome p450, because a billion drugs are metabolized through 3A4. Drugs are either inducers or inhibitors. If you are inhibiting 3A4, what will happen? -- you are blocking 3A4, so there is a back up. You are getting too much drug. You could have toxicity. -Grapefruit juice inhibits 3A4. 12 enzyme families CYP1, CYP2, CYP3 = metabolize drugs Other nine families metabolize endogenous compounds such as steroids and fatty acids.

Vancomycin (Drugs that weaken bacterial cell wall)

-Most widely used antibiotic in hospital setting Bactericidal Inhibits cell wall synthesis Severe infections only such as MRSA, S. epidermis, C. diff Adverse effects: Ototoxicity, "Red man" syndrome (slow the infusion rate), thrombophlebitis (common), thrombocytopenia (rare), allergy

Antimycobacterial Agents: Drugs for Tuberculosis, Leprosy, and Mycobacterium Avium

-Mycobacterium infections mainly in lungs -Slow growing microbes = prolonged treatment Diagnosis is done by chest X RAY, sputum culture -Concerned with toxicity, adherence, resistance -Hospitalization is not usually required if patient is compliant Tuberculosis -Always treat with 2 or more drugs -Treatment is effective if no bacteria present in sputum culture -Multidrug resistant TB (resistant to Isoniazid and Rifampin) -Extensively drug-resistant TB (resistant to isoniazid and rifampin, all fluoroquinolones, and at least one injectable second-line drug) Treatment is guided by prognosis, drug sensitivity -Two phases: 1. Induction phase -Eliminate actively dividing tubercle bacilli 2. Continuation phase -Eliminate intracellular "persisters" 3+ drugs needed over 2 years for active TB -Can be up to 7 different drugs (cycled to prevent resistance) -Latent TB is treated with 1 or 2 drugs Concerns: -HIV infection (can complicate each other's treatment) -Adherence (DOT, Directly observed therapy, intermittent dosing instead of daily dosing, evaluation of treatment throughout) First line drugs Isoniazid and rifampin Rifapentine, rifabutin, pyrazinamide, ethambutol Second-line drugs Levofloxacin, moxifloxacin, kanamycin, amikacin, capreomycin, steptomycin, para-aminosalicylic acid, ethionamide, cycloserine

Buspirone

-NOT CNS depressant -NO abuse potential -Does not intensify the effects of CNS depressants -Anxiolytic effects develop slowly Adverse effects -Dizziness -Nausea -Headache -Nervousness -Sedation -Lightheadedness -Excitement Drug and food interactions --> increase adverse effects -Erythromycin -Ketoconazole -Grapefruit juice Tolerance, dependence, and abuse -No withdrawal symptoms have been observed

Clopidogrel [Antiplatelet drug] [P2Y12 Adenosine Diphosphate (ADP) Receptor Antagonists]

-Oral antiplatelet -Similar to aspirin -Blocks P2Y12 ADP receptors on platelet -Prodrug, so we need to metabolize it to become active (in the CYP450) -Genetic test before start therapy with clopidogrel so they aren't a poor metabolizer Uses: -Prevents blockage/stenosis of coronary artery stents -Reduces thrombotic events in patients with ACS -Secondary prevention of MI and other vascular events MOA: -P2Y12 ADP receptor antagonist Adverse effects: Similar to those of aspirin Black box warning!: Diminished efficacy in poor metabolizers Drug-interactions: -Caution in combination with other drugs that promote bleeding

Overview of Vitamins

-Organic compounds -Required in minute amounts for growth and maintenance of health -Are NOT a source of energy -Essential for energy transformation and regulation of metabolic processes Classification Fat soluble Vitamins A,D,E,K Water soluble -Vitamin C Vitamin B complex: -Thiamin (B1) -Riboflavin (B2) -Niacin (B3) -Pantothenic acid (B5) -Pyridoxine (B6) -Biotin (B7) -Folic acid (B9) -Cyanocobalamin (B12)

Pancreatic Enzymes

-Pancreas produces 3 types of digestive enzymes: Lipases (fat), Amylases (carbs), proteases (protein) When pancreas isn't working right, you need replacement for those enzymes. Pancrelipase: mixture of 3 pancreatic enzymes from hog pancreas. Adverse effects: -Abdominal discomfort, flatulence, headache, cough Formulated for delayed release to dissolve in duodenum and jejunum -Capsules should not be crushed chewed or retained in mouth (due to risk of irritating oral mucosa) ** swallow whole **

Cephalosporins (Weaken Bacterial Cell wall) (Beta-lactam family)

-Similar to penicillin -Bactericidal -Most widely used group of antibiotics -Beta-lactam antibiotics Cephalexin, cefoxitin, ceftriaxone, cefepime, ceftaroline (goes from first generation to fifth generation). As it goes down generations, it is more active against gram negative. The first generation is more likely to cross BBB. MOA: Bind to penicillin-binding proteins (PBPs), disrupt cell wall synthesis, cause cell lysis -Most effective against cells undergoing active growth and division Interactions: Probenecid, ETOH (alcohol) *Disulfiram-interactions, drugs that promote bleeding like anticoagulants or antiplatelets (should not be used with ibuprofen) AE: allergy, bleeding, thrombophlebitis, Hypersensitivity is most common Therapeutic uses: -Used for prophylaxis against infection in surgical patients -Rarely used for active infection -gram-negative -able to penetrate CSF (cerebrospinal fluid) -Treat health care and hospital-associated pneumonias including those caused by seudomonas -MRSA (5th generation only active one against it)

Patho of Pain

-Unpleasant sensory and emotional experience associated with actual or potential tissue damage -Patient report and description is most reliable method of assessing pain, ex: Rating scale: 0-10, PQRST Nociceptive pain Results from injury to tissues 2 forms: 1. Somatic pain = body (skin, tissue, muscle) 2. Visceral pain = organs (thoracic, pelvic, abdominal) Neuropathic pain Results from injury to peripheral nerves Responds poorly to opioids

Discuss pharmacokinetic variable in pediatric patients

-increased sensitivity in infants -Immature state of 5 pharmacokinetic processes (absorption, protein binding of drugs, blood-brain barrier, hepatic metabolism, renal drug excretion)

What are the basic functions of kidneys

1. Clean out extracellular fluid, maintain volume and composition for that ECF. 2. Maintain acid abase balance 3. Get rid of waste and foreign substances such as drugs and toxins.

3 Ways Antiulcer Drugs work

1. Eradicate infection (H. Pylori) with antibiotics 2. Reduce gastric acidity with antisecretory agents, misoprostol 3. Enhance mucosal defenses like covering over the ulcer and letting it heal (sucralfate, misoprostol)

Fungal Otitis Externa (Otomycosis)

10% of OE caused by fungi, not bacteria 2 most common pathogens: 1. Aspergillus 2. Candida S/S -Pruritus and erythema Management: -Thorough cleansing and acidifying drops (2% acetic acid solution) --If that is not effective, then try 1% Clotrimazole. If THAT fails, then try oral antifungal therapy (itraconazole or fluconazole)

Vitamin D (Fat soluble)

2 Compounds: Vitamin D2 (ergocalciferol) Vitamin D3 (cholecalcifeorl) Uses: -Nutritional rickets -Osteomalacia -Hyoparathyroidism (RDA = 600 IUs/day, males and females) Actions: Regulates calcium and phosphorus Sources: -Sunlight -Shiitake mushrooms -Oily fish (salmon, tuna) -Fortified foods (cereals, milk, yogurt, margarine, cheese, OJ) Toxicity: Signs/symptoms: occur secondary to hypercalcemia Early: weakness, fatigue, N/V, anorexia, abdominal cramping, constipation Later: renal symptoms (polyuria, nocturia, protieinuria, nephrolithiasis), neurologic symptoms (seizures, confusion, ataxia), cardiac dysrhythmia, and coma Deficiency:

Thyroid hormones

2 active hormones: 1. Triiodothyronine (T3) 2. Thyroxine (T4) -Synthesis is stimulated by low plasma levels of iodine (via HPT axis) Profound effect on: -metabolism -cardiac function -Growth --promotes maturation in infancy and childhood -Cognitive development 3 principal actions: 1. Stimulate energy use -Elevates basal metabolic rate --> increased oxygen consumption and heat production 2. Stimulate the heart -Increases HR and force of contraction --> increased CO and oxygen demand 3. Promote growth and development -Essential for normal development of the brain and nervous system Exert their effects by modulating activity of specific genes HPT Axis -Hypothalamus thought to be brain, stimulates pituitary to produce TRH to produce TSH and then stimulates thyroid T4, T4 improves metabolism

Receptors of the PNS

2 basic categories of receptors: 1. Cholinergic (Rest and digest) Mediated by acetylcholine Subtypes: -NicotinicN (N think "neuron") -NicotinicM (M think "muscle") -Muscarinic (M1, M2, M3) 2. Adrenergic (Fight or flight) Mediated by NE and Epi (Adrenaline) Subtypes: -Alpha 1 -Alpha 2 -Beta 1 -Beta 2 -Dopamine - Respond ONLY to dopamine in CNS

Types of Hypertension

2 broad categories: Primary (essential) hypertension: -No identifiable cause -Family history -Chronic progressive disorder -Population: older adults, african americans, postmenopausal women -Treated, but not cured. Secondary hypertension: -Identifiable primary cause -Possible to treat cause directly -Some individuals may be cured

Overview of drugs for Asthma and COPD

2 main classes: 1. anti-inflammatory agents (Glucocorticoids such as prednisone) 2. Bronchodilators (Beta 2 agonists like albuterol)

Describe the physiological changes during pregnancy that may affect the absorption, distribution, metabolism, and excretion of drugs

2/3 of pregnant patients take at least one medication, most take more. -Pregnancy-related problems such as nausea -Chronic disorders such as hypertension, diabetes -For infectious diseases or cancer -Drugs of abuse such as alcohol Third trimester: Renal blood flow is doubled and renal excretion is accelerated -Tone and mobility of bowel decrease (prolongation of drug effects) So they have to pee, but the bowels put on the breaks.

Fibric Aid Derivatives (Fibrates)

3 drugs in US: -Gemfibrozil -Fenofibrate -Fenofibric acid Most effective drugs available for triglyceride levels -Can increase HDL cholesterol -Little or no effect on LDL cholesterol Drug interactions: +Warfarin --> increase risk for bleeding +Statin --> increase risk for rhabdomyolysis

Sympathetic Nervous System (SNS)

3 main functions: 1. Regulation of cardiovascular system -Maintain blood flow to the brain -Redistributing blood -Compensating for loss of blood 2. Regulation of body temperature -Regulates blood flow to the skin -Promotes the secretion of sweat -Induces piloerection 3. Implementation of the "fight-or-flight" reaction -Increasing heart rate and blood pressure -Shunting blood away from skin and viscera -Dilating bronchi --> increased oxygenation -Dilating pupils -Mobilizing stored energy (glucose & fatty acids)

Overview of Drugs for Thromboembolic Disorders

3 major groups Anticoagulants -Disrupt coagulation cascade --> suppress fibrin production. Antiplatelets -Inhibit platelet aggregation. Inhibit platelets from sticking together Thrombolytic Drugs -There is a thrombis, there is a clot, you're going to dissolve the clot by promoting the lysis of fibrin

Prostaglandin Analogs

4 approved glaucoma agents MOA: Relaxes ciliary muscle to facilitate aqueous humor outflow. Latanoprost -Once daily application provides same IOP reduction as timolol BID -Generally well tolerated; rarely systemic Adverse effects: Most significant: heightened brown pigmentation of iris; stops progressing when DCd; it's irreversible. -Increased pigmentation of eyelid, and increased length, thickness, and pigmentation of eyelashes -Others: blurred vision, burning, stinging, conjunctival hyperemia

Anticholinergic drugs for OAB (urge incontinence, Overactive Bladder)

4 major symptoms: -Urinary urgency -Urinary frequency -Nocturia -Urge incontinence (often results from involuntary contractions of the bladder detrusor) Can develop at any age but is most predominant among older adults 2 modes of treatment: -Behavioral therapy (should be tried first like scheduled voiding, timing fluid intake, kegel exercises) -Drug therapy with anticholinergic agents MOA: Block muscarinic receptors on the bladder detrusor --> inhibits bladder contractions and urge to void -Each agent with variable selectivity Specific anticholinergic drugs for OAB: -Oxybutynin -Darifenacin -Solifenacin -Tolterodine

Hepatitis (Antiviral)

A,B,C,D,E,G = acute hepatitis B,C,D = Chronic hepatitis Use for Hep C: Interferon Alfa AE: Malaise, neuropsychiatric effects (depression), fatigue, thyroid dysfunction, heart damage, bone marrow suppression, neutropenia, thrombocytopenia Ribavirin AE: Malaise, severe depression, birth defects (category X), hemolytic anemia Boceprevir, telaprevir Protease inhibitors AE: Fatigue, N, altered taste Extensive drug interactions: CYP3A4 Use for Hep B: Interferon alfa Nucleoside analogs -Lamivudine, adefovir, entecavir, telbivudine, tenofovir

The nurse is conducting discharge teaching related to a new prescription for phenytoin [Dilantin]. Which statements are appropriate to include in the teaching for this patient and family? (Select all that apply.) A. "Be sure to call the clinic if you or your family notice increased anxiety or agitation." B. "You may have some mild sedation. Do not drive until you know how this drug will affect you." C. "This drug may cause easy bruising. If you notice this, call the clinic immediately." D. "It is very important to have good oral hygiene and to visit your dentist regularly." E. "You may continue to have wine with your evening meals, but only in moderation."

A. "Be sure to call the clinic if you or your family notice increased anxiety or agitation." B. "You may have some mild sedation. Do not drive until you know how this drug will affect you." D. "It is very important to have good oral hygiene and to visit your dentist regularly." Patients taking an antiepileptic drug are at increased risk for suicidal thoughts and behavior beginning early in their treatment. The U.S. Food and Drug Administration (FDA) advises that patients, families, and caregivers be informed of the signs that may precede suicidal behavior and be encouraged to report these immediately. Mild sedation can occur in patients taking phenytoin, even at therapeutic levels. Carbamazepine, not phenytoin, increases the risk for hematologic effects, such as easy bruising. Phenytoin causes gingival hyperplasia in about 20% of patients who take it; dental hygiene is important. Patients receiving phenytoin should avoid alcohol and other central nervous system depressants, because they have an additive depressant effect.

Which instruction should the nurse provide when teaching a patient to mix regular insulin and NPH insulin in the same syringe? A. "Draw up the clear regular insulin first, followed by the cloudy NPH insulin." B. "It is not necessary to rotate the NPH insulin vial when it is mixed with regular insulin." C. "The order of drawing up insulin does not matter as long as the insulin is refrigerated." D. "Rotate subcutaneous injection sites each day among the arm, thigh, and abdomen."

A. "Draw up the clear regular insulin first, followed by the cloudy NPH insulin." To ensure a consistent response, only NPH insulin is appropriate for mixing with a short-acting insulin. Unopened vials of insulin should be refrigerated; current vials can be kept at room temperature for up to 1 month. Drawing up the regular insulin into the syringe first prevents accidental mixture of NPH insulin into the vial of regular insulin, which could alter the pharmacokinetics of subsequent doses taken out of the regular insulin vial. NPH insulin is a cloudy solution, and it should always be rotated gently to disperse the particles evenly before loading the syringe. Subcutaneous injections should be made using one region of the body (eg, the abdomen or thigh) and rotated within that region for 1 month.

The nurse is completing a preoperative database on a client scheduled for back surgery the next day. Which question is most important to ask to possibly prevent an adverse patient outcome? A. "Have you or any family members ever suffered a reaction to anesthesia?" B. "Did you remember that you can take your blood pressure pill the morning of surgery?" C. "How long have you been suffering from back pain?" D. "When did you last eat?"

A. "Have you or any family members ever suffered a reaction to anesthesia?" Malignant hyperthermia is a rare but potentially fatal reaction that can be triggered by all inhalation anesthetics except nitrous oxide. Predisposition to the reaction is genetic. Malignant hyperthermia can prove fatal and therefore is the highest priority, among the options listed, in a preoperative assessment.

The nurse is teaching a patient about a new prescription for mitoxantrone [Novantrone]. Which statement made by the patient indicates a need for further teaching? A. "I volunteer at a local day care center once a week." B. "I drink grapefruit juice with breakfast each morning." C. "I enjoy walking and outdoor activities in the sun." D. "I understand this drug may cause my urine to turn blue."

A. "I volunteer at a local day care center once a week." Mitoxantrone can cause myelosuppression. Patients taking this drug should be advised to avoid contact with people who have infections, such as children in day care centers. The other statements are appropriate for patients taking this drug.

A patient has been given instructions about levothyroxine [Synthroid]. Which statement by the patient indicates understanding of these instructions? A. "I'll take this medication in the morning so as not to interfere with sleep." B. "I'll plan to double my dose if I gain more than 1 pound per day." C. "It is best to take the medication with food so I don't have any nausea." D. "I'll be glad when I don't have to take this medication in a few months."

A. "I'll take this medication in the morning so as not to interfere with sleep." Levothyroxine is used to treat hypothyroidism by increasing the basal metabolism and thus wakefulness. It is administered as a once-daily dose and is a lifelong therapy. It is best taken on an empty stomach to enhance absorption.

A teaching plan for a patient who is taking lispro [Humalog] should include which instruction by the nurse? A. "Inject this insulin with your first bite of food, because it is very fast acting." B. "The duration of action for this insulin is about 8 to 10 hours, so you'll need a snack." C. "This insulin needs to be mixed with regular insulin to enhance the effects." D. "To achieve tight glycemic control, this is the only type of insulin you'll need."

A. "Inject this insulin with your first bite of food, because it is very fast acting." Lispro is a rapid-acting insulin and has an onset of action of 15 to 30 minutes with a peak action of about 2 hours, not 8 to 10 hours. Because of its rapid onset, it is administered immediately before a meal or with meals to control the blood glucose rise after meals. Lispro insulin must be combined with an intermediate- or a long-acting insulin, not regular insulin (which also is a short-duration insulin), for glucose control between meals and at night. To achieve tight glycemic control, patients must combine different types of insulin based on their duration of action.

When teaching the patient and family about clozapine therapy, which statements should the nurse include? (Select all that apply.) A. "It is important for you to obtain ordered blood tests when taking this medication." B. "Most patients who take this medication lose weight, so you should increase the number of calories you consume each day." C. "If you experience increased urination, increased thirst, or increased appetite, contact your healthcare provider." D. "Inform your healthcare provider if you are taking any medications to control seizures." E. "Contact your healthcare provider if you experience any unexplained tiredness, shortness of breath, increased respirations, chest pain, or heart palpitations."

A. "It is important for you to obtain ordered blood tests when taking this medication." C. "If you experience increased urination, increased thirst, or increased appetite, contact your healthcare provider." D. "Inform your healthcare provider if you are taking any medications to control seizures." E. "Contact your healthcare provider if you experience any unexplained tiredness, shortness of breath, increased respirations, chest pain, or heart palpitations." Clozapine can cause agranulocytosis. Patients should be taught that clozapine will not be dispensed without repeated proof of blood counts. Patients taking clozapine are at increased risk of weight gain and dyslipidemia; they should be taught about the risk of weight gain and encouraged to control caloric intake and get regular exercise. Patients should be informed about early signs of infection (fever, sore throat, fatigue, mucous membrane ulceration) and instructed to notify their healthcare provider immediately if these should develop. Patients taking clozapine are at increased risk for the development of diabetes mellitus; they should be taught about the symptoms of diabetes (eg, hyperglycemia, polyuria, polydipsia, polyphagia, dehydration) and instructed to contact the prescriber if these occur. Clozapine should be used with caution in patients with seizure disorders. In rare cases, clozapine causes myocarditis; patients should be informed about the signs and symptoms (eg, unexplained fatigue, dyspnea, tachypnea, chest pain, palpitations) and advised to seek immediate medical attention if these develop. Clozapine should be withheld until myocarditis has been ruled out. If myocarditis is diagnosed, the drug should never be used again.

A patient with chronic pain has a fentanyl patch applied to his right shoulder. The patient reports that his arm hurts and he requests a warm pack to apply to the area. Which statement by the nurse is correct? A. "Putting a warm pack on the area where the fentanyl patch is located could accelerate fentanyl release." B. "Your arm probably hurts because of the fentanyl patch." C. "I can remove your patch and reapply it after you are done with the warm pack." D. "The fentanyl patch is heat resistant, so I will get you a warm pack."

A. "Putting a warm pack on the area where the fentanyl patch is located could accelerate fentanyl release." Warn patients using fentanyl patches to avoid exposing the patch to direct heat (eg, heating pad, hot tub) because doing so can accelerate fentanyl release. Patches should not be removed and reapplied; use a new patch as ordered if one is removed. Patches should not cause pain, and they are not heat resistant.

A patient has elected to use rasagiline as a monotherapy treatment for PD. Which teaching statement by the nurse is incorrect? A. "Rasagiline may cause insomnia, so monitor your sleeping habits." B. "It is important to avoid tyramine-containing foods." C. "You may be at increased risk for malignant melanoma, so have regular skin checks." D. "You may experience side effects, such as headache, arthralgia, dyspepsia, depression, and flu-like symptoms."

A. "Rasagiline may cause insomnia, so monitor your sleeping habits" Unlike selegiline, rasagiline does not cause insomnia. Rasagiline may pose a risk of hypertensive crisis and hence patients should be instructed to avoid tyramine-containing foods. Rasagiline may increase the risk of malignant melanoma, a potentially deadly cancer of the skin. Periodic monitoring of the skin is recommended. Side effects are headache, arthralgia, dyspepsia, depression, and flu-like symptoms.

A patient is receiving desmopressin [DDAVP] for the treatment of diabetes insipidus. Which instruction is the priority for a nurse to give the patient? A. "Reduce your water intake to prevent water intoxication." B. "Rotate the nostril you use daily to prevent irritation." C. "Weigh yourself several times each week." D. "You'll quickly see the results of a lower urine amount."

A. "Reduce your water intake to prevent water intoxication." Failure to reduce the fluid intake while using desmopressin results in water intoxication, leading to seizures and coma. DDAVP is administered intranasally; therefore, rotating the nostril used is important to prevent irritation. Monitoring weekly weights for volume status and understanding that a rapid treatment response occurs also are important. However, they are not as important as reducing the fluid intake to prevent water intoxication.

Which instruction would be inappropriate to include in the teaching plan for a patient being started on carbamazepine [Tegretol]? A. "Take the medication with a glass of grapefruit juice each morning." B. "Notify the physician if you are gaining weight or your legs are swollen." C. "Nausea, vomiting, and indigestion are common side effects of carbamazepine." D. "Have liver function tests performed on a routine basis."

A. "Take the medication with a glass of grapefruit juice each morning." Grapefruit juice can inhibit the metabolism of carbamazepine, possibly leading to increased plasma drug levels; therefore, it should be avoided. Carbamazepine can inhibit renal excretion of water by promoting increased secretion of antidiuretic hormone. Weight gain and swollen extremities can be a sign of water retention and should be reported to the physician. Nausea, vomiting, and indigestion are common adverse effects of valproic acid, and the patient should be made aware of them. Liver function studies are monitored for patients taking valproic acid because of the risk of liver toxicity.

A patient asks the nurse about treatments for post-traumatic stress disorder (PTSD). Which statement by the nurse is the most helpful? A. "The primary treatment is therapy, but there are some medications that have been somewhat effective." B. "The primary treatment is monotherapy with an SSRI." C. "The primary treatment is a combination of multiple medications." D. "The primary treatment is benzodiazepine for anxiety."

A. "The primary treatment is therapy, but there are some medications that have been somewhat effective." Post-traumatic stress disorder can be treated with psychotherapy and with drugs. There are multiple therapy types and strategies. Regarding drugs, evidence of efficacy is strongest for three SSRIs (fluoxetine, paroxetine, and sertraline) and one SNRI (venlafaxine). Of these four drugs, only two—paroxetine [Paxil] and sertraline [Zoloft]—are FDA-approved for PTSD. If none of the first-line drugs are effective, the guidelines suggest several alternatives: mirtazapine, a TCA (amitriptyline or imipramine), or an MAOI (phenelzine). Current evidence does not support the use of monotherapy with either bupropion, buspirone, trazodone, or a benzodiazepine.

The nurse is teaching a patient who has a new prescription for citalopram [Celexa]. Which statements are appropriate to include in the teaching plan? (Select all that apply.) A. "This medication may cause some sexual side effects. Let your healthcare provider know about this if it occurs." B. "When you stop taking this medication, you should not withdraw it abruptly." C. "You will need to move slowly from a sitting to a standing position to prevent dizziness from low blood pressure." D. "This medication often causes drowsiness. You should take it at bedtime." E. "Let your family or your healthcare provider know if you experience a worsening mood, agitation, or increased anxiety."

A. "This medication may cause some sexual side effects. Let your healthcare provider know about this if it occurs." B. "When you stop taking this medication, you should not withdraw it abruptly." E. "Let your family or your healthcare provider know if you experience a worsening mood, agitation, or increased anxiety." Citalopram [Celexa] and other SSRIs can cause sexual side effects that patients may be hesitant to report. SSRIs should be withdrawn slowly to prevent dizziness, headache, dysphoria, and/or other symptoms of withdrawal. The SSRIs do not generally cause orthostatic hypotension or drowsiness. All antidepressants initially increase the risk of suicide, and patients should be monitored for worsening mood and other signs of suicide risk.

The nurse is teaching a patient with a new prescription for alprazolam [Xanax]. Which statement is the most appropriate to include in the teaching plan? A. "When it is time to discontinue this drug, you will need to taper it off slowly." B. "Protect your skin from the sun to prevent rash and exaggerated sunburn." C. "Increase your intake of fluid and high-fiber food to prevent constipation." D. "Take this medication on an empty stomach at least 2 hours after meals."

A. "When it is time to discontinue this drug, you will need to taper it off slowly." Alprazolam [Xanax] is a benzodiazepine for which abrupt discontinuation can precipitate withdrawal symptoms. Patients should withdraw the drug gradually over several weeks. The other statements are not related to alprazolam [Xanax].

The nurse is caring for a patient with insomnia. The patient asks if there are medications for sleep that are not controlled substances. Which statement by the nurse is correct? A. "Yes, there is a medication that works with your body's melatonin and is not a controlled substance." B. "No, all of the sleep medications are controlled substances." C. "There are some over-the-counter medications, and you can take those without discussing them with your healthcare provider." D. "Yes, but it is not for chronic insomnia."

A. "Yes, there is a medication that works with your body's melatonin and is not a controlled substance." Ramelteon [Rozerem] is a relatively new hypnotic with a unique mechanism of action: activation of receptors for melatonin. The drug is approved for treating chronic insomnia characterized by difficulty with sleep onset, but not with sleep maintenance. Long-term use is permitted. Of the major drugs for insomnia, ramelteon is the only one not regulated as a controlled substance.

Which statement is the most important for a nurse to make to a patient who is taking methimazole? A. "You need to notify your doctor if you have a sore throat and fever." B. "Another medication can be given if you experience any nausea." C. "You may experience some muscle soreness with this medicine." D. "Headache and dizziness may occur but not very frequently."

A. "You need to notify your doctor if you have a sore throat and fever." Agranulocytosis (the absence of granulocytes to fight infection) is the most serious toxicity associated with methimazole. Sore throat and fever may be the earliest signs. Nausea, muscle soreness, and headache and dizziness are other adverse effects of methimazole that are not as serious as agranulocytosis.

The nurse is teaching a patient with a new prescription for ergotamine [Ergomar]. Which statement is most appropriate to include in the teaching plan? A. "You should not use this drug more than 1 or 2 days per week." B. "You should rise slowly from a sitting to a standing position." C. "Be sure to include bananas and melons in your diet to increase potassium." D. "You will need to return to the clinic for blood work monthly."

A. "You should not use this drug more than 1 or 2 days per week." Regular daily use of ergotamine is likely to cause physical dependence. Patients should limit its use to one or two times weekly. Withdrawal symptoms include headache, nausea, vomiting, and restlessness, which are similar to the migraine syndrome. This can lead to a cycle of dependence and overdose. Symptoms of overdose include cold, pale, numb extremities; muscle pain; and eventual gangrene. The other statements are not related to this drug.

Which patient may be given progestin therapy during pregnancy? A. A woman who is 8 weeks pregnant and diagnosed with corpus luteum deficiency syndrome B. A woman pregnant with triplets during her first pregnancy C. A woman experiencing severe nausea and vomiting during pregnancy D. A woman who is trying to achieve pregnancy through planned intercourse

A. A woman who is 8 weeks pregnant and diagnosed with corpus luteum deficiency syndrome Progestins are used to support an early pregnancy in women with corpus luteum deficiency syndrome and in women undergoing in vitro fertilization (IVF). Progestin therapy is also used for prematurity prevention. One progestin—hydroxyprogesterone acetate [Makena]—is approved for preventing preterm birth in women with a singleton pregnancy and a history of preterm delivery. It is not used for nausea or for pregnancy achievement through planned intercourse.

The nurse knows that which statements about postpartum depression are true? (Select all that apply.) A. About 80% of women experience depressive symptoms after giving birth. B. Thyroid insufficiency has been indicated as a contributing factor in postpartum depression. C. Monoamine oxidase inhibitors are the first-line agents of choice for the treatment of postpartum depression. D. Once a woman has had postpartum depression, it will not recur with future deliveries. E. Sertraline [Zoloft] is the drug of choice for treating postpartum depression in breast-feeding mothers.

A. About 80% of women experience depressive symptoms after giving birth. B. Thyroid insufficiency has been indicated as a contributing factor in postpartum depression. E. Sertraline [Zoloft] is the drug of choice for treating postpartum depression in breast-feeding mothers. The drug of choice for postpartum depression is an SSRI, such as sertraline [Zoloft], because these drugs are effective, well tolerated, and present little risk of toxicity if taken in overdose. If a woman has responded to another antidepressant in the past, that drug should be used first. The risk of relapse is high, as is the risk of postpartum depression with subsequent pregnancies. The statements in options C and D are false.

A patient with which condition would most likely be prescribed a glucocorticoid in low doses for replacement therapy? A. Addison's disease B. Rheumatoid arthritis C. Systemic lupus erthematosus D. Cushing's syndrome

A. Addison's disease

A nurse teaches a patient who takes an MAOI about important dietary restrictions. Which foods will the nurse caution the patient to avoid? A. Aged cheese and sherry B. Grapefruit and other citrus juices C. Coffee, colas, and tea D. Potato and corn chips

A. Aged cheese and sherry Foods that contain tyramine can produce a hypertensive crisis in individuals taking MAOI antidepressants. Many aged foods contain tyramines.

Lithium is used in the treatment of bipolar disorder and what other psychiatric disorders? (Select all that apply.) A. Alcoholism B. Bulimia C. Schizophrenia D. Hypertension E. Glucocorticoid-induced psychosis

A. Alcoholism B. Bulimia C. Schizophrenia E. Glucocorticoid-induced psychosis Although approved only for treatment of BPD, lithium has been used with varying degrees of success in other psychiatric disorders, including alcoholism, bulimia, schizophrenia, and glucocorticoid-induced psychosis. Nonpsychiatric uses include hyperthyroidism, cluster headache, and migraine. In addition, lithium can raise neutrophil counts in children with chronic neutropenia and in patients receiving anticancer drugs or zidovudine (AZT).

A patient is scheduled to start taking sildenafil [Viagra]. A nurse should recognize that the patient is at risk for developing an adverse cardiac event if the patient's history reveals which of these conditions? A. Angina B. Hypertension C. Varicose veins D. Prosthetic mitral valve

A. Angina Sildenafil is used in the treatment of erectile dysfunction. It should be used with caution by men with coronary heart disease (CHD), which may be manifested by angina. Research has suggested that in men with CHD, sexual activity, not sildenafil, is the likely cause of adverse cardiac events. Sildenafil is not contraindicated in patients with hypertension, varicose veins, or a prosthetic mitral valve.

A nurse is developing a plan of care for a patient who has Addison's disease and is taking hydrocortisone [Cortef]. Which of these outcomes should receive priority in the plan? A. At times of stress, the patient increases the glucocorticoid dose. B. The patient wears a Medic Alert bracelet at all times. C. The patient carries an injectable form and an oral form of glucocorticoid. D. The patient divides the daily dose, taking two-thirds of it in the morning and one-third in the afternoon.

A. At times of stress, the patient increases the glucocorticoid dose. Patients with adrenal insufficiency require lifelong replacement doses of glucocorticoids. Failure to increase the dosage at times of stress and illness can be life-threatening. Wearing a Medic Alert bracelet, carrying injectable and oral forms of glucocorticoid, and dividing the daily glucocorticoid dose are important for a patient taking hydrocortisone, but they are not priorities over understanding the need to increase the dose during stress.

When comparing benzodiazepines to barbiturates, the nurse identifies which statements about benzodiazepines as true? (Select all that apply.) A. Benzodiazepines have a high safety profile. B. Benzodiazepines have a significant ability to depress central nervous system (CNS) function. C. Benzodiazepines are associated with a high suicide potential. D. Benzodiazepines have a low ability to cause tolerance. E. Benzodiazepines have a low abuse potential.

A. Benzodiazepines have a high safety profile. D. Benzodiazepines have a low ability to cause tolerance. E. Benzodiazepines have a low abuse potential. Statements A, D, and E are true. Compared to barbiturates, benzodiazepines have a low suicide potential and low ability to cause CNS depression.

A patient is scheduled to start taking insulin glargine [Lantus]. On the care plan, a nurse should include which of these outcomes related to the therapeutic effects of the medication? A. Blood glucose control for 24 hours B. Mealtime coverage of blood glucose C. Less frequent blood glucose monitoring D. Peak effect achieved in 2 to 4 hours

A. Blood glucose control for 24 hours Insulin glargine is administered as a once-daily subcutaneous injection for patients with type 1 diabetes. It is used for basal insulin coverage, not mealtime coverage. It has a prolonged duration, up to 24 hours, with no peaks. Blood glucose monitoring is still an essential component to achieve tight glycemic control.

A nurse assesses a patient who has bacterial acute otitis media (AOM). The nurse should recognize which manifestation if identified in the patient? A. Bulging tympanic membrane with otorrhea and otalgia B. Excessive inner ear moisture and loss of protective cerumen C. Rapid onset of ear pain with pruritus and hearing loss D. Pronounced tenderness of the auricle on manipulation

A. Bulging tympanic membrane with otorrhea and otalgia Bacterial AOM is characterized by the acute onset of symptoms that include otalgia (ear pain) and inflammation. An inner ear that is filled with purulent fluid causes the tympanic membrane to bulge outward. If the membrane is perforated, otorrhea can result. Excessive inner ear moisture and the loss of protective cerumen are not effects associated with AOM. Rapid-onset of ear pain with pruritus and hearing loss and pronounced tenderness of the auricle on manipulation are associated with acute otitis externa.

A patient with multiple sclerosis (MS) is participating in a rehabilitation program. The patient has just been started on baclofen [Lioresal] 5 mg 3 times a day to help manage spasticity. How will the baclofen interfere with rehabilitation activities? A. By producing drowsiness, lethargy, and blurred vision B. By causing gastrointestinal distress C. By reducing sensation in the extremities D. By impairing coordinated movements

A. By producing drowsiness, lethargy, and blurred vision Drowsiness, lethargy, and blurred vision are adverse effects of baclofen that initially make it difficult for the patient to participate actively in rehabilitation activities. These adverse effects are most common during the early phase of therapy but subside with continued use. These effects can be reduced by starting with a small dose and gradually increasing it.

Which of the following statements about cocaine is true? A. Cocaine causes intense vasoconstriction. B. Cocaine has no medicinal applications. C. Cocaine is a poor local anesthetic. D. Cocaine has no CNS effects.

A. Cocaine causes intense vasoconstriction. Cocaine causes intense vasoconstriction. Cocaine is an excellent local anesthetic. Administered topically, the drug is employed for anesthesia of the ear, nose, and throat. Cocaine produces generalized CNS stimulation.

The nurse receives a laboratory report indicating that the phenytoin [Dilantin] level for the patient seen in the clinic yesterday is 16 mcg/mL. Which intervention is most appropriate? A. Continue as planned, because the level is within normal limits. B. Tell the patient to hold today's dose and return to the clinic. C. Consult the prescriber to recommend an increased dose. D. Have the patient call 911 and meet him/her in the emergency department.

A. Continue as planned, because the level is within normal limits. The therapeutic range for phenytoin is 10 to 20 mcg/mL. Because this level is within normal limits, the nurse would continue with the routine plan of care.

Before administering metformin [Glucophage], the nurse should notify the prescriber about which laboratory value? A. Creatinine (Cr) level of 2.1 mg/dL B. Hemoglobin (Hgb) level of 9.5 gm/dL C. Sodium (Na) level of 131 mEq/dL D. Platelet count of 120,000/mm3

A. Creatinine (Cr) level of 2.1 mg/dL Metformin can reach toxic levels in individuals with renal impairment, which is indicated by a rise in the serum creatinine level. The prescriber may have to be notified of the hemoglobin, sodium, and platelet values, but they would not affect the administration of metformin.

The selective serotonin reuptake inhibitors (SSRIs) are recommended therapy for a number of psychologic disorders. The nurse identifies the SSRIs as effective for the treatment of patients with which psychologic disorders? (Select all that apply.) A. Depression B. Panic disorder C. Social anxiety disorder D. Post-traumatic stress disorder E. Obsessive-compulsive disorder

A. Depression B. Panic disorder C. Social anxiety disorder E. Obsessive-compulsive disorder Neither the SSRIs nor any other drugs, for that matter, have proved effective in the treatment of post-traumatic stress disorder. SSRIs are used to treat the other psychologic disorders listed.

A nurse prepares a patient for an intraocular examination by administering a topical anticholinergic agent intended to achieve which outcome? A. Dilation of the pupil B. Constriction of the iris C. Relaxation of the ciliary muscle D. Drainage of aqueous humor

A. Dilation of the pupil Anticholinergic medications produce mydriasis and cycloplegia, dilation of the pupil, and paralysis of the ciliary muscle. These actions facilitate diagnosis of and surgery for ophthalmic problems. Dilation of the pupil, constriction of the iris, and drainage of aqueous humor are not therapeutic effects of anticholinergic agents.

The nurse on an orthopedic unit routinely cares for patients receiving carisoprodol [Soma]. For which adverse effects should the nurse monitor these patients? (Select all that apply.) A. Drowsiness and sedation B. Decreased renal function C. Risk of dependence D. Decreased neutrophil count E. Unusual hair growth

A. Drowsiness and sedation C. Risk of dependence Carisoprodol is a centrally acting skeletal muscle relaxant and as such can produce generalized central nervous system (CNS) depression. These agents may also cause physical dependence when taken long term or in high doses.

Progestins may be used to treat which conditions? (Select all that apply.) A. Endometrial hyperplasia B. Dysfunctional uterine bleeding C. Endometriosis D. Breast cancer E. Amenorrhea

A. Endometrial hyperplasia B. Dysfunctional uterine bleeding C. Endometriosis E. Amenorrhea Progestins are used for contraception (see Chapter 62) and to counteract endometrial hyperplasia that could be caused by unopposed estrogen during HT. Other uses include dysfunctional uterine bleeding, amenorrhea, endometriosis, and support of pregnancy in women with corpus luteum deficiency. Progestins are contraindicated in carcinoma of the breast.

A family member of a patient who is experiencing a severe manic episode asks the nurse why the patient is receiving an antipsychotic medication. The nurse informs the family member that antipsychotics are used in the treatment of severe manic episodes to do what? A. Help control symptoms during the severe manic episode. B. Elevate mood during the severe manic episode. C. Produce sedating effects during the severe manic episode. D. Reduce the amount of physical pain the patient experiences during the severe manic episode.

A. Help control symptoms during the severe manic episode. Antipsychotic drugs are given to help control symptoms during severe manic episodes, even if psychotic symptoms are absent. Benzodiazepines are given for their sedating effects. Antidepressants help elevate mood during manic episodes.

The nurse is caring for a postoperative patient who had spinal anesthesia with bupivacaine. The nurse knows to monitor for which possible adverse effects? (Select all that apply.) A. Hypotension B. Headache C. Nausea/vomiting D. Urinary retention E. Tachycardia

A. Hypotension B. Headache D. Urinary retention The most significant adverse effect of spinal anesthesia is hypotension. Autonomic blockade may disrupt function of the intestinal and urinary tracts, causing fecal incontinence and either urinary incontinence or urinary retention. Spinal anesthesia frequently causes headache. Nausea/vomiting and tachycardia are not expected adverse effects of spinal anesthesia with bupivacaine.

Which statements about hydrocortisone are correct? (Select all that apply.) A. It is a synthetic steroid identical to cortisol. B. It is a preferred drug for adrenocortical insufficiency. C. It has glucocorticoid and mineralocorticoid actions. D. It is given IV for chronic replacement therapy. E. It should not be given during times of stress.

A. It is a synthetic steroid identical to cortisol. B. It is a preferred drug for adrenocortical insufficiency. C. It has glucocorticoid and mineralocorticoid actions. Hydrocortisone is a synthetic steroid with a structure identical to that of cortisol. Hydrocortisone is a preferred drug for all forms of adrenocortical insufficiency. Oral hydrocortisone is ideal for chronic replacement therapy. Parenteral administration is used for acute adrenal insufficiency and to supplement oral doses at times of stress. Despite being classified as a glucocorticoid, hydrocortisone also has mineralocorticoid actions.

Which statement about aripiprazole would the nurse identify as true? A. It is the first representative of a unique class of antipsychotic drugs called dopamine system stabilizers. B. It must be administered on an empty stomach. C. Gynecomastia is a common adverse effect. D. It is safe to use in older adult patients with dementia-related psychosis.

A. It is the first representative of a unique class of antipsychotic drugs called dopamine system stabilizers. Aripiprazole is well absorbed in the presence and absence of food, and gynecomastia is not a side effect. Increased mortality is seen when aripiprazole is used in the treatment of older adult patients with dementia-related psychosis.

Which beneficial metabolic effects does estrogen have in nonreproductive tissues? (Select all that apply.) A. It promotes and suppresses coagulation. B. It improves glomerular filtration rates. C. It reduces low-density lipoproteins (LDLs). D. It suppresses bone resorption. E. It reduces fat deposits in the liver.

A. It promotes and suppresses coagulation C. It reduces low-density lipoproteins (LDLs). D. It suppresses bone resorption. Estrogens have a positive effect on bone mass, blocking bone resorption. It also has favorable effects on cholesterol levels in that LDL levels are reduced, and the levels of high-density lipoprotein (HDL) are elevated. Estrogens promote coagulation by increasing factors II, VII, and others; they also suppress coagulation, increasing the activity of factors that promote the breakdown of fibrin. Estrogens do not improve the glomerular filtration rate or reduce fatty deposits in the liver.

Which drug should be used with caution in a patient with first-degree atrioventricular (AV) heart block? A. Lacosamide [Vimpat] B. Felbamate [Felbatol] C. Tiagabine [Gabitril] D. Levetiracetam [Keppra]

A. Lacosamide [Vimpat] Lacosamide can prolong the PR interval and should be used with caution in patients with cardiac conduction problems and in those taking other drugs that prolong the PR interval, such as calcium channel and beta blockers. Felbamate, tiagabine, and levetiracetam do not affect the PR interval.

The nurse identifies which drugs as the principal mood stabilizers used in the treatment of bipolar disorder? (Select all that apply.) A. Lithium B. Risperidone C. Divalproex sodium [Depakote] D. Carbamazepine E. Venlafaxine [Effexor]

A. Lithium C. Divalproex sodium [Depakote] D. Carbamazepine Lithium, divalproex sodium [Valproate], and carbamazepine are the principal mood stabilizers used in the treatment of bipolar disorder. Risperidone is an antipsychotic used in the management of bipolar disorder. Venlafaxine [Effexor] is an antidepressant used in the treatment of bipolar disorder.

The nurse is caring for a patient after total hip replacement on postoperative day 1. The nurse notes that the patient's urine is dark brown. The nurse reviews the medication administration record for which medication? A. Methocarbamol [Robaxin] B. Carisoprodol [Soma] C. Baclofen [Lioresal] D. Cyclobenzaprine [Flexeril]

A. Methocarbamol [Robaxin] Methocarbamol may turn urine brown, black, or dark green; patients should be forewarned of this harmless effect.

Which medications can be used to manage fatigue associated with multiple sclerosis? (Select all that apply.) A. Modafinil [Provigil] B. Clonazepam [Klonopin] C. Amantadine [Symmetrel] D. Carbamazepine [Tegretol] E. Dalfampridine [Ampyra]

A. Modafinil [Provigil] C. Amantadine [Symmetrel] Fatigue develops in about 90% of patients with multiple sclerosis, and the drugs most commonly used to manage this symptom include modafinil and amantadine. Clonazepam may be useful for alleviating tremor and ataxia associated with the disease. Carbamazepine, an antiepileptic drug, may be helpful for alleviating neuropathic pain. Dalfampridine may be given to improve walking.

Which statements about the treatment of bipolar disorder does the nurse identify as true? (Select all that apply.) A. Mood stabilizers are used to prevent recurrent manic-depressive episodes. B. Antipsychotics are used to treat depressive episodes. C. Antidepressants should be used with mood stabilizers in the treatment of patients with bipolar depression. D. Lithium and valproate are the preferred mood stabilizers for BPD. E. A lithium level of 2.0 mEq/L is considered therapeutic.

A. Mood stabilizers are used to prevent recurrent manic-depressive episodes. C. Antidepressants should be used with mood stabilizers in the treatment of patients with bipolar depression. D. Lithium and valproate are the preferred mood stabilizers for BPD. The statements in options A, C, and D are true. Antipsychotics are used to treat manic episodes. A lithium level above 1.5 mEq/L is considered to be above the therapeutic index.

The nurse is caring for a patient with a seizure disorder who takes phenobarbital at bedtime each night to control seizures. Which symptom, if present, would most likely indicate an adverse effect of this drug? A. Morning sedation B. A respiratory rate of 30 breaths per minute C. Constipation A. A blood pressure of 160/88 mm Hg

A. Morning sedation The adverse effects of the barbiturates include respiratory depression, risk of suicide, risk of abuse, and hangover (sedation, impaired judgment, and reduced motor skills).

Which agent is most likely to cause serious respiratory depression as a potential adverse reaction? A. Morphine [Duramorph] B. Pentazocine [Talwin] C. Hydrocodone [Lortab] D. Nalmefene [Revex]

A. Morphine [Duramorph] Morphine is a strong opioid agonist and as such has the highest likelihood of causing respiratory depression. Pentazocine, a partial agonist, and hydrocodone, a moderate to strong agonist, may cause respiratory depression, but they do not do so as often or as seriously as morphine. Nalmefene, an opioid antagonist, would be used to reverse respiratory depression with opioids.

A postoperative patient has an epidural infusion of morphine sulfate [Astramorph]. The patient's respiratory rate declines to 8 breaths per minute. Which medication would the nurse anticipate administering? A. Naloxone [Narcan] B. Acetylcysteine [Mucomyst] C. Methylprednisolone [Solu-Medrol] D. Protamine sulfate

A. Naloxone [Narcan] Naloxone is a narcotic antagonist that can reverse the effects, both adverse and therapeutic, of opioid narcotic analgesics.

When a surgical patient receives nitrous oxide at therapeutic concentrations as part of general anesthesia, which adverse effect is most likely to occur? A. Nausea and vomiting B. Slow emergence from anesthesia C. Hypotension and bradycardia D. Respiratory depression

A. Nausea and vomiting At therapeutic doses, nitrous oxide does not have serious adverse effects, such as longer central nervous system (CNS) depression or cardiac/respiratory depression. The major problem with this drug is postoperative nausea and vomiting.

Sensory stimuli from the retina travel to the brain for interpretation by way of which cranial nerve? A. Optic nerve B. Oculomotor nerve C. Trochlear nerve D. Abducens nerve

A. Optic nerve The optic nerve (cranial nerve II) extends from the eye to the occipital lobes of the brain. The oculomotor, trochlear, and abducens nerves are not cranial nerves associated with vision.

When assessing a patient who has Cushing's syndrome, a nurse associates which clinical manifestations with this disorder? (Select all that apply.) A. Osteoporosis B. Moon face C. Glycosuria D. Ketonuria E. Mood swings

A. Osteoporosis B. Moon face C. Glycosuria E. Mood swings Cushing's syndrome results from excess secretion of adrenocorticotropic hormone (ACTH), and these effects result in manifestations such as redistribution of fat to the face and belly, excess blood sugar, mood changes, and calcium loss from bone. Ketoacidosis does not occur.

The nurse is explaining differential sensitivity to the nursing student with regard to the use of local anesthetics. The nurse explains that which perception is lost first? A. Pain B. Cold C. Warmth D. Touch

A. Pain Although local anesthetics can block traffic in all neurons, blockade develops more rapidly in some neurons than in others. Specifically, small, nonmyelinated neurons are blocked more rapidly than large, myelinated neurons. Because of this differential sensitivity, some sensations are blocked sooner than others. Specifically, perception of pain is lost first, followed in order by perception of cold, warmth, touch, and deep pressure.

A distraught patient is admitted to the emergency department with symptoms of palpitations, tachycardia, chest pain, and shortness of breath. The physical examination reveals no physiologic basis for the symptoms. Which diagnosis therefore is most likely? A. Panic disorder B. Bipolar disorder C. Generalized anxiety disorder D. Clinical depression

A. Panic disorder Panic disorder is characterized by symptoms similar to those of a myocardial infarction (MI). Patients often fear losing control and dying and also may experience dizziness, nausea, depersonalization, and tingling or numbness in the hands. Generalized anxiety disorder is characterized by excessive worrying about events, but it also can include trembling, muscle tension, restlessness, palpitations, tachycardia, sweating, and clammy hands. Bipolar disorder is characterized by mood swings with periods of mania and depression.

Which assessments are essential before a patient receives a second dose of mitoxantrone [Novantrone]? (Select all that apply.) A. Pregnancy test B. Echocardiogram C. Complete blood count D. T3, T4, and TSH levels E. Ophthalmic examination F. Magnetic resonance imaging (MRI)

A. Pregnancy test B. Echocardiogram C. Complete blood count Mitoxantrone [Novantrone] can cause a variety of adverse effects. Myelosuppression, cardiotoxicity, and fetal injury are the greatest concerns. Consequently, a pregnancy test and a complete blood count should be done, as well as an echocardiogram to determine the left ventricular ejection fraction. Thyroid function studies and MRI are not necessary. Ophthalmic examinations are necessary when the patient is experiencing macular edema, an adverse effect of fingolimod.

The healthcare provider orders topical benzocaine spray for a 1-year-old child with a sunburn. Which action should the nurse take? A. Question the order for benzocaine. B. Question the order for further directions. C. Teach the parent about application of the spray. D. Apply the spray to the child.

A. Question the order for benzocaine. Topical benzocaine can cause methemoglobinemia, a blood disorder in which hemoglobin is modified such that it cannot release oxygen to tissues. If enough hemoglobin is converted to methemoglobin, death can result. Methemoglobinemia has been associated with benzocaine liquids, sprays, and gels. Because of this risk, topical benzocaine should not be used in children under the age of 2 years without the advice of a healthcare professional.

The healthcare provider orders lidocaine injection SC before a skin biopsy. Which action should the nurse take? A. Question the order for further instructions. B. Administer the lidocaine. C. Refuse to administer the lidocaine. D. Suggest the use of procaine.

A. Question the order for further instructions. The nurse should question the order for further instructions, including the dose to be administered, the location, and the use of epinephrine. The nurse should not administer, refuse to administer, or suggest the use of another medication without further information.

A patient who has type 2 diabetes has a glycated hemoglobin A1c (HbA1c) of 10%. The nurse should make which change to the nursing care plan? A. Refer the patient to a diabetes educator because the result reflects poor glycemic control. B. Glycemic control is adequate; no changes are needed. C. Hypoglycemia is a risk; teach the patient the symptoms. D. Instruct the patient to limit activity and weekly exercise.

A. Refer the patient to a diabetes educator because the result reflects poor glycemic control. Glycated hemoglobin (HbA1c) is a measure of plasma glucose levels on average over the previous 2- to 3-month period. The target value is 6.5% or lower. If it is greater than 6.5%, a diabetes educator is an additional resource who can facilitate lifestyle, exercise, and medication changes. Hypoglycemia is not a concern, because elevated HbA1c levels indicate poor glycemic control. Exercise should be part of an overall management program, because it counteracts insulin resistance.

The nurse is caring for a patient receiving fluoxetine [Prozac] for depression. Which adverse effect is most likely associated with this drug? A. Sexual dysfunction B. Dry mouth C. Orthostatic hypotension D. Bradycardia

A. Sexual dysfunction Fluoxetine [Prozac], a selective serotonin reuptake inhibitor (SSRI), does not cause anticholinergic effects, orthostatic hypotension, or cardiotoxicity, as do the tricyclic antidepressants. The most common adverse effects are sexual dysfunction, nausea, headache, and central nervous system stimulation.

The nurse is caring for a patient with bipolar disorder (BPD) who is taking lithium [Lithobid]. Which abnormal laboratory value is most essential for the nurse to communicate to the healthcare provider because this patient is taking lithium? A. Sodium level of 128 mEq/L B. Prothrombin time of 8 seconds C. Blood urea nitrogen level of 25 mg/dL D. Potassium level of 5.6 mEq/L

A. Sodium level of 128 mEq/L The sodium level is well below the normal range of 135 to 145 mEq/L. When the serum sodium level is reduced, lithium excretion also is reduced, and lithium accumulates. Because lithium has a narrow therapeutic index, this is a dangerous situation, which can result in symptoms of toxicity and even death.

The nurse is caring for a patient receiving phenytoin [Dilantin] for treatment of tonic-clonic seizures. Which symptoms, if present, would indicate an adverse effect of this drug? (Select all that apply.) A. Swollen, tender gums B. Measles-like rash C. Productive cough D. Unusual hair growth E. Nausea and vomiting

A. Swollen, tender gums B. Measles-like rash D. Unusual hair growth Adverse effects associated with phenytoin at therapeutic doses include mild sedation, gingival hyperplasia (swollen, tender gums), morbilliform (measles-like) rash, cardiovascular effects, and other effects, such as hirsutism (unusual hair growth) and interference with vitamin D metabolism.

Which manifestations should a nurse investigate first when monitoring a patient who is taking levothyroxine [Synthroid]? A. Tachycardia B. Tremors C. Insomnia D. Irritability

A. Tachycardia High doses of levothyroxine may cause thyrotoxicosis, a condition of profound excessive thyroid activity. Tachycardia is the priority assessment, because it can lead to severe cardiac dysfunction. Tremors, insomnia, and irritability are other symptoms of thyrotoxicosis and should be assessed after tachycardia.

a patient is prescribed NPH insulin. which statement should the nurse include in the discharge instructions? A. The insulin will have a cloudy appearance in the vial B. the onset of action is rapid C. The patient should not mix Lantus with short-acting insulin D. The patient will have no risk of allergic reactions with this insulin

A. The insulin will have a cloudy appearance in the vial Don't want to contaminate clear with cloudy.

The Women's Health Initiative (WHI) landmark trial data led to which recommendations about hormone replacement therapy? (Select all that apply.) A. There are benefits to using HRT short term to reduce vasomotor symptoms. B. Postmenopausal women should avoid smoking, exercise regularly, and control hypertension. C. Estrogen/progestin therapy (EPT) is preferred as the primary treatment to prevent loss of bone mass. D. Estrogen and progesterone should be used only to prevent cardiovascular events. E. Treatment with HRT for longer than 5 years increases the risk for pulmonary embolus and stroke.

A. There are benefits to using HRT short term to reduce vasomotor symptoms. B. Postmenopausal women should avoid smoking, exercise regularly, and control hypertension. E. Treatment with HRT for longer than 5 years increases the risk for pulmonary embolus and stroke. The WHI trial has yielded the most current, statistically valid data on the benefits and risks of HRT. The use of HRT short term to reduce vasomotor symptoms generally outweighs the risks if the dose is kept low for the shortest time needed. HRT should not be used to prevent cardiovascular disease; postmenopausal women should avoid smoking, perform regular exercise, and manage hypertension and diabetes with medications as needed. There are preferred alternative therapies to HRT to preserve bone mass. The major risks of HRT taken for longer than 5 years are myocardial infarction, dementia, stroke, deep vein thrombosis, and breast cancer.

The patient reports that she had to switch pharmacies to save money. She noticed that her "thyroid pill" looks different. The nurse anticipates that the healthcare provider will order what? A. Thyroid stimulating hormone (TSH) B. Electrocardiogram (ECG) C. Beta human chorionic gonadotropin (hCG) test D. Creatinine level

A. Thyroid stimulating hormone (TSH) If a switch is made (from one branded product to another, from a branded product to a generic product, or from one generic product to another), retest serum TSH in 6 weeks, and adjust the levothyroxine dosage as indicated.

The nurse is caring for a group of patients being treated for depression. Why might an SSRI be chosen over a TCA? A. To reduce the risk of suicide with overdose B. To avoid weight gain and other gastrointestinal (GI) effects C. To help prevent sexual dysfunction D. To prevent the risk of serotonin syndrome

A. To reduce the risk of suicide with overdose The SSRIs may be chosen because they have fewer side effects and are safer with overdose. However, the SSRIs can cause sexual dysfunction and weight gain, and they carry a risk of serotonin syndrome.

Drugs that inhibit the RAAS

ACE Inhibitors Hemodynamic benefits -Arteriolar dilation -Venous dilation -Suppression of aldosterone release Angiotensin 2 Receptor blockers (ARBs) -Improve Left ventricular ejection fraction -Reduce heart failure symptoms -Increase exercise tolerance -Decrease hospitalization -Enhance quality of life -Reduce mortality Aldosterone antagonists -Spironolactone and eplerenone -Recommended as addition to standard heart failure therapy Direct renin Inhibitors (DRIs) -Aliskiren is being tested in heart failure, but not yet approved for treatment -Benefits in HF should be equal to those of ACE inhibitors or ARBs

Adjuncts to Reperfusion Therapy: Management of STEMI

ACE inhibitors Recommended for all STEMI patients -Help to promote beta blockers -Promote collaterization around damaged area -Decrease both preload and afterload promoting fluid loss and favorable ventricular remodeling. -Decrease short-term mortality in all patients and long-term mortality in patients with reduced Left ventricular function ARBs -Recommended for STEMI patients who are intolerant of ACE inhibitors and who have heart failure or reduced LVEF. Calcium Channel Blockers -NOT recommended for use in management of STEMI

Diagnostic Testing of Adrenocortical Function

ACTH is used primarily for diagnostic tests Cosyntropin -Acts on adrenal cortex to stimulate synthesis and secretion of cortisol and other adrenal glucocorticoids -Plasma cortisol is measured just before injection, then 30 or 60 minutes later -Dose of cosyntropin is injected IM or IV If cortisol level -Rises above 20 mcg/dL = adrenal response is normal -Fails to raise significantly = primary adrenal insufficiency

Erectile Dysfunction (ED)

AKA Impotence -Persistent inability to achieve or sustain an erection suitable for sexual performance Commonly associated with chronic illnesses (diabetes, hypertension, depression) Risk for ED increases with advancing age Treatment Drugs: Oral agents Phosphodiesterase type 5 (PDE5) Inhibitors (first line agents) -Sildenafil [viagra] -Vardenafil -Tadalafil Injected agents -Papaverine plus phentolamine -Alprostadil Psychotherapy Surgical implantation of penile prosthesis

Nonradioactive Iodine: Lugol's Solution

AKA: Strong iodine solution Contains 5% elemental iodine and 10% potassium iodide MOA: -High concentration of iodine --> suppressant effect Use: -Prep for thyroidectomy (surgical removal of all or part of the thyroid gland) Adverse effects: -Brassy taste -Burning sensation in mouth and throat -Soreness of the teeth and gums -Coryza (inflammation of nasal mucous membranes) -Salivation -Various skin eruptions

Antidiuretic Hormone (ADH)

AKA: Vasopressin Actions: -Promotes renal retention of water -Works on the collecting ducts of the kidney to increase their permeability to water Production and regulation: Produced in hypothalamus -Hypothalamus responsible for maintaining fluid osmolality -High osmolality --> release ADH ADH release also triggered by -Hypotension -Decreased plasma volume Adverse effects: Vasoconstriction -Angina, MI -Diminished flow -> periphery -> gangrene Therapeutic uses: -Diabetes insipidus -Cardiac arrest (enhances blood flow from CPR) -Desmopressin for nocturnal enuresis (bedwetting) -Hemophilia A (promotes clotting factor VIII release) -Von Willebrand's disease (As above) -- deficit of vWF = decreased platelet aggregation

Disorders of Fluid Volume and Osmolality

Abnormal stages of hydration -Volume contraction (decrease in total body water) -Volume Expansion (Increase in total body water) Subclassifications based on alterations in extracellular osmolality: -Isotonic -Hypertonic -Hypotonic

Treatment Overview

Abortive agents Nonspecific analgesics -NSAIDS -Opioid analgesics Migraine-specific drugs -Serotonin 1B/1D receptor agonists (known by "-triptan") -Ergot alkaloids Preventive/Prophylactic agents -Beta blockers -Anti-epileptics -Triptans

Explain the four pharmacokinetic phases of absorption, distribution, biotransformation (metabolism) and excretion "ADME"

Absorption -Movement of a drug from site of administration into blood; rate determines how soon effects will begin Distribution -Drug movement from blood to interstitial space of tissues. Amount determines how intense effects will be and from there into cells Biotransformation (metabolism) -Enzymatically mediated alteration of drug structure Excretion -Movement of drugs and their metabolites out of body Biotransformation and excretion together are elimination These processes determine concentration of a drug at it's site of action

Identify variables, which affect each of the four pharmacokinetic phases

Absorption -Physical and chemical properties of drug itself -Physiologic and anatomic factors at absorption site 1. Rate of dissolution (Pharmaceutical preparation) Dissolve fast = faster onset Determinants of rate of release Dosage forms -Solutions have no delay; immediate release. -Capsules & Tablets have delay to dissolve; followed by rapid release -Creams, ointments, and suppositories have no delay and slow release Additives (excipients) -Could be lubricant, coating agent that decrease rate -Disintegrates increase rate -Diluents, coloring agents, flavoring agents have variable effects Manufacturing parameters -Tablet compression (soft vs hard), shape (round vs square), size (small vs large) Delayed-release preparations -Enteric-coating (EC) is resistant to gastric fluid, coating dissolves in intestines, not stomach!! Sustained-release preparations -If you ever see SR or EC drug, never split them. They must be taken whole. 2. Surface Area Larger surface area = faster absorption. -Orally administered drugs absorbed from small intestine rather than stomach because of the microvilli in small intestine -Lungs also have high surface area Low surface areas: eyes, nasal and buccal cavities, stomach, large intestines, rectum 3. Blood flow High blood flow = more rapid Low flow areas = eyes, stomach, Iarge intestines, rectum High flow areas = small intestines, lungs, muscle, buccal/nasal cavities 4. Lipid solubility (Membrane permeability of drug) High lipid-soluble= more rapid. -Readily crosses membranes Lipophilicity --> increases membrane permeability Ionization --> decreases membrane permeability 5. pH partitioning / Drug destruction -Absorption enhanced when difference between pH of plasma & pH at administration site is so that drug molecules have great tendency to be ionized in plasma. -Liver "first pass" effect -Colon, intestinal flora -Stomach, digestive enzymes and acids. Distribution 1. Blood flow to tissues -2 pathologic conditions in which low regional blood flow can affect drug therapy 1. Abscesses: pus-filled pocket of infection that has no internal blood vessels. No blood supply = antibiotics can't reach. Must be surgically drained. 2. Tumors: Limited blood supply. Blood flow becomes lower to core. 2. Ability of drug to exit vascular system -After drug has been delivered to organ/tissue via blood, it exists via the vasculature. -Drugs don't produce effects within blood -Exiting vascular system is necessary for drugs to undergo metabolism and excretion -Leave blood at capillary beds -Albumin is biggest one. If you are taking two drugs, and it knocks it off the protein binding, that will have an affect on the drug and make adverse effects possibly higher. 3. Ability of drug to enter cells -Some must enter cells to reach site of action, all drugs must enter cells to undergo metabolism & excretion. -Cross cell membranes by lipid solubility & presence of a transport system (or bind with receptors on external surface of cell membrane -- don't need to enter cell) Metabolism (Biotransformation) -Most drug metabolism takes place in the liver by hepatic drug-metabolizing enzymes. -Performed by cytochrome P450 (CYp450) system 1. Age -Infants metabolizing capacity is limited -Older adults to metabolize drugs is decreased -Drug does may need to be reduced to prevent drug toxicity 2. Induction & Inhibition of Drug-Metabolizing Enzymes -Drugs may be P450 substrates, P450 enzyme inducers, P450 enzyme inhibitors -Drug may be both substrate and inducer 3. First-Pass effect -Rapid hepatic (liver) inactivation of certain oral drugs -Drugs are absorbed from GI tract --> carry to liver via hepatic portal vein. -If capacity of liver to metabolize drug is extremely high the drug can be inactivated on it's first pass through the liver, which means no therapeutic effects can occur -To prevent this, drug is administered parenterally (non-orally) -Temporarily bypass liver and allow it to reach therapeutic levels in systemic circulation. EXAMPLE: Nitroglycerin undergoes rapid hepatic metabolism following oral administration & has little effect. When it is administer under tongue (sublingually), it is very active. -It is absorbed directly into the systemic circulation and can carry to sites of action before passing through liver and being exposed to hepatic enzymes. 4. Nutritional Status -Liver drug metabolizing enzymes require cofactors to function. -Malnourishment = compromised drug metabolism 5. Competition between drugs -When 2 drugs are metabolized by the same pathway, they may compete for metabolism and decrease the rate. Excretion Can exit in urine, bile, sweat, saliva, breast milk, expired air. most important organ for drug excretion is KIDNEY. 1. pH-Dependent Ionization -Accelerate renal excretion of drugs -The less that drugs are passively reabsorbed = more are excreted 2. Competition for Active Tubular Transport -Delay renal excretion & prolong the effects EXAMPLE: Alone, Penicillin is rapidly cleared from blood. Excretion can be delayed by concurrent administration of Probenecid (which is removed by same tubular transport system). -Now Penicillin is cheap and just given in larger doses.

Neurotransmitters of the Peripheral Nervous System

Acetylcholine (ACh) -Employed at most junctions of the PNS Norepinephrine (NE) -Released by most postganglionic neurons Epinephrine (Epi) -Released by the adrenal medulla

Pyridoxine (Vitamin B6)

Actions: -Coenzyme in the metabolism of amino acids and proteins Sources: Drug interactions: Deficiency: -May result from poor diet, isoniazid use, inborn errors of metabolism -S/S: seborrheic dermatitis, microcytic anemia, peripheral neuritis, convulsions, depression, confusion -Dietary deficiency is rare; common with alcoholics

Vitamin A (Retinol) (Fat soluble)

Actions: -Eyes: adaptation to dim light -Others: embryogenesis, spermatogenesis, immunity, growth, structural and functional integrity of skin and mucous membranes Sources: -Dairy products -meat -fish oil -fish -carrots -cantaloupe -mangoes -spinach -tomatoes -pumpkins -sweet tomatoes Toxicity: -Teratogenic Deficiency: -Night blindness -Xerophthalmia -Keratomalacia -Blindness -Skin lesions and dysfunction of mucous membranes

Thiamine (Vitamin B1)

Actions: Essential coenzyme for CHO metabolism Sources: whole grains, meat, and fish. Breads, cereals Deficiency: Beriberi Wet --> fluid accumulation in legs, cardiac complications Dry--> neurologic and motor deficits (anesthesia off feet, ataxic gait, foot drop, wrist drop) Wernicke-Korsakoff syndrome -Associated with chronic alcohol consumption -S/S: nystagmus, diplopia, ataxia, inability to remember recent past -If not corrected --> irreversible brain damage

Cyanocobalamin (Vitamin B12) and Folic acid (B9)

Actions: Essential factors in DNA synthesis Sources: Deficiency: -Deficiency of either manifests as megaloblastic anemia -B12 deficiency --> neurologic damage Folic acid deficiency during pregnancy -Can impair CNS development -Can result in neural tube defects, anencephaly, spina bifida

Selective Estrogen Receptor Modulators (SERMs)

Activate in some tissues and.block estrogen receptors selectively in others Developed to provide benefit of estrogen while avoiding the drawbacks Four available (classified as hazardous drugs, so you want to wear gloves) 1. Tamoxifen 2. Raloxifene 3. Toremifene 4. Bazedoxifene Tamoxifen Uses: Breast cancer treatment and prevention (it can inhibit cell growth in breast) Protects against osteoporosis BBW: -Serious life-threatening events -Risk for endometrial cancer and thromboembolism Raloxifene -Different from tamoxifen because it DOES not activate estrogen receptors in endometrium (thus not posing risk for uterine cancer) Uses: -Post menopause osteoporosis treatment and prevention -Breast cancer prevention BBW: Venous thromboembolism (VTE) & Fatal Stroke Risk

Functions of Cholinergic Receptors

Activation of nicotinicN (neuronal) receptors Activation of nicotinicM (muscle) receptors -Causes contraction of skeletal muscle Activation of muscarinic receptors (located on target organs) -Increased glandular secretion (pulmonary, GI, and sweat glands) -Contraction of smooth muscle (bronchi and GI tract) -Slowing of heart rate -Pupil constriction and focus for near vision -Dilation of blood vessels -Voiding of urinary bladder

Dantrolene

Acts directly on skeletal muscle to relax the muscle. Relieves spasm by suppressing the release of calcium from the sarcoplasmic reticulum, making muscle less able to contract Used in: -Multiple Sclerosis -Cerebral Palsy -Spinal cord injuries -Malignant Hyperthermia (MH) (used as an "antidote" for MH)

Lipase Inhibitor: Orlistat

Acts in GI tract to reduce absorption of fat -If you eat fat heavy meal and you take orlistat, it will help body not absorb that fat. Adverse effects: -GI effects -Possible liver damage -Acute pancreatitis -Kidney stones Drug and nutrient interactions: -Warfarin, levothyroxine -Fat-soluble vitamins

Oxybutynin [anticholinergic drug for OAB]

Acts primarily on M3 muscarinic receptors Highly lipid soluble. Only indication is for OAB. Adverse effects: -Dry mouth (very high incidence) -Constipation -Tachycardia -Urinary hesitancy -Urinary retention -Mydriasis -Blurred vision -Dry eyes Drug interactions: -Other anticholinergics will intensify anticholinergic adverse effects

Antibiotic combinations

Additive (sum of effects) Potentiative = Effects greater than sum Antagonistic = Effects are less than sum. Disadvantages of combinations: allergies, antagonism, superinfection, select out super-resistant bugs, cost

Other Antidysrhythmic Drugs

Adenosine Use: Termination of paroxysmal SVT Effects on heart: Decreases SA node automaticity, slows conduction through AV node Pharmacokinetics: Half life is 10 seconds, thats why you have to give IV. Adverse effects are Short lived; bradycardia, dyspnea, hypotension, facial flushing, chest discomfort Drug interactions: -Methylxanthines (caffeine) block receptors -Dipyridamole (antiplatelet) blocks adenosine uptake which increases adenosine effects. Digoxin Indications: Afib, Aflutter, supraventricular tachycardia (inactive against ventricular dysrhythmias) Effects on heart: suppresses dysrhythmias by decreasing conduction through AV node and automaticity in SA node Adverse effects: Cardiotoxicity, GI disturbances, CNS effects Dig-toxicity reversal = Digibind ("Digoxin immune fab")

Differentiate between adverse effects, side effects, and toxic effects

Adverse effects Harmful secondary effects -Associated with higher doses -Something bad happened and it can happen in normal doses -Ex; Stevens Johnson syndrome Side effects Unpleasant secondary effects -Associated with low doses -Unintended effect of a drug -Occures at normal dose -example; Benadryl gets you sleepy. Toxic effects Life-threatening effects -Associated with very high doses LD50 (LD= lethal dose, LD50= dose that kills half of animals tested)

Vasodilators

Adverse effects: Postural hypotension (have to get up slowly so you don't get up with swimmy head) Reflex tachycardia: if we are bringing blood pressure down, then heart says "we dont have enough blood going, and you get reflex tachycardia (sends signals to sympathetic nerves for heart to beat faster due to drop in blood pressure) caused by baroreceptors. Expansion of blood volume

Inotropic Agents (Inotropes)

Agents that change force of heart contractions Positive inotrope = Increases strength/force Negative inotrope = Decreases strength/force Sympathomimetics "Adrenergic drugs" Stimulate compounds that mimic effects of agonists on the SNS Prototype: Dopamine Dobutamine Cardiac Glycosides Prototype: Digoxin Phosphodiesterase inhibitors Ex; Milrinone

Distinguish between an agonist, antagonist, and partial agonist

Agonist -Produces physiological effect by activating a drug receptor -When bonding to a receptor, it will stimulate the same response that stimulation of the receptor by body's own chemicals would initiate EXAMPLE: If activation of a receptor causes vasoconstriction, what physiologic action would result if a person takes an agonist drug that activates that receptor? -Vasoconstriction would occur Antagonist -Produces physiological effect by preventing drug receptor activation -When bond to receptor, it will block response that stimulation of the receptor by body's own chemicals would initiate. EXAMPLE: If activation of a receptor causes vasoconstriction, what physiologic action would result if someone takes an antagonist that binds to that receptor? -Vasoconstriction would NOT occur Competitive: compete with agonists for receptor binding Noncompetitive: bind "irreversibly" to receptors --> fewer available receptors for agonists Partial agonist -Bind to and activate receptors so they functions as agonists. -Activation produced is less than full agonist -When agonist & partial agonist are given together, they compete for receptor sites. -Results in partial agonist acts as antagonist by blocking sites that would be fully activated by agonists. -Can act as antagonists as well as agonists Agonists = good receptor that activates fully Partial agonists = Fit receptor but not as well, activation is less. Antagonists = Do not fit and don't activate receptor. -Effect occurs through blocking ability of body's chemicals or other drugs to activate receptor.

Beta1 Activation (HEART) (you have 1 heart)

All clinically relevant responses result from activating receptors in the heart (Activation of renal beta 1 are not associated with no beneficial or adverse effects.) Expected effects and clinical uses: Shock -by drop in blood pressure, so main goal is to increase perfusion to organs = beta 1 stimulation increases force of contraction of heart so cardiac output improves and tissue perfusion will follow Heart failure -Positive inotropic effect -Drugs that activate these receptors can improve cardiac performance Atrioventricular (AV) heart block -Enhance impulse conduction through AV node -Can help overcome AV block -Long-term management = pacemaker Cardiac arrest -Can start contractions in heart that has stopped beating -Initial management focuses on CPR, external pacing, or defibrillation -Epinephrine Adverse effects: -Result of activating beta 1 receptors in heart as well Dysrhythmias -If you overshoot it Angina pectoris -Oxygen demand is greater than supply on hand. -Increase cardiac oxygen demand by increasing heart rate and the force of contraction, patients with compromised coronary circulation are at risk of anginal attack

Describe the placental transfer of drugs from mother to infant

All drugs can cross the placenta, but some can cross more easily than others. Adverse reactions during pregnancy cant affect mom and baby. EXAMPLE; Heparin causes osteoporosis Prostaglandins stimulate uterine contraction Pain relievers used during delivery can depress respiration in neonate. Drugs can be excreted through breast milk and effects can occur in infant. -Take drugs immediately after breast feeding -Avoid drugs that have long half lives

Bowel-Cleansing Products for Colonoscopy

Allow for good visualization of the bowel Make sure bowels are cleaned out before they do x-rays Sodium phosphate -Hypertonic with body fluids -Can cause dehydration and electrolyte disturbance -possibility of renal damage Polyethylene glycol (PEG) plus electrolytes (ELS) Ex; GoLutely -Isotonic with body fluids -Requires ingestion of large volume of bad-tasting liquid Combination products -Sodium picosulfate (stimulant laxative) -Magnesium oxide + Citric acid = Magnesium Citrate (osmotic laxative)

Functions of Adrenergic Receptors

Alpha 1 Located: Eyes, blood vessels, male sex organs, prostatic capsule, and bladder -Pupil dilation -Vasoconstriction -Ejaculation -Contraction of bladder neck and prostate Alpha 2 Located: Nerve terminals (presynaptic junction) PNS receptors = minimal clinical significance CNS receptors = therapeutic cardiac relevance Beta 1 Located: Heart and kidneys Activation at the heart -Increases heart rate -Increases force of contraction -Increases velocity of conduction in AV node Activation at the kidneys -Renin release --> angiotensin synthesis --> vasoconstriction --> increased blood pressure Beta 2 Located: Lungs, uterus, heart, skeletal muscle, and liver -Bronchial dilation -Relaxation of uterine muscle -Vasodilation -Glycogenolysis Dopamine PNS receptors (kidneys): dilate renal blood vessels --> increased renal perfusion CNS receptors (brain): Parkinson's, schizophrenia, and more.

Hyperosmolar Hyperglycemic State (HHS)

Also called hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) Large amount of glucose excreted in urine Results in dehydration and loss of blood volume Increases blood concentrations of electrolytes and nonelectrolytes (particularly glucose); also increases hematocrit Blood "thickens" and becomes sluggish because of loss of water Little or no change in ketoacid levels Little or no change in blood pH No sweet or acetone-like smell to urine or breath Occurs most frequently with type 1 diabetes with acute infection, acute illness, or some other stress Can evolve slowly (metabolic changes begin a month or two before S/S become apparent) If left untreated, can lead to coma, seizures, and death Management -Correct hyperglycemia and dehydration with IV insulin, fluids, and electrolytes

Penicillins (weaken bacterial cell wall)

Ampicillin Amoxicillin Nafcillin Oxacillin Dicloxacillin Ticaricillin Piperacillin Combos: Beta-lactamase inhibitors (Clauvanic acid, tazobactam, sulbactam) Beta-Lactam family; Cephalopsorins, aztreonam, imipenem, meropenem, and ertapenem. Penicillinases "Beta-Lactamases" are enzymes that render penicillin inactive. MOA: Weaken cell wall, causing rupture; bactericidal. Broad-spectrum and narrow-spectrum. Active only against bacteria undergoing growth and division. Low risk of toxicity AE: Hypersensitivity (allergic) reaction (Epipien), bacterial resistance (MRSA), rash, Interactions: aminoglycosides, bacteriostatic antibiotics, probenecid (delays renal excretion of penicillin)

Adrenal Androgens

Androstenedione -Minimal physiologic effects at normal levels -In adult males, effects of testosterone is greater than adrenal androgens -In adult females, adrenal androgens lead to testosterone -Overproduction in congenital adrenal hyperplasia (CAH) --> Virilization(a condition in which women develop male-pattern hair growth and other masculine physical traits)

RAAS regulation of AP

Angiotensin 2 (from lungs) = constriction of arterioles and veins -Vasoconstriction response time = hours Aldosterone = retention of water by kidney through retention of sodium -Water retention response time = days You have increase of decrease in blood pressure --> affect sodium and water retention or secretion --> affects vasoconstriction or vasodilations --> kidneys get stimulated to produce renin --> renin stimulates liver to produce angiotensinogen --> turns into angiotensin 1 --> lungs turn angiotensin 1 to angiotensin 2 --> goes to adrenals to produce aldosterone --> works on heart, kidney, blood vessels

Classes of Antiulcer Drugs

Antibiotics -Eradicate H. pylori via various methods -Amoxicillin/Clarithromycin/+Omeprazole Anti-secretory agents Suppress acid secretion H2 blockers -Cimetidine Proton pump inhibitors (PPIs) -Omeprazole Mucosal protectants -Creates barrier over the ulcer -Sucralfate Anti-secretory agents that enhance mucosal defenses -Suppresses secretion via multiple processes Antacids React with gastric acid to neutralize pH -Aluminum hydroxide/magnesium hydroxide

GI Drugs

Antiemetic agents -Serotonin Antagonists -- Odansetron Drugs for irritable bowel syndrome (IBS) -Constipation -- Lubiprostone -Diarrhea -- Alosetron Drugs for inflammatory bowel disease (IBD) -5-Aminosalicylates -- Sulfasalazine -Glucocorticoids -- Budesonide -Immunosupressants -- Mercaptopurine -Immunomodulators -- Infliximab Pancreatic Enzymes -Pancrelipase

Antiplatelet/Anticoagulant Therapy

Antiplatelet Therapy Started promptly, consisting of: -Aspirin (continue indefinitely) -Clopidogrel (continue for up to 2 months) -Abciximab (only if angioplasty is planned) -Eptifibatide or tirofiban (only for high risk patients and if angioplasty is NOT planned) Anticoagulant Therapy -SC LMW Heparin [Lovenox] -Direct thrombin inhibitors (bivalirudin) -Factor Xa Inhibitors (fondaparinux) -IV heparin (unfractionated)

Beta2 Activation (LUNGS & uterus)

Applications: Lungs (asthma) -Promote bronchodilation -Relieve or prevent asthma attacks -Selective for beta2 receptors (such as albuterol) -Less selective agents (such as isoproterenol) Uterus (delay of preterm labor) -Relaxes uterine smooth muscle -Used to delay preterm labor Beta2 activating drugs: -Epinephrine -Isoproterenol -Albuterol Adverse effects: Hyperglycemia -Activation of beta2 receptors in the liver and the skeletal muscles -breakdown of glycogen into glucose -Cause hyperglycemia only in patients with diabetes Tremor -most common side effect of beta2 agonists -Fades over time and can be minimized by initiating therapy at low doses

Glucocorticoids: Budesonide

Approved for mild to moderate Crohn's disease that involves ileum and ascending colon Prolonged use can cause severe adverse effects (adrenal suppression, osteoporosis, increased susceptibility to infection, and a cushingoid syndrome)

Circulatory system functions

Arterial circulation: Oxygen, nutrients, hormones, electrolytes, other essentials to cells Venous circulation: Carbon dioxide, metabolic wastes, other debris from cells 2 major divisions: Pulmonary circulation Systemic circulation Regulates cardiac output Regulates Arterial pressure (AP)

An older patient with skin cancer and hypertension is prescribed levodopa/carbidopa to treat Parkinson disease. Which action by the nurse is best? A. Give medication if the patient's blood pressure is normal B. Administer the medication as prescribed C. ask the patient about the type of skin cancer D. Hold the medication if the patient is more than 65 years old

Ask the patient about the type of skin cancer. **because of potential to activate malignant melanoma

A patient has been diagnosed with STEMI. which medications does the nurse expect to be prescribed for this patient?

Aspirin, beta blocker, oxygen, morphine, and nitroglycerin "MONA"

The nurse cares for a patient with myasthenia gravis. Before administering pyridostigmine, it is most important for the nurse to take which action?

Assess the patient's ability to swallow a sip of water

A patient is prescribed bethanechol for urinary retention. If the patient exhibits signs of an overdose, such as increased salivation and sweating, bradycardia, or hypotension, which medication should the nurse administer?

Atropine (it reverses signs of poisoning)

Antithrombin (anticoagulant)

Atryn Endogenous compound that suppresses coagulation by inhibiting antithrombin and factor Xa. Uses: -Prevent thrombosis in patients with inherited AT deficiency -Used in patients with antithrombin deficiency to prevent clots during surgery or childbirth MOA: -Suppresses coagulation by inhibiting thrombin and factor Xa Two IV preparations: Recombinant human AT [Atryn] Plasma-derived AT [Thrombate III]

Monobactam (Weaken bacterial cell wall) (Beta-lactam)

Aztreonam Narrow spectrum

Which statements does the nurse include when teaching a patient about antipsychotic drug therapy? (Select all that apply.) A. "Restrict the use of antipsychotic drugs to 3 months to prevent the development of addiction." B. "Dilute oral preparations in fruit juice to improve their palatability." C. "Store oral preparations in a dark area." D. "Do not make skin contact with these drugs; flush the affected area with water if a spill occurs." E. "Take an over-the-counter sleep aid if you have trouble falling asleep at night."

B. "Dilute oral preparations in fruit juice to improve their palatability." C. "Store oral preparations in a dark area." D. "Do not make skin contact with these drugs; flush the affected area with water if a spill occurs." Patients should be informed that antipsychotic drugs do not cause addiction and that they should be taken as prescribed. Patients should be instructed to avoid all drugs with anticholinergic properties, including antihistamines and certain over-the-counter sleep aids, to prevent drug interactions. All of the other statements are appropriate to include in teaching the patient about the use of antipsychotic medications.

A nurse is teaching a postmenopausal patient taking estrogen/progestin therapy (EPT) about breast self-examination (BSE). Which of these instructions should the nurse give? A. "There are no risks for breast cancer, so BSE is not necessary." B. "Do your breast self-examination the first day of each month." C. "Examine your breasts by looking at them in the mirror." D. "Feel each breast while lying on the opposite side."

B. "Do your breast self-examination the first day of each month." All women should perform regular breast self-examinations, preferably 1 week after the menstrual cycle ends. It is especially important for postmenopausal women taking a progestin combined with an estrogen, because this treatment is associated with an increased risk of breast cancer. Recent data suggest that estrogen alone does not increase the risk of breast cancer. For postmenopausal women without monthly cycles, the breasts should be examined once a month on the same day; the first day of the month is suggested.

Which statement made by a female patient newly diagnosed with complex partial seizures and starting treatment with valproic acid indicates a need for further teaching by the nurse? A. "The medication should not make me feel sleepy." B. "I should take the medication on an empty stomach." C. "I'll need to discuss a reliable form of birth control with my gynecologist." D. "I'll call my physician immediately if I develop a yellow tint to my skin or my urine appears tea-colored."

B. "I should take the medication on an empty stomach." Gastrointestinal side effects, such as nausea, vomiting, and indigestion, can occur when valproic acid is taken on an empty stomach; this statement indicates that further teaching is needed. Valproic acid has minimal sedative effects, is teratogenic, and can lead to hepatotoxicity. Female patients of child-bearing age must use effective methods of birth control to prevent pregnancy and must be taught the signs of liver failure (abdominal pain, malaise, jaundice), which must be reported immediately.

The nurse is providing teaching regarding Duavee (conjugated estrogens/bazedoxifene). Which statement by the patient indicates that the teaching was effective? A. "I know I am at an additional risk for increased growth of my uterus lining." B. "I understand that the combination product should help protect me from the side effects of the estrogen." C. "I will have to set an alarm to take my medication four times per day." D. "I am prepared to take this medication for the rest of my life."

B. "I understand that the combination product should help protect me from the side effects of the estrogen." Duavee is the first drug to combine estrogen with an estrogen agonist/antagonist (bazedoxifene). The bazedoxifene component of Duavee reduces the risk of excessive growth of the lining of the uterus that can occur with the estrogen component. The dose is one tablet orally twice daily for the prevention of vasomotor symptoms and osteoporosis in postmenopausal women with a uterus. Contraindications to taking Duavee are the same as for other estrogen-containing products, and as with other products, this drug should be used for the shortest duration possible.

Which statement made by a patient indicates a need for further discharge instruction about baclofen [Lioresal]? A. "If I develop any difficulty urinating, I will call my physician." B. "I'm glad I can still have a glass or two of wine at dinner." C. "I'll contact my healthcare provider when I feel I no longer need the medication." D. "I'll need to check with my healthcare provider before taking my allergy medications."

B. "I'm glad I can still have a glass or two of wine at dinner." Alcohol can intensify the CNS depressant effects of baclofen; therefore, further instruction is needed. The first statement indicates that the patient understands that urinary retention is a potential side effect. Baclofen should not be discontinued abruptly, because this can lead to hallucinations, paranoid ideation, and seizures. Patients should discuss withdrawal of baclofen with their healthcare provider, because it should be done over 1 to 2 weeks. Allergy medications should be evaluated by the healthcare provider to determine whether they contain antihistamines, which intensify the depressant effects.

The nurse instructs a patient about taking levothyroxine. Which statement by the patient indicates the teaching has been effective? A. "To prevent an upset stomach, I will take the drug with food" B. "If I have chest pain or insomnia, I should call my doctor" C. "This medication can be taken with an antacid" D. "The drug should be taken before i go to bed at night"

B. "If i have chest pain or insomnia, I should call my doctor" You should only take it with water

Which instructions does the nurse include when teaching a patient about phenelzine [Nardil] therapy? (Select all that apply.) A. "Take the medication as needed when you are feeling depressed." B. "If you experience a severe headache, inform your healthcare provider." C. "Profuse sweating is an expected side effect of this medication and will diminish with time." D. "Ginseng can be used to treat headache, which patients often experience when they first take phenelzine." E. "Avoid eating avocados when taking this drug."

B. "If you experience a severe headache, inform your healthcare provider." E. "Avoid eating avocados when taking this drug." Patients should be instructed to take MAOIs every day as prescribed—not PRN. They should be warned not to discontinue treatment once mood has improved, because doing so may result in relapse. Patients should be informed of the symptoms of hypertensive crisis—severe headache, tachycardia, hypertension, nausea, vomiting, confusion, and profuse sweating—and instructed to seek immediate medical attention if these develop. Patients should be forewarned of the hazard of hypertensive crisis and the need to avoid tyramine-rich foods, such as aged cheese, Chianti, and avocados. (Patients on low-dose transdermal selegiline need not avoid foods containing tyramine.) Patients taking MAOIs should not take ginseng, because headache, tremulousness, and manic-like reactions have occurred.

The nurse is teaching a patient newly diagnosed with a seizure disorder about her disorder. Which statement made by the nurse best describes the goals of therapy with antiepilepsy medication? A. "With proper treatment, we can completely eliminate your seizures." B. "Our goal is to reduce your seizures to an extent that helps you live a normal life." C. "Seizure medication does not reduce seizures in most patients." D. "These drugs will help control your seizures until you have surgery."

B. "Our goal is to reduce your seizures to an extent that helps you live a normal life." Seizure disorders are often treated successfully with medication in most patients. However, the dosages needed to completely eliminate seizures may cause intolerable side effects. Neurosurgery is indicated only for patients in whom medication therapy is unsuccessful.

The nurse teaches a patient about eszopiclone. Which statement by the patient indicates that the teaching has been effective? A. "I should take the drug 1 hour before bedtime" B. "The drug may leave a bitter taste in my mouth" C. "I may experience amnesia with prolonged use" D. "My body may build up a tolerance to this drug"

B. "The drug may leave a bitter taste in my mouth"

A patient with Cushing's syndrome is prescribed an antibiotic, ketoconazole 600 mg/day, before an adrenalectomy. The patient asks the nurse why an antibiotic is needed. Which response by the nurse is best? A. "The medication will prevent an abdominal infection after surgery" B. "The medication will block the adrenal gland from producing steroids" C. "You have a urinary tract infection that must be treated before surgery" D. "It is essential to prevent skin infection in patients undergoing surgery"

B. "The medication will block the adrenal gland from producing steroids"

A nurse is caring for several patients. In which patient is it appropriate to use the drug chlorpromazine [Thorazine]? (Select all that apply.) A. An 85-year-old man with Alzheimer's disease B. A 78-year-old man with intractable hiccups C. A 76-year-old woman with severe dementia D. A 48-year-old woman with schizoaffective disorder E. A 30-year-old man with anxiety and depression

B. A 78-year-old man with intractable hiccups D. A 48-year-old woman with schizoaffective disorder The primary indications for chlorpromazine, a first-generation antipsychotic agent, are schizophrenia and other psychotic disorders. It may also be used for schizoaffective disorder, bipolar disorder, suppression of emesis, and relief of intractable hiccups. Antipsychotics are not used for dementia because of increased mortality. Chlorpromazine is not a primary treatment for Alzheimer's disease or depression.

The nurse is seeing several patients in the outpatient clinic today. Which patient most requires the nurse's immediate attention? A. A female patient with BPD who takes valproic acid [Depakene] and who reports nausea and vomiting B. A male patient with BPD who takes lithium and who has a lithium level of 1.6 mEq/L C. A male patient with depression who takes fluoxetine [Prozac] and who reports sexual dysfunction D. A female patient with schizophrenia who takes haloperidol [Haldol] and who has a blood pressure of 102/72 mm Hg

B. A male patient with BPD who takes lithium and who has a lithium level of 1.6 mEq/L Lithium levels above 1.5 mEq/L should be reported, because this level may indicate impending serious toxicity. The other findings may be side effects of the drugs the patients are taking, but they are not priority problems.

The nurse is preparing to give ethosuximide [Zarontin]. The nurse understands that this drug is only indicated for which seizure type? A. Tonic-clonic B. Absence C. Simple partial D. Complex partial

B. Absence Absence seizures are the only indication for ethosuximide. The drug effectively eliminates absence seizures in approximately 60% of patients and effectively controls 80% to 90% of cases.

The nurse is caring for a patient whose seizures are characterized by a 10- to 30-second loss of consciousness and mild, symmetric eye blinking. Which seizure type does this most closely illustrate? A. Tonic-clonic B. Absence C. Atonic D. Myoclonic

B. Absence This scenario accurately describes absence seizures. Tonic-clonic seizures present with convulsions and muscle rigidity followed by muscle jerks. Patients may experience urinary incontinence and loss of consciousness. Atonic seizures cause sudden loss of muscle tone. Myoclonic seizures present with sudden muscle contractions that last but a second.

A nurse is preparing teaching materials about high-dose amoxicillin for a parent whose child has AOM. The child must meet which treatment guideline? A. Age 2 years or older with mild otalgia B. Age younger than 6 months with a certain diagnosis C. Weight of 10 lb with a certain diagnosis D. Age 2 years or older with bacterial AOM only

B. Age younger than 6 months with a certain diagnosis New guidelines for treating AOM in children stress the need for basing treatment on three factors: age, the severity of the illness, and the degree of diagnostic certainty. All children younger than 6 months of age should receive antibiotics, regardless of the diagnostic certainty or symptom severity. Observation is the preferred strategy in children age 2 years or older when the illness is not severe (mild otalgia and fever under 39°C). Weight is not a treatment guideline, nor is bacterial AOM alone.

A nurse caring for a patient who has diabetic ketoacidosis recognizes which characteristics in the patient? (Select all that apply.) A. Type 2 diabetes B. Altered fat metabolism leading to ketones C. Arterial blood pH of 7.35 to 7.45 D. Sudden onset, triggered by acute illness E. Plasma osmolality of 300 to 320 mOsm/L

B. Altered fat metabolism leading to ketones D. Sudden onset, triggered by acute illness E. Plasma osmolality of 300 to 320 mOsm/L Diabetic ketoacidosis is the most severe manifestation of insulin deficiency in patients with type 1 diabetes. It develops and worsens acutely over several hours to days. Alterations in fat metabolism lead to the production of ketones and ketoacids. Increased ketoacid levels lead to a fall in arterial blood pH below 7.35. Altered glucose metabolism leads to hyperglycemia, water loss, and an elevated plasma osmolality (285 to 295 mOsm/L).

Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are products of which structure? A. Hypothalamus B. Anterior pituitary gland C. Posterior pituitary gland D. Ovaries

B. Anterior pituitary gland FSH and LH are secreted by the anterior pituitary gland. They both act on the ovaries to promote either follicular growth and development or ovulation and the development of the corpus luteum. They act in a negative feedback loop with the anterior pituitary gland and hypothalamus to affect the ovaries.

A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse, "Why am I receiving codeine? I don't have any pain." The nurse's response is based on the knowledge that codeine also has which effect? A. Immunostimulant B. Antitussive C. Expectorant D. Decongestant

B. Antitussive Codeine provides analgesic and antitussive therapeutic effects.

The nurse is reviewing the care of patients with AD. Which factors are associated with the pathophysiology of this disease? (Select all that apply.) A. Dilation and inflammation of cranial blood vessels B. Beta-amyloid and neuritic plaques C. Neurofibrillary tangles and tau D. Autoimmune changes in the myelin sheath E. Firing of hyperexcitable neurons throughout the brain F. Neuronal degeneration and decreased acetylcholine

B. Beta-amyloid and neuritic plaques C. Neurofibrillary tangles and tau F. Neuronal degeneration and decreased acetycholine AD is characterized by neuronal degeneration, reduced cholinergic transmission, beta-amyloid and neuritic plaques, and neurofibrillary tangles and tau. Dilation and inflammation of cranial blood vessels are associated with migraine. Multiple sclerosis is characterized by autoimmune changes in the myelin sheath, and epilepsy is associated with hyperexcitability of neurons and firing of those neurons throughout the brain.

A nurse teaches a patient who is to start taking brinzolamide [Azopt] about which adverse effect? A. Malaise B. Bitter aftertaste C. Dry mouth D. Photophobia

B. Bitter aftertaste Brinzolamide, a carbonic anhydrase inhibitor, is a topical treatment for elevated IOP in patients with POAG. It reduces the IOP by slowing the production of aqueous humor. Brinzolamide has mild adverse effects of transient blurred vision and a bitter aftertaste. Malaise is common with systemic carbonic anhydrase inhibitors. Dry mouth occurs with alpha2-adrenergic agonists. Photophobia is not associated with brinzolamide.

A nurse at a screening clinic for primary open-angle glaucoma (POAG) assesses patients for which major risk factors? (Select all that apply.) A. Hypertension B. Black race C. Familial history D. Advancing age E. Elevated intraocular pressure (IOP)

B. Black race C. Familial history D. Advancing age E. Elevated intraocular pressure (IOP) The risk factors for POAG include elevation of the IOP, black race, family history of POAG, and advancing age. Hypertension is not associated with the development of POAG.

A nurse should recognize that which therapies would be beneficial to a patient with BPH? (Select all that apply.) A. Saw palmetto B. Botulinum [Botox] C. Tolterodine [Detrol] D. Alfuzosin [Uroxatral] E. Sildenafil [Viagra]

B. Botulinum [Botox] C. Tolterodine [Detrol] D. Alfuzosin [Uroxatral] Botulinum (by single injection into the prostate), tolterodine (a muscarinic antagonist), and alfuzosin (an alpha blocker) are newer drug therapies used to relieve urinary symptoms associated with BPH. Viagra is used to treat erectile dysfunction. Saw palmetto, an herbal preparation, has been widely used to treat BPH, but recent research has shown it is not effective.

A surgical intensive care unit patient has been on a propofol drip for an extended period of time related to multiple injuries and surgeries. The nurse knows to monitor for which signs of propofol infusion syndrome? (Select all that apply.) A. Metabolic alkalosis B. Cardiac failure C. Respiratory failure D. Renal failure E. Rhabdomyolysis

B. Cardiac failure D. Renal failure E. Rhabdomyolysis Rarely, prolonged, high-dose infusion leads to propofol infusion syndrome, characterized by metabolic acidosis, cardiac failure, renal failure, and rhabdomyolysis. Patients should be on a ventilator if they are on a propofol infusion because of respiratory depression.

Which statement should the nurse include in the teaching plan for a patient being started on levodopa/carbidopa [Sinemet] for newly diagnosed Parkinson's disease? A. Take the medication on a full stomach. B. Change positions slowly. C. The drug may cause the urine to be very dilute. D. Carbidopa has many adverse effects.

B. Change positions slowly Postural hypotension is common early in treatment, so the patient should be instructed to change positions slowly. Administration with meals should be avoided, if possible, because food delays the absorption of the levodopa component. If the patient is experiencing side effects of nausea and vomiting, administration with food may need to be considered. The levodopa component in Sinemet may darken the color of the urine. Carbidopa has no adverse effects of its own.

A nurse administers dexamethasone [Decadron], 1 mg, at 11:00 PM to a patient who has suspected adrenal dysfunction. The nurse obtains blood for which of these laboratory tests at 8:00 AM the next morning? A. Potassium B. Cortisol C. Glucose D. Sodium

B. Cortisol The overnight dexamethasone suppression test is used to diagnose Cushing's syndrome. Normally, dexamethasone acts to suppress the release of ACTH, thereby suppressing the release of cortisol. In a patient with Cushing's disease, no cortisol suppression occurs. Potassium, glucose, and sodium are not used as measures of adrenal function.

Which skeletal muscle relaxant is also the drug of choice for treating malignant hyperthermia? A. Baclofen [Lioresal] B. Dantrolene [Dantrium] C. Diazepam [Valium] D. Tizanidine [Zanaflex]

B. Dantrolene [Dantrium] Dantrolene, a direct-acting skeletal muscle relaxant, is the preferred treatment for malignant hyperthermia. Malignant hyperthermia is a life-threatening syndrome that usually occurs when a general anesthetic is used with a neuromuscular blocking agent. It presents with muscle rigidity and profound temperature elevation.

The nurse is assessing a patient receiving dihydroergotamine [Migranal] for potential side effects. Which symptom, if found, would indicate a side effect of this drug? A. Nausea and vomiting B. Diarrhea C. Physical dependence D. Constipation

B. Diarrhea Diarrhea is a common problem with dihydroergotamine. The advantage of dihydroergotamine is that, unlike ergotamine, it does not cause nausea, vomiting, or physical dependence. Dihydroergotamine is not associated with constipation.

A patient with Parkinson's disease is prescribed pramipexole [Mirapex] along with his levodopa/carbidopa [Sinemet]. Which symptom is most likely a manifestation of an adverse effect of these drugs when given together? A. Diarrhea B. Dyskinesia C. Wheezing D. Headache

B. Dyskinesia When pramipexole is combined with the levodopa component in Sinemet, patients are most likely to experience symptoms of dyskinesias, such as dyskinesia (head bobbing) and orthostatic hypotension. The other effects are not common responses to these drugs.

A nurse teaches a health education class to male adolescents. Which of these topics should be a priority for the nurse to include? A. Adoption of healthy lifetime hygienic practices B. Effects of performance-enhancing androgens C. Pituitary gland regulation of sexual development D. Self-esteem issues related to delayed onset of puberty

B. Effects of performance-enhancing androgens The nurse should consider the developmental stages and tasks of adolescents to understand why androgens may appeal to this group. However, the effects of androgens have potentially hazardous long- and short-term health effects that are essential to convey to adolescent males. The harmful physiologic effects of performance-enhancing androgens take priority over the health promotion teaching topics. Healthy hygienic practices, pituitary gland function, and self-esteem issues are important topics to include, but not as important health issues as the risks of taking androgens.

A nurse is teaching a class to new parents about the prevention of AOM. Which strategies should the nurse include? (Select all that apply.) A. Avoid day care and childcare centers when respiratory infections are prevalent. B. Eliminate exposure to tobacco smoke. C. Encourage the use of pacifiers after 6 months. D. Promote bottle feeding in an upright position. E. Use a topical antibiotic monthly after age 2 years.

B. Eliminate exposure to tobacco smoke. D. Promote bottle feeding in an upright position. The risk of acquiring AOM can be reduced by avoiding childcare centers when respiratory infections are prevalent and by eliminating exposure to tobacco smoke and avoiding supine bottle feeding. Reducing pacifier use after age 6 months may be an additional benefit. Topical antibiotic use does not reduce the risk of acquiring AOM and is not recommended.

Which finding in a patient taking levothyroxine [Synthroid] and warfarin [Coumadin] would require follow-up by a nurse? A. Cardiac dysrhythmias B. Excessive bruising C. Weight loss of 5 kg D. Shortness of breath

B. Excessive bruising Levothyroxine intensifies the effect of warfarin, an anticoagulant that increases the patient's risk for bleeding. The warfarin dose may need to be reduced. Bruising, weight loss, and shortness of breath are not effects associated with interactions of levothyroxine and warfarin.

The nurse in the emergency department is caring for a patient with a suspected overdose of diazepam [Valium]. Which agent is most likely to be administered to reverse the effects of diazepam? A. Naloxone [Narcan] B. Flumazenil [Romazicon] C. Acetylcysteine [Mucomyst] D. Vitamin K

B. Flumazenil [Romazicon] Flumazenil [Romazicon], a benzodiazepine receptor antagonist, is the treatment of choice for overdose of the benzodiazepine diazepam [Valium]. Naloxone [Narcan] is used to reverse opioid overdose. Acetylcysteine [Mucomyst] is used to reverse acetaminophen [Tylenol] overdose. Vitamin K is used to reverse warfarin toxicity.

A nurse is caring for a patient with decreased triiodothyronine (T3) and thyroxine (T4) and elevated thyroid-stimulating hormone (TSH) levels. The nurse knows the patient is likely suffering from what? A. Thyrotoxicosis B. Hypothyroidism C. Hyperthyroidism D. Graves' disease

B. Hypothyroidism The anterior pituitary increases the production of TSH when thyroid hormone levels of T3 and T4 are reduced, reflecting primary hypothyroidism. Patients may experience fatigue caused by a lowered basal metabolic rate. Thyrotoxicosis, hyperthyroidism, and Graves' disease are medical conditions indicative of excessive thyroid activity.

The nurse is planning care for a patient receiving morphine sulfate [Duramorph] by means of a patient-controlled analgesia (PCA) pump. Which intervention may be required because of a potential adverse effect of this drug? A. Administering a cough suppressant B. Inserting a Foley catheter C. Administering an antidiarrheal D. Monitoring liver function tests

B. Inserting a Foley catheter Morphine can cause urinary hesitancy and urinary retention. If bladder distention or inability to void is noted, the prescriber should be notified. Urinary catheterization may be required. Morphine acts as a cough suppressant and an antidiarrheal, so neither of those types of drugs would be needed to counteract an adverse effect of morphine. Liver toxicity is not a common adverse effect of morphine.

The nurse is reviewing the anesthetic record for a postoperative patient. The nurse notes that morphine sulfate, an opioid, was given during the operative procedure. What is the rationale for giving an opioid as part of balanced anesthesia? A. It promotes generalized muscle relaxation. B. It allows a lower dose of the general anesthetic. C. It reduces the adverse effects of surgery. D. It prevents postoperative respiratory depression.

B. It allows a lower dose of the general anesthetic. An opioid enhances analgesia and reduces the required dosage of the general anesthetic. Opioids are not muscle relaxants. They can cause respiratory depression and do not necessarily reduce the adverse effects of surgery.

Which statements about levothyroxine [Synthroid] are correct? (Select all that apply.) A. Levothyroxine should be taken with food. B. Levothyroxine can be given by IV but is usually taken orally. C. Levothyroxine brands should not be changed if possible. D. Levothyroxine should be taken at night to avoid adverse effects. E. Levothyroxine can affect the metabolism of other medications.

B. Levothyroxine can be given by IV but is usually taken orally. C. Levothyroxine brands should not be changed if possible. E. Levothyroxine can affect the metabolism of other medications. Levothyroxine is almost always administered by mouth. Oral doses should be taken once daily on an empty stomach (to enhance absorption). Dosing is usually done in the morning, at least 30 to 60 minutes before breakfast. Maintain patients on the same brand-name levothyroxine product. Intravenous administration is used for myxedema coma and for patients who cannot take levothyroxine orally. Levothyroxine affects the metabolism of other medications, including warfarin.

The nurse anticipates giving propofol [Diprivan] to a patient who is undergoing mechanical ventilation. Which is an expected outcome for this medication? A. Improved respiratory excursion and oxygenation B. Loss of consciousness and hypotension C. Decreased respiratory and gastric secretions D. Analgesia and muscle relaxation

B. Loss of consciousness and hypotension Diprivan is an intravenous (IV) sedative-hypnotic used for sedation during mechanical ventilation. It can cause profound respiratory depression and hypotension. It does not improve excursion or oxygenation, nor does it decrease secretions. It does not have analgesic or muscle-relaxant properties.

The nurse is caring for a female patient receiving sumatriptan [Imitrex]. Which concept guides the nursing care of this patient? A. Coronary vasospasm is a common problem with this drug. B. Many patients experience symptoms of chest pressure or heavy arms. C. Sumatriptan increases the risk of nausea and vomiting with migraines. D. Sumatriptan is considered safe to use during pregnancy.

B. Many patients experience symptoms of chest pressure or heavy arms. About 50% of patients taking sumatriptan have chest symptoms, including a feeling of "heavy arms" or chest pressure. These symptoms subside, and they do not indicate cardiac ischemia. Coronary vasospasm can occur but is rare. Patients with coronary artery disease should avoid sumatriptan. Sumatriptan relieves not only headache but also other migraine-associated symptoms, such as photophobia, nausea, and phonophobia. Sumatriptan may cause harm to the developing fetus and should be avoided in pregnancy. It is classified as Pregnancy Risk Category C.

The nurse is caring for a patient hospitalized with an acute episode (relapse) of MS. Which agent is the preferred treatment during relapse? A. Interferon beta-1a [Avonex] IM B. Methylprednisolone [Solu-Medrol] IV C. Glatiramer acetate [Copaxone] subQ D. Natalizumab [Tysabri] IV infusion

B. Methylprednisolone [Solu-Medrol] IV During an acute relapse episode of MS, the treatment of choice is a high-dose IV glucocorticoid, such as methylprednisolone, to reduce the inflammation and diminish symptoms. The other agents are disease-modifying drugs that are used in the long-term management of MS.

The nurse is caring for a patient who is receiving lidocaine [Xylocaine] by epidural injection. Which nursing intervention is most important when caring for this patient? A. Keeping the patient in a supine position for about 12 hours B. Monitoring the patient's blood pressure throughout the epidural infusion C. Preparing a double tourniquet for use during the infusion D. Reducing the intravenous (IV) infusion rate to prevent hypertension

B. Monitoring the patient's blood pressure throughout the epidural infusion Hypotension is the most common complication with epidural anesthetics. Monitoring of the blood pressure is an essential nursing intervention. Supine positioning is not required for epidural injections (spinal only). A double tourniquet is used for regional anesthesia. Hypertension is not an anticipated outcome.

The nurse is working with the multidisciplinary healthcare team to optimize the care of a patient with schizophrenia. Which concepts will guide the nursing care of this patient? (Select all that apply.) A. The second-generation antipsychotics generally are more effective than the first-generation agents. B. Most antipsychotic agents increase the risk of mortality in elderly patients with dementia. C. Antipsychotic depot preparations carry a greater risk of neuroleptic malignant syndrome. D. The lipid levels of patients receiving second-generation antipsychotics should be monitored. E. Schizophrenia is characterized by disordered thinking and loss of touch with reality.

B. Most antipsychotic agents increase the risk of mortality in elderly patients with dementia. D. The lipid levels of patients receiving second-generation antipsychotics should be monitored. E. Schizophrenia is characterized by disordered thinking and loss of touch with reality. The first- and second-generation antipsychotics are considered equally effective, even though the second-generation agents are more widely used today. Most antipsychotics should be avoided in elderly patients with dementia because of increased mortality. Antipsychotic depot preparations are effective for the long-term control of schizophrenia and do not have an increased risk of side effects. Second-generation antipsychotics may cause weight gain, diabetes, and dyslipidemia. Schizophrenia is characterized by disordered thinking and loss of touch with reality.

Which medication used for the management of multiple sclerosis cannot be self-administered? A. Fingolimod [Gilenya] B. Natalizumab [Tysabri] C. Glatiramer acetate [Copaxone] D. Interferon beta-1b [Betaseron]

B. Natalizumab [Tysabri] Natalizumab [Tysabri] is administered by intravenous infusion over 1 hour. The patient must be observed during the infusion and also must be monitored for 1 hour after the infusion is complete. Before this medication can be prescribed and administered, everyone involved with the drug—patients, physicians, pharmacists, infusion nurses, and infusion centers—must be registered with the TOUCH Prescribing Program. The other medications can be self-administered: fingolimod (oral), glatiramer acetate, and interferon beta-1b (subcutaneous injection).

An emergency department patient reports that she took frovatriptan 2.5 mg at home an hour ago but still has a migraine. Which action should the nurse take next? A. Give a second dose of frovatriptan. B. Notify the healthcare provider. C. Provide education about the use of frovatriptan. D. Administer a different migraine medication.

B. Notify the healthcare provider. Notify the healthcare provider. Do not give a second dose. The initial dose is 2.5 mg. If headache recurs after initial relief, dosing can be repeated—but no sooner than 2 hours after the first dose. If there was no response to the first dose, repeat dosing is unlikely to help. The maximum dose per 24 hours is 7.5 mg.

An adult patient presents to the emergency department and is diagnosed with a severe migraine headache. Which classes of medication would the nurse expect to be ordered for this patient? (Select all that apply.) A. Beta blocker B. Opioid analgesic C. Migraine-specific agent D. Antiemetic E. Aspirin-like agent

B. Opioid analgesic C. Migraine-specific agent D. Antiemetic For a severe attack, the patient likely will be given a migraine-specific agent. If that is ineffective, an opioid analgesic is indicated. Migraine headaches often are accompanied by nausea and vomiting; therefore, an antiemetic may be indicated as well. Beta blockers are used for preventive therapy, not for an acute attack. Aspirin-like agents are used for mild to moderate symptoms.

The nurse identifies which most common serious adverse effect of TCA therapy? A. Excitation B. Orthostatic hypotension C. Skin rash D. Sexual dysfunction

B. Orthostatic hypotension Orthostatic hypotension is the most common adverse effect of tricyclic antidepressant therapy.

Which measurements should a nurse obtain to evaluate the effects of androgen therapy on the epiphyses of a patient with hypogonadism? A. Monthly height and weight B. Periodic hand and wrist x-rays C. Body mass/fat ratio indices D. Blood testosterone levels

B. Periodic hand and wrist x-rays Hypogonadism is a condition in which the testes fail to produce adequate amounts of testosterone. One adverse effect of androgen therapy, which is used to correct the condition, is premature epiphyseal closure. X-rays of the wrist and hand should be performed every 6 months to evaluate androgen's effects, which could decrease adult height. Monthly height and weight, body mass/fat ratio indices, and blood testosterone levels are not effective for determining the effects of androgen therapy on epiphyseal closure.

Androgens are prescribed for a patient with anemia. The nurse is aware that the action of the androgen in this patient is what? A. Iron replacement B. Promoting synthesis of erythropoietin C. Prevention of blood loss D. Increase in bone formation

B. Promoting synthesis of erythropoietin Androgens may be used in men and women to treat anemias that have been refractory to other therapy. Androgens help relieve anemia by promoting synthesis of erythropoietin;the renal hormone that stimulates production of red blood cells. Androgens may also stimulate production of white blood cells and platelets. Anemias that may respond include aplastic anemia, anemia associated with renal failure, Fanconi's anemia, and anemia caused by cancer chemotherapy.

A patient who has type 2 diabetes is taking nateglinide [Starlix]. Which response should a nurse expect the patient to have if the medication is achieving the desired therapeutic effect? A. Inhibition of carbohydrate digestion B. Promotion of insulin secretion C. Decreased insulin resistance D. Inhibition of ketone formation

B. Promotion of insulin secretion Nateglinide is a meglitinide medication that acts to increase pancreatic insulin release. It is used as an adjunct to calorie restriction and exercise to maintain glycemic control in patients with type 2 diabetes. It does not act to reduce insulin resistance or inhibit carbohydrate digestion. It should not be used to manage diabetic ketone formation, because its glucose-lowering effects are too slow to be of benefit.

A nurse notices that one of the anesthesiologists returns from the staff lounge every day in a brief state of euphoria after her break. The nurse speaks to the unit manager, because she is concerned about abuse of which of these medications? A. Clonidine B. Propofol C. Midazolam D. Lorazepam

B. Propofol Although not regulated as a controlled substance, propofol is subject to abuse, primarily by anesthesiologists, nurse anesthetists, and other medical professionals, all of whom have easy access to the drug. Clinicians use it to produce instantaneous (but brief) sleep, after which they wake up feeling refreshed. When patients awake after receiving propofol, they often are talkative and report feeling elated and even euphoric.

A nurse administers pilocarpine [Pilocar] eye drops to a patient who has glaucoma. The nurse would expect an increase in which outcome if the medication is having the desired effect? A. Aqueous inflow B. Pupillary constriction C. Aqueous production D. Pupillary dilation

B. Pupillary constriction Pilocarpine is a direct-acting cholinergic agonist that is used as a miotic in the treatment of open-angle glaucoma. In addition, contraction of the ciliary muscle lowers the IOP. Miosis causes pupillary constriction, increasing the outflow of aqueous humor. Aqueous inflow and production and pupillary dilation are not expected therapeutic responses to pilocarpine.

Which cholinesterase inhibitor has the highest incidence of adverse gastrointestinal (GI) effects? A.Donepezil [Aricept] B. Rivastigmine [Exelon] C. Galantamine [Reminyl] D. Memantine [NMDA]

B. Rivastigmine All these drugs have the potential to cause GI distress, including nausea, vomiting, anorexia, and weight loss. Rivastigmine is thought to have the highest probability of producing these effects. Memantine (NMDA) is not a cholinesterase inhibitor.

The nurse is caring for a patient with MS who is having worsening recurrent episodes of neurologic dysfunction followed by periods of partial recovery. How would this subtype be classified? A. Relapsing-remitting B. Secondary progressive C. Primary progressive D. Progressive-relapsing

B. Secondary progressive Relapsing-remitting MS is marked by defined episodes of neurologic dysfunction separated by periods of partial or full recovery. In secondary progressive MS, the patient with the relapsing-remitting subtype experiences declining function with or without occasional recovery of function. Primary progressive MS presents with progressive decline of function from the onset. Progressive-relapsing MS is rare and is similar to primary progressive but has acute episodes in addition to the progressively worsening dysfunction.

The nurse is caring for a patient in the emergency department who reports the onset of agitation, confusion, muscle twitching, diaphoresis, and fever about 12 hours after beginning a new prescription for escitalopram [Lexapro]. Which is the most likely explanation for these symptoms? A. Depressive psychosis B. Serotonin syndrome C. Escitalopram overdose D. Cholinergic crisis

B. Serotonin syndrome Serotonin syndrome can occur within 2 to 72 hours after initiation of treatment with an SSRI. The symptoms include altered mental status, incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, and fever.

The nurse knows that local anesthetics stop axonal conduction by blocking what? A. Potassium channels in the axonal membrane B. Sodium channels in the axonal membrane C. Calcium channels in the axonal membrane D. Protein channels in the axonal membrane

B. Sodium channels in the axonal membrane Local anesthetics stop axonal conduction by blocking sodium channels in the axonal membrane. Propagation of an action potential requires movement of sodium ions from outside the axon to the inside. This influx takes place through specialized sodium channels. By blocking axonal sodium channels, local anesthetics prevent sodium entry, thereby bringing conduction to a halt.

Which outcome should a nurse establish for a patient who has acromegaly and is receiving octreotide [Sandostatin]? A. Normal urine volume B. Softening of facial features C. Increase in long-bone growth D. Stimulation of the milk reflex

B. Softening of facial features Octreotide suppresses GH, which is excessive in acromegaly. This results in coarse facial features, splayed teeth, and large hands and feet. Treatment with octreotide reduces the continued development of these effects. The epiphyses have closed in adults, so height is not affected. Urine volume is affected by antidiuretic hormone. Prolactin stimulates the milk reflex.

The nurse has just administered the first dose of haloperidol [Haldol] to a patient with schizophrenia. Which finding, if present, is the most important for the nurse to report to the healthcare provider before administering the next dose of medication? A. Dry mouth B. Temperature of 101°F C. BP of 104/72 mm Hg D. Drowsiness

B. Temperature of 101°F Sudden high fever is a symptom of neuroleptic malignant syndrome, a rare but serious complication of high-potency, first-generation antipsychotics, such as haloperidol. The other findings are potential side effects of the drug but would not necessarily need to be reported to the healthcare provider.

The nurse is working on a postoperative unit in which pain management is part of routine care. Which statement is the most helpful in guiding clinical practice in this setting? A. At least 30% of the U.S. population is prone to drug addiction and abuse. B. The development of opioid dependence is rare when opioids are used for acute pain. C. Morphine is a common drug of abuse in the general population. D. The use of PRN (as needed) dosing provides the most consistent pain relief without risk of addiction.

B. The development of opioid dependence is rare when opioids are used for acute pain. The development of dependence on or addiction to opioids as a result of clinical exposure is extremely rare. In fact, some estimate that only 25% of patients receive doses of opioids that are sufficient to relieve suffering. Only about 8% of the population is estimated to be prone to drug abuse. Morphine is a drug of abuse, but this fact is not helpful in guiding clinical practice. A patient-controlled analgesia (PCA) pump provides the most consistent pain relief, better than PRN and fixed-dosing schedules.

The nurse suspects that a female patient is experiencing phenytoin toxicity if which manifestation is noted? (Select all that apply.) A. The patient complains of excessive facial hair growth. B. The patient is walking with a staggering gait. C. The patient's gums are swollen, tender, and bleed easily. D. The patient complains of double vision. E. The nurse observes rapid back-and-forth movement of the patient's eyes.

B. The patient is walking with a staggering gait. D. The patient complains of double vision. E. The nurse observes rapid back-and-forth movement of the patient's eyes. Manifestations of phenytoin toxicity can occur when plasma levels are higher than 20 mcg/mL. Nystagmus (back-and-forth movement of the eyes) is a common indicator of toxicity, as are ataxia (staggering gait), diplopia (double vision), sedation, and cognitive impairment. Hirsutism (excess hair growth in unusual places) and gingival hyperplasia (swollen, tender, bleeding gums) are adverse effects of phenytoin.

The nurse identifies which antidepressant as effective in the treatment of generalized anxiety disorder (GAD)? (Select all that apply.) A. Fluoxetine [Prozac] B. Venlafaxine [Effexor XR] C. Paroxetine [Paxil] D. Escitalopram [Lexapro] E. Duloxetine [Cymbalta]

B. Venlafaxine [Effexor XR] C. Paroxetine [Paxil] D. Escitalopram [Lexapro] E. Duloxetine [Cymbalta] Fluoxetine [Prozac] is not approved for the treatment of generalized anxiety disorder. All the other medications listed are approved for the treatment of GAD.

Pyrazinamide

Bactericidal AE: Hepatotoxicity, non-gouty pararthralgias, hyperuricemia, GI, photosensitivity, dermatitis

Metronidazole

Bactericidal (anaerobes only) -Disrupts DNA synthesis Use: Protozoal infections (Trichomonas) obligate anaerobe infections, H. pylori infections, CDI AE: Neurotoxicity, allergy, superinfections Interaction; ETOH, alcohol (disulfiram-like reaction)

Daptomycin

Bactericidal (gram-positive, include MRSA) Use: Sepsis with S/ aureus, complicated skin infections AE; Myopathy (small risk)

Beta Blockers - Propranolol

Beneficial in thyrotoxic crisis Use: -Suppress tachycardia and other symptoms of Graves' disease Therapeutic effects: -Derived from beta-adrenergic blockade, not from reducing levels of T3 or T4

Antipsychotic Drugs

Benefit patients with or without psychotic symptoms Can be combined with a mood stabilizer *second generation antipsychotics are preferred treatment for bipolar disorder Acute: -Symptom control during manic episodes Long term: -Help stabilize mood Approved for use: -Olanzapine -Quetiapine -Risperidone -Aripiprazole -Ziprasidone

Drugs Used for Treatment of Insomnia

Benzodiazepines Benzodiazepine-like drugs -Zolpidem -Zaleplon -Eszopiclone Ramelteon -Melatonin agonist, which is approved for longterm use -Good for falling asleep but not staying asleep Antidepressants -Trazodone (used a lot for sleep. Atypical antidepressant with strong sedative actions. can decrease sleep latency and prolong sleep duration. Does not cause tolerance or physical dependence) -Doxepin (TCA with sedation. Old TCA with strong sedative actions. Used to treat patients who have trouble staying asleep) Antihistamines -Diphenhydramine (benadryl. Weird nightmares, all kinds of CNS type things) -Doxylamine -Can be purchased without prescription -Less effective than others -Tolerance develops quickly (in 1 to 2 weeks) -Adverse effects: daytime drowsiness & anticholinergic effects. Associated with mental fog, forgetfulness Herbals -Melatonin appears to be moderately effective -Valerian root, chamomile, passionflower, lemon balm, and lavender have very mild sedative effects -Proof of benefits for insomnia is lacking

Bronchodilators

Beta2-adrenergic agonists Use for: Symptomatic relief Asthma & COPD use with ICS Activation of Beta 2 receptors in lungs, causing bronchodilation Also, suppress histamine release, increase ciliary motility. Albuterol -Inhaled or po -Short-acting beta antagonist (SABA) -Use PRN to abort an ongoing attack -EIB -Patient education: separate puffs by 1 min Salmeterol (Advair) -Inhaled -Long-acting beta atagonist (LABA) Use: long-term control in patients with frequent attacks. Fixed schedule -Stable COPD -For asthma, combine with glucocorticoid AE (inhaled): Tachycardia, palpitations, angina, tremor, insomnia, sweating, anxiety/agitation AE (PO): angina, tachydysrhythmias (toxicity), tremor Methylxanthines Theophylline Use: PO for maintenance therapy of chronic stable asthma, also IV -Asthma and COPD Relaxes smooth muscle in lungs, bronchodilation Narrow therapeutic index AE: Hyperactivity Interactions: Caffeine, chocolate; phenobarbital, phenytoin, rifampin (reduce theophylline); cimetidine, fluoroquinolones (increase) Anticholinergics Ipratropium*** -Inhaled, short-acting -Effects begin in 30 sec, max in 3 min, last 6 hours Use: COPD, off-label for asthma Blocks muscarinic receptors in bronchi, bronchodilation AE: xerostomia, irritation of pharynx, glaucoma, CV event Tiotropium -Inhaled, long-acting -Effects begin in 30 min, peak in 3 hours, last 24 hours -Plateau after 8 days of consecutive dosing Use for: Bronchospasm d/t COPD, NOT for asthma. Anticholinergic agent, blocks muscarinic receptors in lung AE: xerostomia, cough (powder inhalations) Requires coordination-- hard to put capsule in device Combinations ICS /LABA -long-term maintenance Anticholinergic/LABA

Growth hormone

Biologic effects -Promotes growth -Promotes protein synthesis -Carbohydrate metabolism Physiology -Regulation of release -Biologic effects -Promotion of protein synthesis -Effect on carbohydrate metabolism Pathophysiology Deficiency Pediatric: short stature, slowed growth, mental function not impaired Adult: Reduced muscle mass Treatment: Replacement therapy Excess Pediatric: Gigantism (7-9 ft tall) -Treatment: removal of pituitary gland Adult: acromegaly if epiphyses already closed -Treatment: surgery, radiation Uses Pediatric: growth hormone deficiency, non-growth hormone-deficient short stature, short stature associated with Prader-Willis syndrome (PWS) Adult: growth hormone deficiency Adverse effects and interactions -Hyperglycemia -Neutralizing antibodies -Interaction with glucocorticoids -Fatality with PWS

MS Symptom Management

Bladder dysfunction (when you think of MS, think of bladder dysfunction) Detrusor hyperreflexia -Tolterodine -Oxybutynin -Darifenacin -Solifenacin Detrusor-sphinctor dyssynergia Promote sphincter to relax, use in patients with BPH. -Tamsulosin -Terazosin Flaccid bladder With patients with repaired bladder emptying -Bethanechol Fatigue Stimulants: -Modafinil -Methylphenidate -Amphetamine mixture Selective serotonin reuptake inhibitors (SSRIs) Bowel dysfunction Constipation -Increase dietary fibers and fluids -Taking fiber supplements -Regular exercise -Bulk-forming laxative such as psyllium Fecal incontinence -Establishing regular bowel routine -Use bulk-forming laxative -Anticholinergic agent (hyoscyamine) to reduce bowel motility Depression -Fluoxetine -Sertraline -Bupropion -TCAs: Amitriptyline, Nortriptyline Spasticity Non-drug measures -Physical therapy -Stretching -Regular exercise Medications -Baclofen and tizanidine (caution: high doses of either agent can exacerbate MS-related muscle weakness) -Diazepam and botulinum toxin -Intrathecal infusion of baclofen Neuropathic pain Anti-epileptic drugs -Carbamazepine -Gabapentin -Oxcarbazepine Anti-depressants -Nortriptyline -Imipramine -Amitriptyline Cognitive dysfunction -Donepezil (cholinesterase inhibitor developed for AD) -Memantine (N-methyl-D-aspartate receptor blocker developed for AD) Dizziness and vertigo -Meclizine: used for motion sickness -Ondansetron: powerful antiemetic

Discuss the blood-brain barrier, the fetal-placental barrier, their influence on drugs, and the application to practice

Blood-brain barrier -Anatomy of capillaries in the CNS. -have tight junctions between cells that compose walls of most capillaries in CNS. -Prevents drug passage -To reach sites of action in the brain, drug must pass through cells of capillary wall -So only drugs that are lipid soluble or have transport system can cross BBB. -BBB also has P-glycoprotein; A transporter that pumps drugs out of cells and back into the blood. T -This is good because it protects brain from toxic substances -This is bad because it is obstacle to therapy of CNS disorders. -Newborns have sensitivity to medicines that act on brain because BBB is not fully developed at birth. Fetal-placental barrier -Placenta membranes separate maternal circulation from fetal circulation -Do NOT constitute absolute barrier to drugs. -Lipid-soluble, ionized compounds readily pass -Compounds that are ionized, highly polar, or protein bound are excluded (& drugs that are substrates for P-glycoprotein) -Some compounds can cause birth defects -If pregnant women use opioids (heroin), child will be drug dependent -Use of respiratory depressants (anesthetics and analgesics) can cause depress respiration in baby.

Ergot Derivatives (Dopamine Agonist)

Bromocriptine Uses: -Monotherapy for early PD -Combination with levodopa for advanced PD MOA: -Direct acting dopamine agonist -activates dopamine receptors in brain Advantages: -Combined with levodopa, can prolong therapeutic responses and reduce motor fluctuations -Allows for reduced levodopa dosage -Reduced incidence of levodopa-induced dyskinesias Adverse effects: -Nausea -Psychological reactions: confusion, nightmares, agitation, hallucinations, paranoid delusions -Pulmonary infiltrates, Raynaud-like phenomenon, valvular heart disease These drugs are poorly tolerated and have limited use in treatment of PD

Other Loop Diuretics

Bumetanide Torsemide Ethacrynic acid All can cause: Similar adverse effects as furosemide, but can also cause lipid changes which can be problem (decreasing good HDLs and increasing LDLs) -Ototoxicity -Hypovolemia -Hypotension -Hypokalemia -Hyperuricemia -Lipid changes

Atypical Antidepressants

Bupropion Uses: -Major depressive disorder -Seasonal affective disorder -Smoking cessation -ADHD MOA: -Acts as a CNS stimulant and suppresses appetite -Antidepressant effects begin in 1 to 3 weeks -Does not affect serotonergic, cholinergic, or histaminergic transmission Adverse effects: -Seizures -Agitaiton -Tremor -Tachycardia -Blurred vision -Dizziness -Headache -Insomnia -Dry mouth -GI -Constipation -Weight loss Drug interactions: MAOIs can increase the risk of bupropion toxicity -MAOIs should be discontinued 2 weeks before starting buproprion Ordered to help stop smoking too

Which statement by a nursing student indicates a need for further instruction? A. "Phenylephrine is an adrenergic agonist that produces pupil dilation." B. "Fluorescein may be applied to the surface of the eye to assess for corneal abrasions." C. "Artificial tears should not be used more than 4 times daily to avoid adverse effects." D. "Oral carbonic anhydrase inhibitors, such as acetazolamide, may be used in the management of open-angle glaucoma refractory to preferred medications."

C. "Artificial tears should not be used more than 4 times daily to avoid adverse effects." Artificial tears are devoid of adverse effects and may be administered as long and as often as desired. The other four statements are accurate.

The nurse is caring for a patient taking buspirone [BuSpar]. Which statement by the patient indicates a need for further teaching about this drug? A. "This medication should not make me feel drowsy." B. "This medication should help me feel less anxious." C. "I will drink grapefruit juice instead of coffee with breakfast." D. "I will take my medication three times per day."

C. "I will drink grapefruit juice instead of coffee with breakfast." Grapefruit juice can greatly increase buspirone levels and should be avoided. The other statements are appropriate.

A patient with Graves' disease is treated with iodine-131 therapy. Which statement by the patient would indicate understanding of the treatment's effects? A. "I'll have to isolate myself from my family so I don't expose them to radiation." B. "I'm looking forward to feeling better immediately after this treatment." C. "I'll tell my doctor if I have fatigue, hair loss, or cold intolerance." D. "I'll need to take this drug on a daily basis for at least 1 year."

C. "I'll tell my doctor if I have fatigue, hair loss, or cold intolerance." Iodine-131 usually is given as a single treatment to produce remission of Graves' disease. Fatigue, hair loss, and cold intolerance are signs of hypothyroidism, which is a complication of the treatment. Iodine-131 has a quick radioactive decay and half-life; therefore, isolation is not needed, but it can take up to 2 months for the desired response to develop.

A patient newly diagnosed with MS asks the nurse how a person gets this disease. Which response by the nurse is most accurate and appropriate? A. "Multiple sclerosis is a congenital condition that typically manifests itself in late adulthood." B. "Multiple sclerosis is a disease believed to be caused by exposure to drugs during a mother's pregnancy." C. "This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor." D. "This disease is most often caused by an increase of rapidly dividing cells in the central nervous system."

C. "This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor." Although the exact cause is unknown, MS is believed to have a genetic link. Susceptible individuals have an autoimmune response when exposed to environmental or microbial factors. It is more common among first-degree relatives of individuals who have the disease and is more prevalent among Caucasians. It also is more common in cooler climates, with increased incidence moving away from the equator. MS may also be associated with the Epstein-Barr virus, human herpesvirus 6, and Chlamydia pneumonia.

A patient with Parkinson's disease who has been positively responding to drug treatment with levodopa/carbidopa [Sinemet] suddenly develops a relapse of symptoms. Which explanation by the nurse is appropriate? A. "You have apparently developed resistance to your current medication and will have to change to another drug." B. "This is an atypical response. Unfortunately, there are no other options of drug therapy to treat your disease." C. "This is called the 'on-off' phenomenon. Your healthcare provider can change your medication regimen to help diminish this effect." D. "You should try to keep taking your medication at the current dose. These effects will go away with time."

C. "This is called the 'on-off' phenomenon. Your healthcare provider can change your medication regimen to help diminish this effect" Patients who have been taking levodopa/carbidopa for a period of time may experience episodes of symptom return. Adding other medications to the drug regimen can help minimize this phenomenon.

The nurse is teaching a patient with cancer about a new prescription for a fentanyl [Sublimaze] patch, 25 mcg/hr, for chronic back pain. Which statement is the most appropriate to include in the teaching plan? A. "You will need to change this patch every day, regardless of your pain level." B. "This type of pain medication is not as likely to cause breathing problems." C. "With the first patch, it will take about 24 hours before you feel the full effects." D. "Use your heating pad for the back pain. It will also improve the patch's effectiveness."

C. "With the first patch, it will take about 24 hours before you feel the full effects." Full analgesic effects can take up to 24 hours to develop with fentanyl patches. Most patches are changed every 72 hours. Fentanyl has the same adverse effects as other opioids, including respiratory depression. Patients should avoid exposing the patch to external heat sources, because this may increase the risk of toxicity.

The patient states that when he takes hydrocortisone 24 mg in the morning, he is very tired by mid-afternoon. Which statement by the nurse is correct? A. "You can take 12 mg in the morning and 12 mg at night." B. "You can take 24 mg at night instead." C. "You can take 16 mg in the morning and 8 mg in the afternoon." D. "This is an adverse effect and you should stop taking the medication."

C. "You can take 16 mg in the morning and 8 mg in the afternoon." To mimic normal cortisol secretion, patients can take the entire daily dose in the morning, immediately after waking. If this schedule results in afternoon or evening fatigue, patients may split the dosage, taking two-thirds in the morning and one-third around 4:00 PM. Patients should not stop taking their medication unless advised by their healthcare provider.

The student nurse prepares to administer ketamine to a patient. The supervising nurse questions this administration for which patient? A. A 6-year-old boy with an allergy to lidocaine B. A 55-year-old female with a history of hypertension C. A 40-year-old male with a history of bipolar disorder D. A 12-month-old with a history of burns

C. A 40-year-old male with a history of bipolar disorder In the past, ketamine was used primarily in children. However, an updated guideline, issued in 2011, now recommends expanding ketamine use to include adults, and babies between 3 and 12 months old. Because of its potential for adverse psychologic effects, ketamine should generally be avoided in patients with a history of psychiatric illness.

A nurse identifies therapeutic goals for androgen therapy for which patients? (Select all that apply.) A. A male patient with prostate cancer B. A female patient with breast cancer C. A male patient with hypogonadism D. A female patient with breast engorgement E. A female patient with acquired immunodeficiency syndrome (AIDS)

C. A male patient with hypogonadism D. A female patient with breast engorgement E. A female patient with acquired immunodeficiency syndrome (AIDS) Androgens are indicated to treat females with breast engorgement, to treat males with hypogonadism, and to reduce catabolic loss of muscle mass in patients with AIDS. Androgens are contraindicated in men with prostate cancer, because they can promote growth of the cancer. Androgens are no longer recommended for the treatment of breast cancer.

Administration of dantrolene [Dantrium] for the treatment of muscle spasticity is contraindicated in which patient? A. A patient with a C6 spinal cord injury B. A patient with cerebral palsy C. A patient with multiple sclerosis and underlying cirrhosis D. A patient experiencing malignant hyperthermia

C. A patient with multiple sclerosis and underlying cirrhosis Although dantrolene is effective for treating spasticity in multiple sclerosis, it is contraindicated in this patient because of the underlying liver disease. Dantrolene is useful for relieving muscle spasticity associated with cerebral palsy and spinal cord injury and, in intravenous form, for managing life-threatening malignant hyperthermia.

The nurse is caring for a patient taking lithium [Lithobid]. The nurse understands that many drugs interact with lithium. Which agent is safe to administer with lithium? A. Ibuprofen [Motrin] for muscle pain B. Hydrochlorothiazide (HCTZ) for edema C. Aspirin (ASA) for mild headache D. Diphenhydramine [Benadryl] for cold symptoms

C. Aspirin (ASA) for mild headache Aspirin is safe to use as an analgesic with lithium. Other nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can increase lithium levels by as much as 60%. Diuretics increase lithium levels by reducing the serum sodium level. Diphenhydramine has anticholinergic properties and can aggravate lithium-induced polyuria by causing urinary hesitancy.

For which underlying condition would treatment with betaxolol ophthalmic drops for open-angle glaucoma be contraindicated? A. History of asthma B. History of type 2 diabetes mellitus C. Asymptomatic first-degree heart block D. Newly diagnosed COPD

C. Asymptomatic first-degree heart block Betaxolol, a beta1-selective blocker, is contraindicated in patients with an AV block, as well as those with bradycardias and cardiogenic shock. Type 2 diabetes mellitus, asthma, and COPD are not contraindications for the administration of betaxolol.

A nurse should consider which diagnostic test a priority to obtain before a patient receives iodine-131? A. White blood cell (WBC) count B. Electrocardiogram (ECG) C. Beta human chorionic gonadotropin (hCG) test D. Creatinine level

C. Beta human chorionic gonadotropin (hCG) test Any female patient of reproductive age requires a negative result on a beta hCG (pregnancy hormone) test before iodine-131 (131I) can be administered. 131I is a radioactive isotope used to treat hyperthyroidism and is contraindicated in pregnancy and lactation. A WBC count, ECG, and creatinine level are not indicated before treatment with iodine-131.

Which assessment should a nurse monitor more frequently in a patient who takes both an alpha blocker for BPH and metoprolol [Lopressor]? A. Blood glucose level B. Hemoglobin level C. Blood pressure D. Urine output

C. Blood pressure Caution must be exercised in combining an alpha blocker (terazosin [Hytrin], doxazosin [Cardura], Tamsulosin [Flomax], alfuzosin [Uroxatral]) with an antihypertensive medication such as metoprolol, because severe hypotension could result. Blood glucose, hemoglobin, and urine output are not affected by combining an alpha blocker and a hypertensive medication.

A patient in cardiac arrest receives vasopressin [Pitressin] during cardiopulmonary resuscitation (CPR). An increase in which finding would indicate a desired effect of the medication? A. Respiratory rate B. Blood pH C. Blood pressure D. Body temperature

C. Blood pressure Vasopressin is a potent vasoconstrictor. Benefits derive from increased blood flow to the heart and brain during CPR. The blood pH, body temperature, and respiratory rate are not affected by vasopressin.

Which of the following measurements would prompt the nurse to hold the sumatriptan dose and contact the provider? A. Respiratory rate 20 B. Heart rate 59 C. Blood pressure 190/100 D. SpO2 90%

C. Blood pressure 190/100 Triptans are contraindicated in hypertension. The patient may be hypertensive because he or she is in pain, but the nurse should consult the provider before administering the dose.

A patient who took NPH insulin at 0800 reports feeling weak and tremulous at 1700. Which action should the nurse take? A. Take the patient's blood pressure. B. Give the patient's PRN dose of insulin. C. Check the patient's capillary blood sugar. D. Advise the patient to lie down with the legs elevated.

C. Check the patient's capillary blood sugar. The patient is showing symptoms of hypoglycemia at 5:00 PM. NPH has a peak action of 8 to 10 hours after administration. Based on the duration of action of NPH insulin, the patient's hypoglycemic symptoms are from the 8:00 AM injection of NPH insulin. An injection of NPH insulin at 2:00 AM, 1:00 PM, or 3:00 PM would not cause hypoglycemic symptoms based on the average duration of action of NPH insulin.

Which complaint by a patient taking fingolimod [Gilenya] requires prompt evaluation by the prescriber? A. Hair loss B. Backache C. Dizziness and fatigue D. Blue-green tint to the skin

C. Dizziness and fatigue Fingolimod slows the heart rate and can cause bradycardia. Dizziness and fatigue may be consequences of bradycardia. Backache is an adverse effect that occurs in 12% of patients taking the medication, but it does not require prompt attention. Reversible hair loss and a blue-green tint to the skin are adverse effects of mitoxantrone [Novantrone].

The nurse should monitor for which central nervous system (CNS) adverse effect that can result when sufficient amounts of local anesthetics are absorbed systemically? A. Hallucinations and nightmares B. Tremors of the lower extremities C. Excitation followed by depression D. Vertigo and nausea/vomiting

C. Excitation followed by depression Local anesthetics can cause CNS excitation followed by depression when large enough amounts are absorbed in the system. This can lead to drowsiness, loss of consciousness, and death.

The nurse is planning care for a patient with signs of acute adrenal insufficiency. What is the priority nursing diagnosis? A. Altered comfort B. Altered nutrition C. Fluid volume deficit D. Activity intolerance

C. Fluid volume deficit Acute adrenal insufficiency (adrenal crisis) is characterized by hypotension, dehydration, weakness, lethargy, and gastrointestinal (GI) symptoms of nausea and vomiting. Rapid replacement of fluid, salt, and glucocorticoids is essential to prevent shock and death. Comfort, nutrition, and activity are important to address once fluid balance has been restored.

Which nursing diagnosis should be the priority for a patient who is receiving desmopressin [DDAVP]? A. Activity intolerance B. Alteration in comfort C. Fluid volume imbalance D. Deficient knowledge

C. Fluid volume imbalance Desmopressin is a form of antidiuretic hormone that increases sodium and water retention, leading to an alteration in fluid volume. Monitoring of urine volumes and body weights is essential to prevent complications. Alteration in comfort, deficient knowledge of the condition, and activity intolerance are important nursing problems; however, they are not priorities according to the Maslow hierarchy of needs.

Which drugs does the nurse identify as a selective serotonin reuptake inhibitor? (Select all that apply.) A. Bupropion [Wellbutrin] B. Imipramine [Tofranil] C. Fluoxetine [Prozac] D. Desvenlafaxine [Pristiq] E. Sertraline [Zoloft]

C. Fluoxetine [Prozac] E. Sertraline [Zoloft] Fluoxetine [Prozac] and sertraline [Zoloft] are selective serotonin reuptake inhibitors. Bupropion [Wellbutrin] is an atypical antidepressant. Imipramine [Tofranil] is a tricyclic antidepressant. Desvenlafaxine [Pristiq] is a serotonin/norepinephrine reuptake inhibitor (SNRI).

The nurse cares for a patient who is receiving lithium. Which medication, if prescribed by the healthcare provider, should the nurse question? A. Levothyroxine B. Sulindac C. Furosemide D. Propranolol

C. Furosemide NO Diuretics!!!

A nurse is educating a patient about sildenafil [Viagra]. The nurse should instruct the patient that which adverse effect would be a priority for the patient to report to his prescriber? A. Flushing B. Diarrhea C. Hearing loss D. Dyspepsia

C. Hearing loss In rare cases, sildenafil has caused sudden hearing loss, usually in one ear, which may be partial or complete. The medication should be discontinued if it is being taken for erectile dysfunction. Flushing, diarrhea, and dyspepsia are other, less serious adverse effects.

A patient infected with the human immunodeficiency virus (HIV) is diagnosed with severe necrotizing otitis externa. Which would be the most appropriate treatment for this condition? A. Oral fluconazole [Diflucan] B. Intramuscular ceftriaxone C. Intravenous imipenem/cilastatin [Primaxin] D. 2% acetic acid solution to the external ear canal

C. Intravenous imipenem/cilastatin [Primaxin] Patients with severe necrotizing otitis externa should receive intravenous antipseudomonal therapy with imipenem/cilastatin [Primaxin], meropenem [Merrem], or ciprofloxacin [Cipro]. Fluconazole is an antifungal agent. Ceftriaxone given intramuscularly (IM) is an alternative to amoxicillin/clavulanate in the treatment of resistant AOM. Topical acetic acid solution is used to treat AOE.

A patient with a history of Parkinson's disease treated with selegiline [Eldepryl] has returned from the operating room after an open reduction of the femur. Which physician order should the nurse question? A. Decaffeinated tea, gelatin cubes, and ginger ale when alert B. Docusate 100 mg orally daily C. Meperidine 50 mg IM every 4 hours as needed for pain D. Acetaminophen 650 mg every 6 hours as needed for temperature

C. Meperidine 50 mg IM every 4 hours as needed for pain Selegiline can have a dangerous interaction with meperidine, leading to stupor, rigidity, agitation, and hyperthermia; therefore, this order should be questioned. Foods that contain tyramine should be restricted, but there is no contraindication to the fluids that have been ordered. Docusate and acetaminophen are not contraindicated for use with selegiline.

The nurse is preparing to administer the aripiprazole extended-release 400-mg injection. The nurse is aware that this medication is scheduled to be given how often? A. Daily B. Weekly C. Monthly D. As needed

C. Monthly Aripiprazole for IM therapy is available in single-use vials (7.5 mg/mL) sold as Abilify, and extended-release injections as Abilify Maintena. The extended-release injection is available in 300- and 400-mg doses to be given once monthly.

A patient is taking fludrocortisone [Florinef]. A nurse should recognize that the patient is at risk for developing an electrolyte imbalance if the patient reports which symptom? A. Syncope B. Weight loss C. Muscle weakness D. Numbness and tingling

C. Muscle weakness Muscle weakness is a sign of hypokalemia, which can occur because fludrocortisone has mineralocorticoid properties, resulting in sodium and fluid retention and potassium excretion. Syncope and weight loss do not occur because of salt and water retention. Numbness and tingling may be associated with another problem but are not related to fludrocortisone.

The nurse is assessing a patient receiving valproic acid [Depakene] for potential adverse effects associated with this drug. What is the most common problem with this drug? A. Increased risk of infection B. Reddened, swollen gums C. Nausea, vomiting, and indigestion D. Central nervous system depression

C. Nausea, vomiting, and indigestion Valproic acid is generally well tolerated. Gastrointestinal effects, which include nausea, vomiting, and indigestion, are the most common problems but tend to subside with use and can be lessened by taking the medication with food. Valproic acid does not cause hematologic effects resulting in an increased risk of infection, nor does it cause gingival hyperplasia. It causes minimal sedation.

A nurse monitors for which adverse cardiovascular effects in a male patient taking testosterone [Androderm]? (Select all that apply.) A. Postural hypotension B. Atrial fibrillation C. Pedal edema and weight gain D. Prolonged QT interval E. Decrease in high-density lipoprotein (HDL) levels

C. Pedal edema and weight gain E. Decrease in high-density lipoprotein (HDL) levels Androgens can lower plasma levels of HDL cholesterol ("good cholesterol") and elevate levels of low-density lipoproteins (LDLs, "bad cholesterol"). This may increase the risk for atherosclerosis. Edema can result from androgen-induced retention of salt and water and may be a complication for patients with heart failure. Postural hypotension, atrial fibrillation, and a prolonged QT interval are not adverse effects of androgen therapy.

A patient who is diagnosed with BPD is prescribed lithium. To monitor for lithium toxicity, the nurse should observe the patient for which signs and symptoms? A. Insomnia, increased appetite, and abdominal distention B. Dry cough, hyperactive reflexes, and hypertension C. Polydipsia, slurred speech, and fine hand tremors D. Constipation, asterixis, and generalized edema

C. Polydipsia, slurred speech, and fine hand tremors

During the follicular phase of the menstrual cycle, estrogen has which effects on the female reproductive organs? A. Maturation of a corpus luteum B. Ripening of an ovarian follicle C. Proliferation of the endometrium D. Monthly menstrual bleeding

C. Proliferation of the endometrium During the first half of the menstrual cycle, called the follicular phase, estrogen released from maturing ovarian follicles causes the endometrial lining to proliferate. Follicle-stimulating hormone (FSH) acts on the developing ovarian follicles, causing them to ripen and release estrogens in the first half of the cycle. Luteinizing hormone (LH) levels rise at midcycle, causing rupture of the follicle, which evolves into a corpus luteum. At the end of the cycle, without fertilization, the corpus luteum atrophies, leading to menstrual bleeding as the endometrial lining is shed.

The nurse is reviewing the patient's current medication list and recognizes that which medication is considered a first-line drug for migraine prevention? A. Topiramate [Topamax] B. Metoclopramide [Reglan] C. Propranolol [Inderal] D. Ergotamine [Ergomar]

C. Propranolol [Inderal] Beta blockers, such as propranolol, are preferred drugs for migraine prevention. Metoclopramide is used to prevent and treat nausea and vomiting associated with migraines. Topiramate is a second-line drug for preventing migraines. Ergotamine is used to treat migraines, not prevent them.

What is the primary difference between the selective estrogen receptor modulators tamoxifen and raloxifene? A. Raloxifene does not protect against breast cancer. B. Raloxifene does not produce hot flashes. C. Raloxifene does not increase the risk for uterine cancer. D. Raloxifene does not increase the risk for thromboembolism.

C. Raloxifene does not increase the risk for uterine cancer. Raloxifene is very similar to tamoxifen. The principal difference is that raloxifene does not activate estrogen receptors in the endometrium and hence does not pose a risk of uterine cancer. Like tamoxifen, raloxifene protects against breast cancer and osteoporosis, promotes thromboembolism, and induces hot flushes. Raloxifene is approved only for prevention and treatment of osteoporosis, and for prevention of breast cancer in high-risk women.

Which outcome would be appropriate for a nurse to establish for a patient who has otitis media with effusion (OME) after resolution of AOM? A. Decrease in ear pain B. Improvement in balance C. Recovery of hearing loss D. Reduction in high fever

C. Recovery of hearing loss OME is characterized by fluid accumulation in the middle ear without evidence of local or systemic illness. OME may cause mild hearing loss, and the condition can persist for weeks to months after AOM has resolved. OME does not cause pain nor disrupt balance.

The nurse is planning care for a patient taking imipramine [Tofranil]. Which finding, if present, would most likely be an adverse effect of this drug? A. Blood pressure of 160/90 mm Hg B. Insomnia and diarrhea C. Sedation and dry mouth D. Tachypnea and wheezing

C. Sedation and dry mouth Anticholinergic effects (dry mouth, blurred vision, constipation, tachycardia, urinary retention) and sedation are potential adverse effects of the tricyclic antidepressants (TCAs), such as imipramine [Tofranil]. The most serious common adverse effect is orthostatic hypotension; therefore, a blood pressure of 160/90 mm Hg probably is not caused by this drug. Respiratory problems are not commonly associated with the TCAs.

The nurse is reviewing the medication orders for a patient on sumatriptan and sertraline [Zoloft]. The nurse notes which of the following possible interactions between these medications? A. Both medications can cause hypotension. B. The combined medications can cause severe sedation. C. The combined medications can cause serotonin syndrome. D. Both medications treat migraines and can be used together.

C. The combined medications can cause serotonin syndrome. Sertraline [Zoloft] is a selective serotonin reuptake inhibitor or SSRI. Triptans should not be combined with SSRIs or SNRIs because serotonin syndrome could occur. Triptans can cause hypertension, not hypotension. Neither medication causes sedation.

The nurse is caring for a patient with migraine headaches. Which assessment best indicates that sumatriptan is exerting the desired therapeutic effect A. The patient experiences decreased frequency of migraine headaches B. The patient does not experience any more migraine headaches C. The patient reports the termination of the migraine headache after the drug is administered D. the patient experiences decreased nausea associated with the migraine headache

C. The patient reports the termination of the migraine headache after the drug is administered. Used to abort an attack

What is the goal of pharmacologic therapy in the treatment of Parkinson's disease? A. To increase the amount of acetylcholine at the presynaptic neurons B. To reduce the amount of dopamine available in the substantia nigra C. To balance cholinergic and dopaminergic activity in the brain D. To block dopamine receptors in presynaptic and postsynaptic neurons

C. To balance cholinergic and dopaminergic activity in the brain Parkinson's disease results from a decrease in dopaminergic (inhibitory) activity, leaving an imbalance with too much cholinergic (excitatory) activity. With an increase in dopamine, the neurotransmitter activity becomes more balanced, and symptoms are controlled.

The nurse is caring for a patient who is to receive a local anesthetic with lidocaine and epinephrine. What is the primary purpose of the epinephrine? A. To reduce the risk of an allergic reaction B. To improve transport of anesthetic into the axon C. To delay systemic absorption of the anesthetic D. To suppress excitability of the myocardium

C. To delay systemic absorption of the anesthetic As a vasoconstrictor, epinephrine reduces local blood flow and delays systemic absorption of the anesthetic. This prolongs the effects of the anesthetic at the site of action and reduces the risk of systemic toxicity.

Which manifestations does the nurse associate with tardive dyskinesia? A. Pacing and squirming, with an uncontrollable need for motion B. Mask-like face with drooling, tremors, rigidity, and shuffling gait C. Twisting, worm-like movements of the tongue and face D. Sudden high fever, sweating, and blood pressure fluctuations

C. Twisting, worm like movements of the tongue and face Parkinsons is B Neuroleptic malignant syndrome is D.

Which agent is most likely to be prescribed today for short-term management of insomnia? A. Secobarbital [Seconal Sodium] B. Meprobamate [Miltown] C. Zolpidem [Ambien] D. Flumazenil [Romazicon]

C. Zolpidem [Ambien] Zolpidem is a benzodiazepine-like drug that is widely used in the treatment of insomnia. It is safer than the barbiturates (secobarbital) or miscellaneous sedative-hypnotics (meprobamate). Flumazenil is a reversal agent for the benzodiazepines.

Acute Adrenal Insufficiency (Adrenal Crisis)

Can lead to shock/death Causes: -Adrenal failure -Pituitary failure -Inadequate doses of glucocorticoids or abrupt withdrawal Clinical presentation: -hypotension -Dehydration -Weakness -Lethargy -GI symptoms (vomiting and diarrhea) Treatment: -Rapid replacement of fluid, salt, and glucocorticoids (hydrocortisone) -Glucose: NS w/dextrose

Regulation of Cardiac Output

Cardiac output = heart rate x stroke volume Heart rate is controlled by ANS Factors that affect HR: -Autonomic innervation -Hormones -Fitness levels -Age stroke volume = myocardial contractility. Cardiac afterload: Arterial Pressure that left ventricle must overcome to eject blood. Resistance heart is pumping against Cardiac preload: End-diastolic volume or end-diastolic pressure Factors that affect SV: -heart size -fitness levels -Gender -Contractility -Duration of contraction -Preload -Afterload (resistance) Control of stroke volume by venous return: Frank-Starling's Law of the heart = stroke volume of heart increases in response to an increase of volume of blood in ventricles before contraction

Congenital Adrenal Hyperplasia

Cause: -Inborn deficiency of enzymes needed for glucocorticoid synthesis --> pituitary release large amounts of ACTH --> hyperplasia (an increase in the amount of organic tissue that results from cell proliferation. It may lead to the gross enlargement of an organ) of adrenal tissue and increased synthesis of glucocorticoids and adrogens Clinical presentation (r/t overproduction of androgens): Girls: Masculinization, acne, others Males: Precocious genital enlargement All: Accelerated linear growth Treatment: -Lifelong glucocorticoid replacement -Preferred agents: Hydrocortisone, dexamethasone, prednisone Newborn screening

Cushing's Syndrome

Causes (adrenal hormone excess): -Hyper-secretion of adrenocorticotropic hormone (ACTH) (pituitary mass) -Hyper-secretion of glucocorticoids (adrenal mass) -Administration of glucocorticoids in large doses Clinical presentation: -Hyperglycemia -Glycosuria (excretion of glucose into the urine) -Hypertension -Fluid and electrolyte disturbances -Osteoporosis -Muscle weakness and myopathy -Menstrual irregularities -Hirsutism (Excessive hair growth on unexpected areas of the body, such as on the face, chest, and back) -Striae -Fat redistribution "pot belly" "moon face" "buffalo hump" Treatment--directed at cause: Adrenal carcinoma/adenoma: surgical removal -If bilateral adrenalectomy --> replacement therapy with glucocorticoids and mineralcorticoids Inoperable adrenal carcinoma: mitotane (chemotherapy) -Selective destruction of adrenocortical cells Pituitary adenoma (somewhat common in young women-- headache, lactation, menstrual irregularities) -Surgery or radiation Drugs used as adjuncts, not primary intervention -High dose ketoconazole --> blocks glucocorticoid synthesis

Post-Traumatic Stress Disorder

Characteristics Develops after a traumatic event -Re-experiencing the event -Avoiding reminders of the event -Persistent state of hyperarousal Treatment Psychotherapy alone Psychotherapy with drugs -Evidence of efficacy is strongest for three SSRIs (fluoxetine, paroxetine, and sertraline) and one SNRI (venlafaxine)

Generalized Anxiety Disorder

Characteristics -Uncontrollable worrying that lasts 6 months or longer -Not situational anxiety Treatment Nondrug approaches -Supportive therapy -CBT -Biofeedback -Relaxation training Drug therapy -Benzodiazepines -Buspirone

Explain the classification of drugs by their chemical, generic, and trade names

Chemical -Drug has only ONE chemical name -Can help predict drugs physical and chemical properties -Uses nomenclature of chemistry Generic -Use generic name -Assigned by US adopted names council -each drug has ONE generic name -Nonproprietary name Brand/Trade names -Proprietary names -Names under which drug is marketed -Created by drug companies -One drug may have many name brands -Must be approved by FDA

Diagnosis of STEMI

Chest pain -Severe substernal, crushing/constricting, down arm and jaw. Could be on both sides or just left. Characteristic ECG change Sweating, weakness, sense of impending doom Lab/Biochemical markers for MI -Cardiac troponin 1 -Cardiac troponin T -MB isozyme of creatine kinase (CK-MB)

Low-Potency FGAs

Chlorpromazine Uses: -Schizophrenia & Schizoaffective disorder -Manic phase of bipolar disorder Adverse effects: -Sedation -Orthostatic hypotension -Anticholinergic effects Drug interactions: Intensifies CNS depressants and anticholinergic drugs

Echothiophate

Cholinesterase inhibitor, treatment of glaucoma MOA: Inhibits the breakdown of ACh --> accumulation of ACh at muscarinic receptors -Same ocular effects as pilocarpine -Miosis, focusing of the lens for near vision, reduction of IOP Long duration of action No longer a first-line drug due to adverse effects: -Myopia (A condition in which close objects appear clearly, but far ones don't) -Cataracts (associated with long-acting agents) -Systemic absorption --> parasympathomimetic responses (bradycardia, bronchospasm, sweating, salivation, urinary urgency, diarrhea)

What is Multiple Sclerosis?

Chronic, inflammatory, autoimmune disorder who's exact cause is unknown. Damages myelin sheaths of neurons in the CNS (making antibodies to the myelin sheath of neurons in CNS) --> wide variety of sensory and motor deficits Periods of acute clinical exacerbation/attack (relapses) alternating with periods of complete or partial recovery (remissions) Over time, symptoms grow progressively worse Pathology: -Multifocal regions of inflammation and myelin destruction (brain, spinal cord, optic nerve) -Demyelination: axonal/nerve conduction slowed or blocked After an acute attack: Inflammation subsides -Damaged tissue replaced by astrocyte-derived filaments that form scars known as scleroses (fill in gaps of damaged tissue with connective tissue, forming scars) -Some degree of recovery occurs (partial remyelination) Functional axonal compensation Development of alternative neuronal circuits that bypass the damaged region Recurrent episdoes: -Less complete recovery due to mounting astrocytic scarring, irreversible axonal injury, and death of neurons and oligodendrocytes Signs and Symptoms: Paresthesias -Numbness -tingling -pins and needles sensation Muscle or motor problems -Weakness -clumsiness -ataxia (impaired balance/coordination) -spasms -spasticity -tremors -cramps Visual impairment -Blurred vision -Double vision -Blindness Bladder and bowel symptoms -Incontinence -Urinary urgency -Urinary hesitancy -Constipation Other: -Sexual dysfunction -Disabling fatigue -Emotional lability, depression, and cognitive impairment -Slurred speech and dysphagia -Dizziness and vertigo -Neuropathic pain

COPD

Chronic, progressive disorder -Air flow restrictions and inflammation -SMOKING or other irritants -Air gets trapped in alveoli s/s -chronic cough -excessive sputum production -wheezing -dyspnea -poor exercise tolerance -barrel chest classification of severity -mild -moderate -severe -very severe -Reduce s/s, risks, mortality; prevent progression; exacerbations -SABAs, systemic glucocorticoids, Antibiotics, O2.

What each drug does to ECG

Class 1A: Quinidine Widens QRS, prolongs QT Class 1B: Lidocaine No significant change Class IC: Flecainide, Propafenone Widens QRS, prolongs PR Class II: Propranolol Prolongs PR, bradycardia Class III: Amiodarone Prolongs QT and PR, widens QRS Class IV: Verapamil, Diltiazem Prolongs PR, bradycardia Others: Adenosine, Digoxin Adenosine: Prolongs PR Digoxin: Prolongs PR, depresses ST

Classification of Antidysrhythmic Drugs

Class I: Sodium channel blockers Class 1A: Quinidine Class 2A: Lidocaine Class 3A: Flecainide If you block out part of the sodium channels, you are going to slow conduction through AV node and the ventricles Class II: Beta blockers Propranolol Class III: Potassium channel blockers Amiodarone Class IV: Calcium Channel blockers Verapamil Others: Adenosine Digoxin

Acarbose

Class: Alpha-glucosidase inhibitors MOA: -Delay absorption of CHO (carbohydrates) use: -T2DM; alone or in combination with other agents Adverse effects: -Profound flatulence -Abdominal cramps -Abdominal distention -Borborygmus -Diarrhea

Exenatide

Class: GLP-1 receptor agonists AKA: Incretin mimetics MOA: -Slow gastric emptying -stimulate glucose-dependent release of insulin -inhibit postprandial release of glucagon -suppress appetite Adverse effects: -Hypoglycemia (when combined with sulfonylurea) -GI effects (N/V/D) -Pancreatitis -Renal impairment

Miglitol

Class: Alpha-glucosidase inhibitor Especially effective among Latinos and african americans Adverse effects: -Flatulence -Abdominal discomfort -Other GI effects Has not been associated with liver dysfunction (Acarbose is associated with causing liver dysfunction)

Metformin

Class: Biguanide Use: -Drug of choice for initial therapy in most T2DM patients -Prevention of T2DM -GDM -Polycystic ovary syndrome (characterized by insulin resistance) MOA: -Inhibits hepatic glucose production (inhibits glucose production in liver) -Slightly reduces GI glucose absorption (why you have GI effects) -Sensitizes insulin receptors in skeletal muscle and fat (to increase glucose uptake in response to insulin available) Most common adverse effects: -Gastrointestinal (GI) disturbances -Decreased B12 and Folic Acid absorption BBW: Lactic acidosis -Inhibition of mitochondrial oxidation of lactic acid Patients that have renal insufficiency should NEVER USE metformin -S/S = breathing really fast, muscle pain, sleepy, signs and symptoms Drug interactions: -Alcohol --> increased lactic acidosis risk -Cimetidine --> increased lactic acidosis risk -Iodinated Radiocontrast media --> risk of ARF Patient teaching: -Take with meals -Bowel changes -Signs and symptoms of lactic acidosis -If receiving contrast dye for test, the metformin needs to be stopped for at least 1-2 days prior to that test and not started again until 2 days after

Sitagliptin

Class: DPP-4 inhibitors ("-gliptins") MOA: -Inhibits incretin breakdown by DPP-4 -Stimulate glucose-dependent release of insulin -Supress postprandial release of glucagon Use: -T2DM Adverse effects: -Most common: URI, headache, UTI -Pancreatitis -Hypersensitivity reactions (should be stopped immediately)

Canagliflozin

Class: Sodium-glucose co-transporter 2 (SGLT-2) inhibitors ("-flozin") MOA: Blocks reabsorption of renal glucose in the kidney --> glucosuria (you are peeing out your glucose instead of reabsorbing it) Use: T2DM Adverse effects: -Genital yeast infections (females > males) (you are going to have carby urine = greeding ground for bugs) -UTIs -Increase urination -Postural hypotension -Dizziness BBW!!: -Limb (leg and foot) amputations (you are peeing alot and get very dehydrated)

Pharmacologic Therapy

Classes of antihypertensive drugs Diuretics -Thiazide diuretics -Loop diuretics -Potassium-sparing diuretics Sympatholytics (Adrenergic antagonists) -Beta-adrenergic blockers -Alpha 1 blockers -Alpha/beta blockers: Carvedilol and labetalol -Centrally acting alpha 1 agonists -Adrenergic neuron blockers Drugs that suppress RAAS -ACEIs -ARBs -Aldosterone antagonists -Direct renin inhibitors Others -Direct-acting vasodilators -Calcium channel blockers *Always start with diuretics first then add one of the others, and maybe add a second one. Ways to promote adherence: -Education -Self monitoring -minimize side effects -Collaborative relationship -Simplify the regimen

Pathophysiology of STEMI

Classic MI, crushing chest pain. Blood flow to a region of myocardium is blocked usually from a clot, thrombis, or spasm and thrombis formation there -Hydrogen ions accumulate --> local metabolic changes occur Ventricular remodeling Residual cardiac impairment

Muscle Relaxants

Classification of Skeletal Muscle Relaxants According to their mechanism of action -Depolarizing vs non-depolarizing According to their duration of action -Long-acting agents -Intermediate-acting agents -Short-acting agents According to their role of elimination from the body -Kidney -Liver -Plasma Cholinesterase enzyme

The nurse knows that diuretics mostly affect which function of the kidneys?

Cleansing and maintenance of extracellular fluid volume Most diuretics block sodium and chloride reabsorption, thus affecting the maintenance of extracellular fluid volume.

HIV (Antiviral)

Clinical course: Early = Acute retroviral syndrome (malaise) Middle = Clinical latency (CD4 cells decline) Late: CD4 cells drop below 200 cells/mL = AIDS Standardized antiretroviral therapy (ART) -Prevent mother-to-baby transmission Labs Regular monitoring CD4 T-cell counts Viral load assays NRTIs (Nucleoside/Nucleotide reverse transcriptase inhibitors) Zidovudine -Inhibits HIV replication by suppressing DNA synthesis -Use for: preventing mother-to-baby transmission -AE: anemia, neutropenia, lactic acidosis, hepatomegaly, GI Interactions: Myelosuppressive and nephrotoxic agents (ganciclovir) NNRTIs (Non-nucleotide reverse transcriptase inhibitors) Bind to active center of reverse transcriptase and cause direct inhibition Efavirenz Use for: preferred treatment for HIV Interactions: CYP450 inducer AE: CNS effects, rash, teratogenicity nevirapine, delavirdine, etravirine, rilpivirine INSTIs (Integrase strand transfer inhibitors) Raltegravir Prevents viral DNA insertion into host AE: Insomnia, HA, hypersensitivity Precautions: Pregnancy risk category C PIs (Protease inhibitors) Reduces viral load Lopinavir/ritonavir, indinavir, saquinavir, nelfinavir, fosamprenavir, atazanavir, tipranavir, darunavir AE: Hyperglycemia/DM, fat redistribution, hyperlipidemia, reduced bone density, increase bleeding, AST/ALT ( serum transaminase) elevation HIV fusion inhibitor Enfuvirtide (t-20) Blocks entry of HIV into CD4 cells CCR5 antagonist (Chemokine receptor 5) Maraviroc Blocks Viral entry into CD4 cells Interactions: CYP4A3 inhibitors or inducers Occupational Exposure Exposure to body fluids (saliva, sweat, urine) -Wash off -Continue shift -Report exposure to nurse manager Exposure to blood, non-invasive -Thoroughly wash off -Continue shift -Report exposure to nurse manager Exposure to blood, invasive -Immediately report exposure to nurse manager -Begin postexposure prophylaxis within 72 hours of exposure

Hypothyroidism

Clinical presentation -Pale, puffy face -Cold, dry skin -Brittle hair or loss of hair -Lowered HR and temperature -Lethargy and fatigue -Intolerance to cold -Impaired mentality ("brain fog") Causes -Usually due to malfunction of thyroid -Hashimoto's disease: chronic autoimmune thyroiditis -Insufficient iodine in the diet -Surgical removal and/or destruction of thyroid with radioactive iodine -Insufficient secretion of TSH and thyrotropin-releasing hormone (TRH) Treatment Lifelong replacement therapy -Synthetic T4: Levothyroxine -Synthetic T3: Liothyronine Standard: T4 taken alone

Explain drug half-life and its application to practice

Combination of metabolism and excretion cause the amount of drug in body to decline. Half life is how rapidly that decline occurs. "Time required for amount of drug in the body to decrease by 50%" More drug in body, the larger amount lost during one half-life. EXAMPLE: Morphine. Half life is ~ 3 hours. Morphine will decrease by 50% every 3 hours. Half-life determines the dosing interval

Drug Therapy for UTIs

Complicated and uncomplicated UTIs -Uncomplicated happen in women in child bearing age, in children, and older adults. -Complicated are associated with predisposing factors such as kidney stones Upper (renal/kidney) -Acute pyelonephritis = uncomplicated Mild = treat at home Severe= Hospital and IV anitbiotics -Acute bacterial prostatitis Lower (bladder/urethra) -Acute cystitis -Acute urethral syndrome Recurrent UTIs -relapse, reinfection Usually E. coli Also, HAI like foley catheter. Treatment: Trimethroprim/Sulfamethoxazole (TMP/SMZ) Nitrofurantoin (Macrobid) -Bacteriostatic at low concentration/Bactericidal at high concentration -Use: lower UTIs, prophylaxis, recurrent UTIs AE: GI, Pulm, hematologic, peripheral neuropathy, hepatotoxicity, birth defects

Management of Generalized Convulsive Status Epilepticus

Continuous series of tonic-clonic seizures that lasts 20 to 30 minutes (what people think of when they think of seizures) Goals of treatment: #1. Maintain ventilation/airway -Correct hypoglycemic -Terminate seizures (Benzodiazepine/Lorazepam is recommended for first-line management. However, Diazepam may be used if lorazepam is not available) -Initiate or continue long-term suppression drugs such as phenytoin or fosphenytoin to prevent seizures

Dopamine Antagonists: Promethazine

Contraindicated for children under 2 MOA: Block dopamine2 receptors Use: -N/V associated with surgery, cancer, chemotherapy, and toxins Adverse Effects: -EPS -Anticholinergic effects -Hypotension -Sedation -Respiratory Depression -Local tissue injury (IV extravasation --> abscess, necrosis, gangrene) IV Administration: -Must be given through a large-bore, freely flowing line, concentration of 25 mg/mL or less (very slowly) -Advise patient to immediately report local swelling, burning, or pain at site of IV.

Drugs for Cognitive Impairment

Current drug goals: -Slow progression of disease process down -Slow loss of memory and cognition -prolong time of independent function Four drugs approved for treatment of AD: Cholinesterase inhibitors -Donepezil -Galantamine -Rivastigmine N-methyl-D-aspartate (NMDA) receptor blocker -Memantine

Cycloplegics and Mydriatics

Cycloplegics: paralyze ciliary muscles Mydriatics: Dilate the pupil 2 classes of cycloplegic and mydriatic agents 1. Muscarinic antagonists (anticholinergic agents) -MOA: Block receptors that promote contraction of iris sphincter (mydriasis) and ciliary muscle (cycloplegia) 2. Adrenergic agonists -MOA: Activates alpha1-adrenergic receptors on radial (dilator) muscle of the iris --> mydriasis only -Don't paralyze that ciliary muscle Uses: Diagnosis and surgery of ophthalmic disorders -Adjunct to measurement of refraction -Intraocular examination -Intraocular surgery Treatment of anterior uveitis

A family member asks the nurse about amantadine. Which statement by the nurse is the most helpful in explaining the use of amantadine? A. "Amantadine was developed as an antiviral agent but is now used for treatment of PD." B. "Amantadine works slowly over time but can lose its effectiveness in 3 to 6 months." C. "Amantadine works rapidly and does not lose its effectiveness." D. "Amantadine is not as effective as some other medications, so it is not a first-line treatment, but it may be used in addition to other medications."

D. "Amantadine is not as effective as other medications, so it not a first-line treatment, but it may be used in addition to other medications" Amantadine was developed as an antiviral agent, but this response is not helpful to explain the use of the medication to the family member. Medication effects develop rapidly—often within 2 to 3 days—but are much less profound than with levodopa or the dopamine agonists. Furthermore, effects may begin to diminish within 3 to 6 months. Amantadine is not considered a first-line agent. However, the drug may be helpful for managing dyskinesias caused by levodopa.

The nurse is monitoring a patient with depression in the early phase of treatment with amitriptyline [Elavil]. Which question is most important for the nurse to ask the patient? A. "Have you noticed dry mouth or blurred vision?" B. "Have you had any changes in your urine function?" C. "When was your last bowel movement?" D. "Have you had any changes in your mood or anxiety level?"

D. "Have you had any changes in your mood or anxiety level?" In the early phase of treatment for depression, suicide risk may increase. Patients should be monitored closely for worsening mood, unusual changes in behavior, and suicide risk. The other questions would be useful in assessing the patient for adverse effects of amitriptyline [Elavil], but assessing suicide risk is the most important intervention.

The nurse teaches a patient about bupropion. Which statement by the patient indicates that more teaching is indicated? A. "I can take the drug with food to reduce nausea" B. "This drug will increase my interest in sex" C. "I may experience decreased appetite and weight loss" D. "I had a serious head injury 3 years ago"

D. "I had a serious head injury 3 years ago"

A patient with BPD is prescribed lithium. Which statement, if made by the patient, indicates the need for further teaching? A, "I can take the medication with milk or a snack" B. "I will call my doctor if i feel hyperactive" C. "I should drink at least 8 to 10 glasses of water every day" D. "I will reduce my salt intake while taking this medication"

D. "I will reduce my salt intake while taking this medication" Lithium will accumulate if sodium is restricted

A patient taking sildenafil [Viagra] asks a nurse what action to take if priapism occurs. Which response should the nurse make? A. "Take an additional half-strength dose of sildenafil." B. "The condition usually resolves in 12 hours or less." C. "Wait until the following day and notify the doctor." D. "Seek emergency help, because permanent damage can occur."

D. "Seek emergency help, because permanent damage can occur." Sildenafil is a phosphodiesterase type 5 (PDE5) inhibitor that can cause priapism. Patients are advised to seek medical attention for an erection that lasts longer than 4 hours, because left untreated, priapism can damage penile tissue, causing permanent loss of potency. Increasing the dose or waiting to seek help would do more harm.

Which instruction should the nurse include in the teaching plan for a patient who is to be started on brimonidine [Alphagan] ophthalmic drops? A. "A common side effect is an increase in salivation." B. "The drug may cause an increase in brown pigmentation of your iris." C. "You may notice an increase in the length and thickness of your eyelashes." D. "Wait 15 minutes after instilling the eye drops before putting in your contact lenses."

D. "Wait 15 minutes after instilling the eye drops before putting in your contact lenses." Brimonidine can be absorbed into contact lenses. Patients should wait at least 15 minutes between applying the eye drops and putting in their contact lenses. The drug can lead to dry mouth, not increased salivation. Changes in iris pigmentation and eyelash length and thickness are associated with the prostaglandin analogs.

Which application instruction is the priority for a nurse to provide to a patient starting to use AndroGel testosterone gel? A. "Apply the gel to clean, dry skin of the shoulders or upper arms." B. "Squeeze the entire packet into your palms and then rub the gel into your skin." C. "Wait about 5 or 6 hours before showering or swimming." D. "Wash your hands after applying the gel to prevent transfer to others."

D. "Wash your hands after applying the gel to prevent transfer to others." The principal disadvantage of the testosterone gel is that it can be transferred to others by skin-to-skin contact. Ninety percent of the applied dose remains on the skin after the gel dries. Blood levels of testosterone have been shown to double in the female partners of gel users after intimate contact. Teaching the patient to apply the gel to clean, dry skin, to use the total dose in the packet, and to wait 6 hours until showering is important, but not as important as preventing the transfer of testosterone to others.

The nurse is teaching the patient about oral steroid therapy. Which statement by the patient indicates a need for further teaching? A. "I can take my full dose in the morning." B. "I can break up my dose and take some in the afternoon if I get tired." C. "I understand that I shouldn't experience many adverse effects." D. "When I am traveling for work I will take lower doses."

D. "When I am traveling for work I will take lower doses." To mimic normal cortisol secretion, patients can take the entire daily dose in the morning, immediately after waking. If this schedule results in afternoon or evening fatigue, patients may split the dosage, taking two-thirds in the morning and one-third around 4:00 PM. Stress, such as travel for work, may require an increase in medication.

Which statement should a nurse include when providing teaching to a patient who is scheduled to start taking dutasteride [Avodart]? A. "Protect yourself from sun exposure to avoid any skin sensitivity." B. "You may notice immediate relief of your urinary symptoms." C. "Dutasteride will increase both ejaculatory volume and libido over time." D. "You cannot donate blood while on this medication or for 6 months after stopping it."

D. "You cannot donate blood while on this medication or for 6 months after stopping it." Dutasteride is harmful to a developing male fetus. To avoid transmission to women by way of infusion, men should avoid donating blood while using it and for 6 months after stopping it. Beneficial effects on the symptoms of benign prostatic hyperplasia (BPH) occur over time. Dutasteride reduces ejaculate volume and libido. Photosensitivity is unrelated.

A nurse assesses a patient receiving haloperidol [Haldol]. The nurse notices that the patient is shifting in the chair, rocking back and forth, and tapping both feet constantly. What is the most accurate term to document these findings? A. Dystonia B. Tardive dyskinesia C. Parkinsonism D. Akathisia

D. Akathisia Haloperidol is a traditional antipsychotic medication with the adverse effects of extrapyramidal symptoms. Akathisia, or motor restlessness, is an extrapyramidal symptom. Dystonia manifests as severe spasm of the muscles of the tongue, face, neck, or back and may include upward deviation of the eyes, severe cramping, and impaired respiration. Tardive dyskinesia presents with involuntary twisting, writhing, wormlike movements of the tongue and face, lip smacking, and tongue flicking. Parkinsonism appears with bradykinesia, masklike facies, drooling, tremor, rigidity, shuffling gait, and stooped posture.

The nurse is caring for a patient with severe generalized anxiety disorder. Which agent would be most effective for immediate stabilization? A. Venlafaxine [Effexor] B. Buspirone [BuSpar] C. Paroxetine [Paxil] D. Alprazolam [Xanax]

D. Alprazolam [Xanax] Alprazolam, a benzodiazepine, would provide the most rapid onset of relief. Buspirone, paroxetine, and venlafaxine are also first-line agents for the treatment of generalized anxiety disorder, but their onset is delayed. They are preferred for long-term management.

The nurse prepares to administer dantrolene to a patient. Before the administration of the drug, it is most important for the nurse to assess which laboratory value? A. Serum amylase B. Creatinine clearance C. Blood glucose D. aminotransferases

D. Aminotransferases Aminotransferases are liver and the dose related liver damage is most serious adverse effect of dantrolene so we want to monitor patients liver function. Amylase breaks down carbs Creatinine clearance is going to be kidney Blood glucose not too worried

A nurse teaches a patient at risk of developing progressive vision loss from dry age-related macular degeneration (ARMD) to increase the dietary intake of which nutrients? A. Potassium-rich foods B. Green, leafy vegetables C. Calcium and phosphorus D. Antioxidants and zinc

D. Antioxidants and zinc In patients with dry ARMD, prophylactic treatment with high-dose antioxidants and zinc may prevent the disease from progressing to the advanced stage. No evidence indicates that potassium-rich foods; green, leafy vegetables; and calcium and phosphorus, reduce the effects of dry ARMD.

A nurse prepares to apply timolol [Timoptic] eye drops to a patient who has asthma. Which action should the nurse take when applying the eye drops? A. Give the patient a bronchodilator inhaler before administering the eye drops. B. Keep the patient in an upright sitting position for 3 hours after administration. C. Administer the drops to one eye, wait 30 minutes, and then apply them to the other eye. D. Apply pressure to the inner aspects of the eye during and after administration.

D. Apply pressure to the inner aspects of the eye during and after administration. Timolol is a beta-adrenergic blocking agent. Systemic absorption should be minimized to reduce the risk of bronchospasm. Applying pressure to the inner aspects of the eye during and after administration reduces systemic absorption. This action is particularly important for a patient with a history of asthma. Giving a bronchodilator inhaler, keeping the patient upright, and waiting 30 minutes between administrations to each eye are incorrect actions to take with a patient who has asthma and is receiving timolol.

A patient in the emergency department reports taking sildenafil [Viagra] and nitroglycerin 1 hour before sexual activity. Which finding should the nurse immediately report to the physician? A. White blood cell (WBC) count of 3200 units/L B. Respiratory rate of 26 breaths per minute C. Body temperature of 100.4°F (38°C) D. Blood pressure (BP) of 70/50 mm Hg

D. Blood pressure (BP) of 70/50 mm Hg When taken in conjunction with nitroglycerin, sildenafil can cause severe hypotension that is unresponsive to treatment. At least 24 hours should elapse between the last dose of sildenafil and a nitrate. A WBC count of 3200 units/L, a respiratory rate of 26 breaths per minute, and a body temperature of 100.4°F are abnormal findings and must be reported. However, they are not as important to report as the BP of 70/50 mm Hg, which is directly related to sildenafil and nitroglycerin.

A patient is receiving isoflurane [Forane]. Which physical assessment finding is the most likely to be a potential adverse effect of this drug? A. Blood glucose level of 180 mg/dL B. Blood urea nitrogen (BUN) level of 22 mg/dL C. Respiratory rate (RR) of 28 breaths per minute D. Blood pressure (BP) of 86/52 mm Hg

D. Blood pressure (BP) of 86/52 mm Hg Hypotension is a potential adverse effect of most inhaled anesthetics, including isoflurane. Hyperglycemia, kidney dysfunction, and tachypnea are not expected adverse effects of this drug.

A patient is diagnosed with otitis externa (OE) caused by Aspergillus organisms. Which treatment would not be effective against Aspergillus spp.? A. Oral fluconazole [Diflucan] B. 2% acetic acid solution ear drops C. Topical 1% clotrimazole [Lotrimin] D. Ciprofloxacin plus hydrocortisone [Cipro-HC] otic solution

D. Ciprofloxacin plus hydrocortisone [Cipro-HC] otic solution Ciprofloxacin is effective against bacteria. Aspergillus spp. are fungi and must be treated with agents that have an antifungal effect, such as fluconazole, 2% acetic acid, or 1% clotrimazole.

A child with AOM and a previous type I allergic reaction to penicillin requires treatment with an antibiotic. Which antibiotic would be a safe choice? A. Cefdinir B. Amoxicillin C. Cefuroxime D. Clarithromycin

D. Clarithromycin Clarithromycin or azithromycin is indicated when a patient has had a previous type I allergic reaction to penicillin. Cefdinir and cefuroxime are cephalosporins and should be avoided in patients who have had a type I allergic reaction to penicillin because of the risk of cross-reactivity. Amoxicillin is contraindicated in patients with a penicillin allergy, because it is an aminopenicillin.

The nurse is caring for a patient with social anxiety disorder. The patient is currently experiencing intense anxiety. The nurse should prepare to administer which medication for the immediate relief o anxiety? A. Fluvoxamine B. Paroxetine C. Sertraline D. Clonazepam

D. Clonazepam You're going to want a benzo for that, for intense anxiety.

A pediatric patient has gigantism caused by excess growth hormone (GH). Which finding would indicate to the nurse that the patient has developed an additional complication related to this condition? A. Blood glucose below 70 mg/dL B. Elevation of liver function test results C. Atrophy of sweat glands D. Enlarged heart on chest x-ray

D. Enlarged heart on chest x-ray Gigantism caused by GH excess can cause children not only to grow very tall but also to develop complications such as headache, profuse sweating, cardiomegaly (enlarged heart), and diabetes. Because of its effect on carbohydrate metabolism, excess GH may cause an elevated blood glucose level, not hypoglycemia. It does not damage the liver; therefore, liver function tests are not affected. It also does not cause the sweat glands to atrophy.

A female patient who is originally from Thailand is seen in the clinic for seizure control. She receives a new prescription for carbamazepine [Tegretol]. Before the patient takes the drug, which is the most appropriate initial nursing intervention? A. Warn her not to withdraw this drug abruptly. B. Recommend that she take this medication at bedtime with meals. C. Teach her family to assist by maintaining a seizure frequency chart. D. Ensure that genetic testing for HLA-B1502 is performed.

D. Ensure that genetic testing for HLA-B1502 is performed. Although all these interventions are appropriate for this patient, the initial nursing intervention would be to ensure that genetic testing is performed. Carbamazepine is associated with several dermatologic effects, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Patients of Asian descent are at higher risk for serious dermatologic reactions with this drug because of a genetic variation known as HLA-B1502. The FDA now recommends that before taking carbamazepine, patients of Asian descent undergo genetic testing.

A patient with hyperthyroidism is taking propylthiouracil (PTU). It is most important for the nurse to assess the patient for which adverse effects? A. Gingival hyperplasia and dysphagia B. Dyspnea and a dry cough C. blurred vision and nystagmus D. Fever and sore throat

D. Fever and sore throat

A patient is brought to the emergency department for the treatment of an overdose of alprazolam. Which medication should the nurse prepare to administer to this patient? A. Protamine sulfate B. Acetylcysteine C. Naloxone D. Flumazenil

D. Flumazenil

Alprazolam [Xanax] is prescribed for an adult with panic attacks. The nurse recognizes that this drug exerts its therapeutic effect by interacting with which neurotransmitter? A. Norepinephrine B. Acetylcholine C. Serotonin (5-HT) D. Gamma-aminobutyric acid (GABA)

D. Gamma-aminobutyric acid (GABA) Alprazolam is a benzodiazepine; this class of drugs reduces anxiety by potentiating the action of GABA.

The nurse is preparing to administer phenelzine [Nardil] to a patient with depression. Why is this drug considered a second- or third-line agent in the treatment of depression? A. It increases the risk of suicide in the early phase. B. It is less effective than the tricyclic antidepressants. C. It increases the risk of psychoses and parkinsonism. D. It has more side effects and drug interactions.

D. It has more side effects and drug interactions. Phenelzine [Nardil], a monoamine oxidase inhibitor (MAOI), is considered a second- or third-line treatment because of the risk of triggering hypertensive crisis when the patient eats foods high in tyramine. Also, an increased incidence of drug-drug interactions is seen with phenelzine. Phenelzine does not pose an increased risk for suicide, psychoses, or parkinsonism, and it is as effective as the tricyclic and SSRI antidepressants.

A patient newly diagnosed with type 1 diabetes asks a nurse, "How does insulin normally work in my body?" The nurse explains that normal insulin has which action in the body? A. It stimulates the pancreas to reabsorb glucose. B. It promotes the synthesis of amino acids into glucose. C. It stimulates the liver to convert glycogen to glucose. D. It promotes the passage of glucose into cells for energy.

D. It promotes the passage of glucose into cells for energy. The hormone insulin promotes the passage of glucose into cells, where it is metabolized for energy. Insulin does not stimulate the pancreas to reabsorb glucose or synthesize amino acids into glucose. It does not stimulate the liver to convert glycogen into glucose.

A postoperative patient who received an intravenous infusion of morphine has a respiratory rate of 8 breaths per minute and is lethargic. Which as-needed medication should the nurse administer to the patient? A. Methadone B. Nalbuphine C. Tramadol D. Naloxone

D. Naloxone

The nurse is preparing to give ergotamine [Ergomar]. This agent is effective against headaches of which origin? A. Hypertension B. Hyperthyroidism C. Sinus pressure D. No identifiable cause

D. No identifiable cause Headaches caused by hypertension, hyperthyroidism, and disorders of the eye, ear, nose, sinuses, and throat should be treated based on their underlying cause. Ergotamine is effective against headaches that have no other identifiable cause and are assumed to be migraine or cluster headache. Also, ergotamine is a vasoconstrictor and is contraindicated in an individual with high blood pressure or other cardiac ailments.

A nurse should recognize that a patient is at risk for developing necrotizing otitis externa (OE) if the patient shows which finding? A. Skin lesions on the auricles B. Ruptured tympanic membranes C. Deformities of the malleus and stapes D. Pain at the mastoid or temporal bone

D. Pain at the mastoid or temporal bone Necrotizing OE is a rare complication of acute OE that develops when bacteria in the external ear canal invade the mastoid or temporal bone. Spread of infection to the skull base can affect the cranial nerves, and spread to the dura mater can cause meningitis. Skin lesions on the auricles, ruptured tympanic membranes, and deformities of the malleus and stapes are not symptoms associated with necrotizing OE.

The nurse is caring for a group of patients who have been prescribed sedative-hypnotic agents. Which agent has the greatest abuse potential? A. Diazepam [Valium] B. Triazolam [Halcion] C. Zolpidem [Ambien] D. Phenobarbital [Luminal Sodium]

D. Phenobarbital [Luminal Sodium] Phenobarbital is a barbiturate drug that carries a higher abuse potential than the benzodiazepine or benzodiazepine-like drugs.

Natalizumab [Tysabri] is a very effective agent for treating MS. Which problem is associated with the administration of this drug, making it a second-line agent? A. Increased risk of sudden cardiac death B. Documented reports of necrotizing colitis C. Increased risk of Stevens-Johnson syndrome D. Rare cases of dangerous brain infections

D. Rare cases of dangerous brain infections Soon after natalizumab was released on the market, there were three reports of progressive, multifocal leukoencephalopathy. All patients who developed this problem were taking natalizumab in combination with another immunosuppressant. The drug is now available only through a specialized, carefully controlled prescribing program.

A patient takes fluoxetine [Prozac] for premenstrual disorder (PMD). Which priority assessment allows the nurse to evaluate the effectiveness of this treatment? A. Decreased craving for carbohydrates B. Reduction in breast tenderness C. Less abdominal bloating D. Reports of mood improvement

D. Reports of mood improvement Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, are considered first-line therapy for the psychologic symptoms of PMD. They are most effective for reducing the affective symptoms (mood improvement) of PMD; however, they also can reduce physical symptoms, such as breast tenderness, bloating, and headaches.

Which description should a nurse document for a patient experiencing miosis as an adverse effect of a systemic medication? A. Opaque, cloudy lens B. Unequal pupil size C. Increased pigment in the iris D. Small, constricted pupils

D. Small, constricted pupils The term miosis refers to constricted pupils; it can be associated with the phrase "pupils move in." An opaque, cloudy lens; unequal-sized pupils; and increased iris pigment are not associated with miosis or pupillary constriction.

A patient is prescribed phenytoin for epileptic seizures. Which of the following is the priority for patient teaching? A. teach patient to adjust the dose according to the presence of symptoms B. Tell the patient to take medication with meals C. inform the patient about the prevention of gingival hyperplasia D. Teach the patient to avoid the abrupt cessation of treatment

D. Teach the patient to avoid the abrupt cessation of treatment

A patient takes oxycodone [OxyContin] 40 mg PO twice daily for the management of chronic pain. Which intervention should be added to the plan of care to minimize the gastrointestinal adverse effects? A. The patient should take an antacid with each dose. B. The patient should eat foods high in lactobacilli. C. The patient should take the medication on an empty stomach. D. The patient should increase fluid and fiber in the diet.

D. The patient should increase fluid and fiber in the diet. Narcotic analgesics reduce intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can help manage this adverse effect. If increased fluid and fiber is not sufficiently effective, use of a laxative may be considered.

A patient is prescribed insulin glargine. Which statement should the nurse include in the discharge instructions? A. The insulin will have a cloudy appearance in the vial B. The insulin should be injected twice daily (before breakfast and dinner) C. The patient should mix Lantus with the intermediate-acting insulin D. The patient will have less risk of hypoglycemic reactions with this insulin

D. The patient will have less risk of hypoglycemic reactions with this insulin It has long duration of action, so it's given once a day. Its clear and should not be mixed with other insulins -Gives steady flow over 24 hours so risk is much less NPH is cloudy.

Which medication acts as an agonist at the presynaptic alpha-2 receptor site? A. Baclofen [Lioresal] B. Dantrolene [Dantrium] C. Diazepam [Valium] D. Tizanidine [Zanaflex]

D. Tizanidine [Zanaflex] Tizanidine promotes inhibition by acting as an agonist at presynaptic alpha2 receptors. Dantrolene relieves spasm by suppressing release of calcium from the sarcoplasmic reticulum. Baclofen and diazepam promote inhibition by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter.

A 6-year-old is diagnosed with acute otitis externa (AOE). What would not be recommended as part of the treatment plan for this child? A. Ear drops should be warmed before they are instilled. B. A 2% solution of acetic acid should be instilled. C. The external auditory canal (EAC) should be kept as dry as possible. D. Tympanostomy tubes may need to be inserted if no response is seen to conventional treatment.

D. Tympanostomy tubes may need to be inserted if no response is seen to conventional treatment. Tympanostomy tubes may be indicated for recurrent otitis media to permit aeration and drainage of the middle ear. They are not part of the treatment plan for AOE. Ear drops should be warmed before instillation to prevent dizziness. A topical 2% solution of acetic acid is a safe, effective treatment for AOE. The EAC should be kept as dry as possible to prevent bacterial growth.

The nurse is caring for a patient receiving clozapine [Clozaril]. Which assessment finding is most indicative of an adverse effect of this drug? A. Blood urea nitrogen level of 25 mg/dL B. Blood glucose level of 60 mg/dL C. Bilirubin level of 2.5 mg/dL D. White blood cell (WBC) count of 2000/mm3

D. White blood cell (WBC) count of 2000/mm3 Clozapine, an atypical antipsychotic, carries a risk of fatal agranulocytosis. For this reason, the WBC count should be monitored and should be greater than 3500/mm3. Renal function (blood urea nitrogen) should not be affected by clozapine. Clozapine may cause metabolic effects, including diabetes, that would result in an increased blood glucose level (greater than 110 mg/dL). Elevated bilirubin indicates liver disease and is not commonly an adverse effect of clozapine.

Streptogramins (Bacteriostatic inhibitors of protein synthesis)

Dalfopristin, Quinupristin Indication: VRE AE: Hepatotoxicity CYP3A4 interactions

The nurse plans to closely monitor for which clinical manifestation after administering furosemide [Lasix]?

Decreased blood pressure High-ceiling loop diuretics, such as furosemide, are the most effective diuretic agents. They produce more loss of fluid and electrolytes than any others. A sudden loss of fluid can result in decreased blood pressure. When blood pressure drops, the pulse probably will increase rather than decrease. Lasix should not affect respiration or temperature. The nurse should also closely monitor the patient's potassium level.

Pathogenesis of Peptic Ulcers

Defensive factors: Mucus -Secreted by GI mucosa cells -Forms barrier to protect from hydrochloric acid and pepsin Bicarbonate -Secreted by epithelial cells of stomach and duodenum -Most remains trapped in mucus layer to neutralize hydrogen ions that penetrate the mucus Blood flow -Poor blood flow can lead to ischemia, cell injury, and vulnerability to attack Prostaglandins -Stimulate secretion of mucus and bicarbonate Aggressive factors: H. pylori = #1 cause -Not infectious. -Lives between epithelial cells and the mucus barrier (escapes destruction by acid) -Can remain in GI tract for decades -Destroys the lining and infects lining. -If we can eradicate it, healing of PUD and minimizes recurrence. NSAIDs = #2 cause -inhibits biosynthesis of prostaglandins -Reduce mucus and bicarbonate Gastric acid -Direct injury because of something person has ingested -Indirect injury by activating pepsin -Increased acid alone does not increase ulcers, but is a definite factor in PUD. Pepsin Proteolytic enzyme in gastric juice --> injures like acid Smoking Delays ulcer healing and increases risk for recurrence

Dabigatran Etexilate [Anticoagulant][Direct Thrombin Inhibitor]

Direct and reversible thrombin inhibitor. 5 major advantages over warfarin: 1. Acts fast 2. You don't have to monitor 3. Very few interactions 4. Less likelihood of bleeding as a side effect 5. Same dose for all patients Therapeutic uses: -Prevents thromboembolism/stroke -Prevents DVT/PE and treats it MOA: Direct thrombin inhibitor (unlike Heparin which enhances antithrombin activity) Adverse effects: -Bleeding -Gastrointestinal (GI) disturbances -Take with food or antacid suppressing drug to help. Pros: -doesn't require monitoring -little risk of adverse interactions -no age or weight dependent dosing Cons: -Expensive -Twice a day dosing

Warfarin [Anticoagulant][Vitamin K Antagonists]

Discovered when cattle were eating spoiled food, they started having bleed. Initially used as rat poison, now used as an oral anticoagulant with delayed onset MOA: -Vitamin k antagonist -Blocks biosynthesis of factors VII, IX and X and prothrombin -Suppresses coagulation by decreasing production of clotting factors, which takes time which is why it has delayed onset. Therapeutic uses: Long term prevention of thrombosis -Venous thrombosis (VT) and PE -Thromboembolism (prosthetic heart valves) -Thrombosis during atrial fibrillation (AF) Not useful in emergencies Monitoring treatment: -Prothrombin time: PT (a blood test that measures how long it takes blood to clot) More current measure is International ratio: INR (s a calculation based on results of a PT and is used to monitor individuals who are being treated with the blood-thinning medication. monitor the effectiveness of the anticoagulant warfarin) Adverse effects: -Hemorrhage -Fetal hemorrhage (can cross placenta), and teratogenesis -Not for use during lactation Don't want to use during pregnancy. Use heparin in pregnancy. Drug interactions: -Interacts with everything -Drugs that Increase anticoagulant effects like aspirin -Drugs that decrease anticoagulant effects like oral contraceptives -Drugs that promote bleeding like heparin and aspirin Antidote: Vitamin K Food interactions: Dietary vitamin K: -Mayonnaise -Canola oil -Soybean oil -Green leafy veggies (need to be consistent intake)

Drug Therapy for MS

Disease-modifying therapy -Used to treat acute relapse and manage symptoms -Immunomodulators and immunosuppressants (decease the frequency and severity of relapses. Immunomodulators means you are trying to get antibodies in right range, where as suppression you are tampering things down) -Reduce development of brain lesions -Decrease future disability -Help maintain quality of life -May prevent permanent damage to axons -Does not work for all patients -Most effective for patients with relapsing-remitting MS Relapsing-remitting: -Immunomodulators Secondary progressive: -Interferon beta -Mitoxantrone Progressive relapsing: -Mitoxantrone Primary progressive: -No disease-modifying therapy shown effective -Possible benefit from immunosuppressants Treating an acute episode (relapse) -Short course of high-dose IV glucocorticoid (preferred treatment) -IV gamma globulin (if you can't tolerate steroids) All 4 subtypes of MS have the same symptoms: -Fatigue -Spasticity -Neuropathic pain -Bladder dysfunction -Bowel dysfunction (constipation) -Sexual dysfunction

Diabetes Mellitus Overview

Disorder of carbohydrate (CHO) metabolism -Deficiency of insulin -Resistance to action of insulin Sustained hyperglycemia (too much sugar in blood) -Polyuria -Polydipsia -Polyphagia -Ketonuria (needing fuel and body is burning fat) -Weight loss Types Type 1 (T1DM) Type 2 (T2DM) Gestational diabetes (GDM)

Echinocandins

Disrupt fungal cell wall Use for: Aspergillus and Candida infections Caspofungin, micafungin, anidulafungin

Non-Opioid Centrally-Acting Analgesics

Do not cause respiratory depression, physical dependence, or abuse Do not use the Mu receptors Tramadol Schedule IV Agents: -Tramadol -Clonidine -Ziconotide -Dexmedetomidine

Dopamine vs Dobutamine

Dopamine -Is a vasopressor (Vasopressors are medicines that constrict (narrow) blood vessels, increasing blood pressure) -Alpha 1 adrenergic agonist -Great for septic shock (in septic shock, there is massive vasodilation, so it acts on alpha receptors for vasoconstriction for increased vascular resistance) -Leads to increased vascular resistance Dobutamine -NOT a vasopressor -Beta 1 receptors agonist -Increase fight or flight response -Given to increase cardiac output and heart failure, cardiogenic shock (ventricles aren't wanting to contract. it is going to increase squeeze and push more blood out here) -Leads to increased cardiac output

Insulin therapy of diabetes

Dosage: Matched to meet insulin needs -Increased CHO intake (if carb intake is high, need more insulin) -Increased physical activity (need less insulin) -Infection -Stress (if stress is high, they need more insulin) Dosing schedules: -Twice daily premixed insulin regimen -Intensive basal/bolus strategy Hospital "sliding scale" -Provider determines insulin type -Dose to administer depends on pre-meal glucose level -- 150-199 = 1 unit -- 200-249 = 3 units -- 250-299 = 5 units Continuous subcutaneous insulin infusion (CSII)

Mechanisms of Adrenergic Receptor Activation

Drugs can activate by 4 mechanisms 1. Bind directly 2. Promote norepinephrine (NE) release 3. Block NE reuptake leaving it around longer 4. Inhibition of NE inactivation Most drugs discussed are: -Peripherally acting sympathomimetics -Direct receptor activation Indirect-acting sympathomimetics -Amphetamine -Cocaine

Overview of PUD treatment

Drugs do not alter the disease process; they create conditions that are conducive to healing Goals of Drug Therapy -Alleviate symptoms -Promote healing -Prevent complications -Prevent recurrence Evaluation of Treatment Monitor for relief of pain -Cessation of pain and disappearance of ulcer rarely coincide. -Pain may subside after complete healing or may continue after healing. Radiologic or endoscopic examination of ulcer site.

Drug Therapy

Drugs given to restore balance between dopamine and ACh 2 major categories: Dopaminergic agents -Most commonly used -MOA: Promote activation of dopamine receptors -Levodopa Anticholinergic agents -MOA: Prevent activation of cholinergic receptors; block receptors for ACh -Benztropine

Headache overview

Drugs used in two ways Abortive -NSAIDs -Migraine-specific drugs -Opioid analgesics Preventive -Beta blockers -TCAs -Anti-epileptics

A patient who takes oxybutynin for an overactive bladder takes an over-the-counter antihistamine for hay fever symptoms. What symptoms should the nurse watch for that would indicate toxicity?

Dry mouth, increased temperature, and blurred vision

Organisms with Resistance to Antimicrobial Drugs & the mechanisms of drug resistance

E. faecium S. aureus Enterobacter species Klebsiella species P. aeruginosa A. baumannii C. difficile MRSA Pseudomonas 4 basic actions 1. Decrease concentration of a drug at it's site of action 2. Inactivate a drug 3. Alter the structure of drug target molecules 4. Produce a drug antagonist Mechanisms for acquired resistance Spontaneous mutation; random changes in microbes DNA; resistance to one drug. Conjugation (1 microbe transfers their DNA to another) -Gram-negative bacteria -Multiple drug resistance E.Coli

Testosterone

Effects on sex characteristics in males -Pubertal transformation -Spermatogenesis (produce sperm) Effects on sex characteristics in females -Clitoral growth -Maintenance of normal libido -Overproduction of androgens --> virilization Anabolic effects Skeletal muscle (promotes growth of skeletal muscle) Erythropoietic effects -Synthesis of erythropoietin -Explains higher Hct in men than woman

Receptor Specificity of the Adrenergic Neurotransmitters

Epinephrine -Can activate all alpha and beta receptors but NOT dopamine receptors Norepinephrine -Can activate alpha 1, alpha 2, and beta receptors but NOT beta 2 or dopamine receptors Dopamine -Can activate alpha 1, beta 1, and dopamine receptors -Dopamine is the only neurotransmitter capable of activating dopamine receptors

Multiple Receptor Activation

Expected effects and clinical uses: Anaphylactic shock -Severe allergic response --> hypotension, bronchoconstriction, and edema of the glottis -Treatment of choice: Epinephrine (can activate all 4 subtypes of receptors so its a broad spectrum of beneficial effects)

Alpha1 Activation

Expected effects and clinical uses: Hemostasis -Arrests bleeding via vasoconstriction Nasal decongestion -Mucosal vasoconstriction Adjunct to local anesthesia -Delays absorption of local anesthetic Elevation of blood pressure -Vasoconstriction Mydriasis -Dilation of the radial muscle of the iris Adverse Effects Vasoconstriction -Hypertension -Necrosis (alpha-1 agonist): Extravasation (NE-associated). If IV line used to administer becomes extravasation, it will get irritated and result in necrosis where tissue dies. --Treated with alpha antagonist (Phentolamine) -Bradycardia --Can cause reflux slowing of heart because of triggering of baroreceptor reflex and it causes heart rate to decline.

Myasthenic Crisis vs. Cholinergic Crisis

Extreme muscle weakness is caused by not enough ACh at neuromuscular junction Myasthenic crisis -Inadequate medication -Extreme muscle weakness -Caused by insufficient ACh at the neuromuscular junction -Left untreated, myasthenic crisis can result in death as a result of paralysis of the muscles of respiration -A cholinesterase inhibitor (such as neostigmine) is used to relieve the crisis Cholinergic crisis -Characterized by extreme muscle weakness or frank paralysis and signs of excessive muscarinic stimulation -Treatment with respiratory support and atropine Summary -If patient is undertreated, it is probably Myasthenic crisis -Challenging dose of edrophonium (used to diagnosis MG) -History of medication use or signs of excessive muscarinic stimulation assist with differential diagnosis -Identification (Medic Alert item) worn by patient

Therapeutic uses of Neuromuscular Blockers

Facilitation of mechanical ventilation -Reduce resistance to ventilation (we don't like tubes going down our throat) -Ensure patient comfort at all times -Hearing not affected -Patient is fully awake and completely paralyzed Adjunct to electroconvulsive therapy (ECT) -Prevent convulsive movements during ECT ET intubation -Suppresses gag reflex

Cardiac (Digitalis) Glycosides

Family/Class: Cardiac glycosides Positive Inotropic actions -Increases strength of muscular (myocardial) contractile force -Profound mechanical and electrical effects -Second-line agent today, but still used. Naturally occurring compound -Biennial plant -Digitalis purpurea species -"Foxglove" flower Slows heart rate

Sodium Nitroprusside

Fastest-acting antihypertensive agent Indication: Hypertensive emergencies MOA: -Venous and arteriolar dilation Pharmacokinetics: IV infusion-- must be titrated to keep blood pressure within range. Immediate onset;If nitro is given for chest pain = a dose every 5 minutes, then another dose. if that doesn't take care of it, then another dose. -Up to 3 doses of nitroglycerin within 15 minutes; then person is to call 911. Adverse effects: -Hypotension -Contains 5 cyanide groups broken down by metabolism = headache because of vasodilation in brain. -Thiocyanate toxicity

Other Strong Opioid Agonists

Fentanyl -Super strong opioid, 100x more potent than morphine Formulations (three routes): 1. Parenteral -Surgical anesthesia 2. Transdermal patch -Last several days 3. Transmucosal -Lozenge on a stick -Buccal film -Buccal tablets -Sublingual tablets -Sublingual spray

Dopamine Agonists

First line drugs MOA: -Direct activation of dopamine receptors in striatum Compared with levodopa: -Less effective than levodopa -Not dependent on enzyme conversion -Does not compete with dietary proteins -Lower incidence of response failure -Less likely to cause dyskinesias Two types of dopamine agonists: 1. Non-ergot derivatives 2. Derivatives of ergot

Ranolazine

First of new antianginal class -Modest benefits; works better in men than woman. -Does not reduce heart rate, blood pressure, or vascular resistance -Can prolong QT interval; multiple drug interactions Exact mechanism is unknown Approved for first-line therapy Combine with first line agents for inadequate response to other first-line medications Might be good for patients with diabetes

Glyburide

First oral antidiabetic available Class: Second- generation Sulfonylurea Use: -Only used for T2DM MOA: -Promotes pancreatic insulin release -Slight increase to insulin sensitivity Adverse effects: -Dose dependent hypoglycemia -Weight gain Drug interactions: Drugs that intensify hypoglycemia -NSAIDS -Sulfonamide antibiotics -Alcohol -Cimetidine -Beta blockers can inhibit benefits by suppressing insulin release

Carbidopa/Levodopa/Entacapone

Fixed-dose combinations More convenient than taking separate doses Disadvantages: -Available only in immediate-release tablets -Available in only three strengths (lose ability to titrate one drug differently)

Influenza (Antiviral)

Flu vaccines -Inactivated, live/attenuated AE; Guillain-Barre syndrome, allergy Precautions: egg allergy, acute febrile illness, minor illnesses with or without fever Neuraminidase inhibitors -Oseltamivir (Tamiflu), Zanamivir (Relenza) Start within 48 hours of onset

Cytomegalovirus (CMV) Infection (Antiviral)

Ganciclovir MOA same as acyclovir; inhibits DNA polymerase Use for: Herpes simplex virus, prevention and treatment of CMV infection in immunocompromised patients AE; Thrombocytopenia, granulocytopenia, reproductive toxicity, N, fever, rash, anemia, liver dysfunction, confusion and other CNS effects Valganciclovir Use for: CMV retinitis, prevention of CMV disease in high-risk organ transplant patients AE: Blood dyscrasias (bone marrow suppression, granulocytopenia, anemia, thrombocytopenia), N/V/D, Potential for mutagenesis and carcinogenesis Avoid direct contact with broken tablet Foscarnet Use for: CMV retinitis in patient's with AIDS, acyclovir resistance AE: nephrotoxicity, electrolyte and mineral imbalances

Aminoglycosides (Bactericidal Inhibitors of Protein Synthesis)

Gentamycin, Tobramycin, streptomycin, Neomycin, kanamycin, paromomycin, amikacin Narrow spectrum Bactericidal Microbial resistance is common AE: Nephrotoxicity, ototoxicity, hypersensitivity reactions, neuromuscular blockade disruption (reverse w/ IV Ca gluconate), blood dyscrasias, contact dermatitis (topical) Interactions: penicillins, cephalosporins (enhanced bacterial kill), vancomycin (enhanced effect); ototoxic drugs (ehacrynic acid), nephrotoxic drugs (NSAIDS) -Don't give penicillin with aminoglycosides together, penicillin deactivates aminoglycosides. Monitor serum levels -Peak (30 min after admin) high enough to kill bacteria -Trough low enough to minimize toxicity Treatment: IV infusion of calcium salt

A patient plans to stop taking prescribed clonidine to treat hypertension because of the side effect of dry mouth. Which action by the nurse is best?

Give the patient hard candy or gum to relieve the symptom

What do Calcium Channel Blockers do?

Given to help control blood pressure Prevents calcium from entering the cells. (Calcium is a positive ion that will promote contraction) Has greatest impact on heart and blood vessels Used to treat: -Hypertension -Angina pectoris (chest pain or pressure, usually due to not enough blood flow to the heart muscle) -Cardiac dysrhythmias

Antiemetics

Given to suppress nausea and vomiting Emetic response: -Complex reflex that occurs after activation of vomiting center in the medulla oblongata Several types of receptors involved in emetic response: -Serotonin, glucocorticoids, substance P, neurokinin1, dopamine, acetylcholine, histamine -Many antiemetics interact with one or more of the receptors Drug Classes: Serotonin Antagonists -Odansetron Glucocorticoids -Not FDA approved Substance P/Neurokinin1 Antagonists Benzodiazepines Dopamine Antagonists -Promethazine Cannabinoids Anticholinergics

Eye conditions and agents

Glaucoma -Beta blockers -Alpha-adrenergic agonists -Prostaglandin Analogs Cycloplegics and Mydriatics -Cycloplegics are drugs that paralyze cilliary muscle -Mydriatics dilate the pupil -Helpful in diagnosing eye conditions Allergic Conjunctivitis -Inflammation of conjunctiva in response to a specific allergen Age-related macular degeneration (ARMD) -Function of aging -Painless and progression -Middle portion of vision is blurred and results from injury to macula (central part of retina) -Angiogenesis inhibitors Others -Dry eyes (artifical tears) -Glucocorticoids (steroids for inflammatory conditions) -Dyes (detect lesions of cornea)

Non-Insulin Injectable Drugs

Glucagon-like Peptide-1 (GLP-1) receptor AGONISTS -Exenatide -Exanatide ER -Liraglutide -MAY CAUSE MEDULLARY THYROID CARCINOMA. BBW about possibility of causing thyroid cancer -Albiglutide Amylin mimetic -Amylin is secreted with insulin that makes you feel full and reduces spikes in glucose Pramlintide -Used to treat type 1 and type 2 diabetes -Adverse effects: hypoglycemia and nausea, injection-site reactions -Never given in drugs that slow intestional activity

A patient is newly prescribed carbamazepine for seizure control. It is most important for nurse to teach the patient to avoid which food?

Grapefruit juice

Hyperthyroidism

Graves' Disease -most common among women 20-40 Cause (autoimmune): -Thyroid-stimulating immunoglobulins (TSIs) --> increased stimulation of TSH receptors -Too much TSIs that increase stimulation of TSH Signs and symptoms -elevated thyroid hormones -Eyes: Exophthalmos -Goiter -Cardiac: tachycardia, dysrhythmias, angina -CNS: Nervousness, insomnia, rapid thoughts/speech -MSK: Weakness and muscular atrophy -Metabolism: increased heat production (intolerance to heat), temperature, warm, moist skin, increased appetite Treatment -Surgical removal of thyroid tissue -Destruction of thyroid tissue -Suppression fo thyroid hormone synthesis -Beta blockers (propranolol) -Nonradioactive iodine Plummer's disease "Toxic nodular goiter" Cause: -Thyroid adenoma (benign lesions of the thyroid gland) Signs/symptoms: -Similar to Graves' disease -No exophthalmos Treatment: -Similar to Graves' disease -Surgery and radiation preferred Thyrotoxic Crisis (Thyroid Storm) Cause: -Patients with hyperthyroidism who undergo significant stress (surgery, illness) -Not triggered by a rise in thyroid hormones -Cannot be identified by lab testing Signs: -Hyperthermia (105 or higher) -severe tachycardia -Restlessness -Agitation -Tremor -Unconsciousness -Coma -Hypotension -Heart failure Treatment: -Anti-thyroid drugs -Beta blockers -Sedation -Cooling -Glucocorticoids -IV fluids

Darifenacin [anticholinergic drugs for OAB]

Greatest degree of M3 selectivity Can reduce OAB symptoms while having no effect on M1 receptors in the brain or M2 receptors in the heart Still blocks M3 receptors outside of the bladder --> dry mouth and constipation Dry mouth and constipation can still happen.

Classification of Laxatives

Group 1 -Act rapidly (within 2-6 hours) -Watery consistency -Use: diagnostic or surgical bowel preparation Osmotic laxatives (at HIGH doses) -Magnesium hydroxide (MOM) *prototype* -Polyethylene Glycol -Lactulose (patients who are in liver failure for removal of ammonia) Group 2 -Intermediate latency (6-12 hours) -Semifluid stool Osmotic laxatives (at LOW doses) Stimulant laxatives -Bisacodyl *prototype* Group 3 -Most frequently abused by general public -Slow acting (1 to 3 days) -Soft, formed stool -Use: treating chronic constipation, preventing straining Bulk-forming laxatives -Methycellulose *prototype* -Psyllium Surfactant laxatives -Docusate sodium *Prototype* Chloride Channel Activator Lubiprostone *Prototype* Others Mineral oil (its a lubricant in lining of intestine, so stool will pass) -It can interfere with absorption of other foods, minerals and vitamins through gut. -it would interfere with fat soluble vitamins.

Major Groups and Classes of Antifungal Agents

Groups: Drugs for systemic mycoses/ infections Drugs for superficial mycoses/infections A few drugs used for both Classes: 1. Polyene antibiotics 2. Azoles 3. Echinocandins 4. Pyrimidine analogs

Amoxicillin [antibiotic]

H. pylori is highly sensitive to amoxicillin MOA: -Kills bacteria by disrupting cell wall Most common side effect: -Diarrhea Antibacterial activity is highest at neutral pH: -Reducing gastric acidity --> enhanced effect -PPIs (ex: omeprazole)

High-Potency FGAs

Haloperidol Uses: -Schizophrenia and acute psychosis -Preferred agent for Tourette's syndrome Adverse effects: -Early extrapyramidal reactions -Neuroendocrine effects (galactorrhea: milky nipple discharge, gynecomastia: enlargement or swelling of breast tissue in males, irregular menstruation) -Can prolong QT interval and cause dysrhythmias

RAAS regulation of BP

Helps regulate BP in presence of hemorrhage, dehydration, or sodium depletion Acts in 2 ways: 1. Constricts renal blood vessels 2. Acts on kidney to promote retention of sodium and water and excretion of potassium

Diagnosis of Diabetes

Hemoglobin A1c -"Glycosylated" or "glycated" hemoglobin -Average glucose level over past 2-3 months (3 months because it's lifespan of RBC) Estimated average glucose - 6 = 126 mg/dL - 7 = 154 mg/dL - 12 = 298 mg/dL Tests based on glucose Fasting plasma glucose (FPG) test -Fasting = no caloric intake for at least 8 hours -126 or greater is suggestive of diabetes. Casual (random) plasma glucose test -Casual = any time of day, without regard to meal -if its 200 or more AND patient has symptoms of diabetes, that would be considered diagnostic Oral glucose tolerance test (OGTT) -75 gm glucose load -you give patients nasty syrupy glucose to drink after they have been fasting over night and then you measure their blood glucose 2 hours later -200 or more is generally indicative of diabetes

Physiology and Pathophysiology of Coagulation

Hemostasis = blood. Stop bleeding. Stage 1: Formation of platelet plug -Platelet aggregation. Reinforcement of sticky platelets with fibrin. Stage 2: Coagulation -Intrinsic coagulation pathway -Extrinsic coagulation pathway

Metabolic Alkalosis

High pH, Normal CO2, High HCO3 Causes: -Excess loss of stomach acid (vomiting) -Administering alkaline salts like sodium bicarbonate -Severe volume contraction Treatment: Infusing Normal saline and Potassium chloride --> facilitates secretion of sodium bicarbonate in kidneys

Describe methods for determining safe pediatric drug doses

Dosing is called Body Surface Area Calculation -Initial pediatric dosing is approximation. Body surface area of child x Adult dose / 1.73 m^2.

Telithromycin (Bacteriostatic inhibitors of protein synthesis)

-Effective against strains of S. pneumoniae AE: Hepatotoxicity, prolonged QT interval